Lehigh Valley Hospital and Health Network Allentown, Pennsylvania

1. L V o EHI H A L L E Y HOSPITAL AND HEALTH NETWORK Practical Applications of Palliative Care in Critical Care Medicine Daniel E. Ray MD, MS, FCCP Lehigh Valley Hospital and Health Network Allentown, Pennsylvania

2. Disclosure • Supported, in part, by : • The Robert Wood Johnson Foundation (#047999) • Dorothy Rider Pool Healthcare Trust • Dexter F. and Dorothy H. Baker Foundation • No other conflicts of interest

3. Objectives • Describe palliative care principles that are pertinent to the ICU setting • List practical interventions to immediately integrate palliative care in the ICU • Review methods to facilitate cultural change around palliative care in the ICU

4. Palliative Care • Philosophy of care • Organized, highly structured system for delivering care • Provided during routine course of health care • Provided by palliative care specialists in complex cases

5. Palliative Care • Enhancing quality of life for patient and family • Helping with decision-making • Providing opportunities for growth • Optimizing function http://www.nationalconsensusproject.org/

6. Quality Indicators for Palliative Care in the ICU • Patient and family-centered decision making. • Communication. • Continuity of care. • Emotional and practical support. • Symptom management. • Spiritual support. • Support for ICU clinicians. Clarke EB, et al. Crit Care Med 2003, 31:2255-62.

7. Barriers to ICU Palliative Care • Unrealistic patient/family expectations • Inadequate prognostication by physicians • Insufficient training of physicians in palliative medicine Nelson JE. Crit Care Med 2006; 34:S324-S331

8. Barriers to ICU Palliative Care • ICU culture • ‘rescue from life-threatening illness’ • ‘death denying’

9. “…it would be naïve and self-defeating to take direct aim at strong belief systems in devising strategies to improve care. We cannot ignore the fear - even if irrational - that palliative care will shorten life nor the powerful biological drive to survive…” Nelson JE. Crit Care Med 2006; 34:S324-S331

10. Palliative care is delivered as part of routine comprehensive care in the ICU

11. Patient and Family-centered Decision Making • Recognize the patient and the family as the unit of care • Elicit patient’s values and preferences for ICU care • Reduce patient anonymity

12. Patient and Family-centered Decision Making • Protocolize timing of family meetings • Initial family contact within 24-48 hours of ICU admission • Daily contact for update • Scheduled family meeting for any significant status change

13. Patient and Family-centered Decision Making • Set up family expectations

14. Patient and Family-centered Decision Making • Reduce patient anonymity • ‘Get to Know Me’ poster www.massgeneral.org/palliativecare/palliative-micuproject.htm

15. Communication • With patients and families • Within the team

16. Communication - Family Before After (n=134)(n=396)p value ICU LOS (d) 4 3 0.004 Worst APACHE quartile Survivors 5 4.5 0.8 Died 5 3 0.02 Overall mortality odds ratio* After:before 0.61 (0.38-0.98) *adjusted for APACHE III Lilly, Am J Med 2000; 109:469

17. Communication - Team 100 2.5 90 80 2 70 60 1.5 50 Avg LOS (days) Daily Goals in the ICU 40 1 30 0.5 20 10 0 0 Oct Feb May Dec Nov Aug April Sept 2-Jun 2-Jan Jul 03 March Jun 03 Week 1 Week 2 Week 3 Week 4 Week 5 Week 6 Week 7 Week 8 Percent of residents and nurses per week understanding goals Impact of daily goals sheet on ICU LOS Pronovost P et. al. J Crit Care 2003; 18:71-75

18. Communication - Team • Poor interdisciplinary communication associated with: • Increased mortality • Increased length of stay • Higher readmission rates • Improved communication is associated with: • Enhanced professional relationships and learning • Decreased job stress • Higher patient satisfaction

19. Continuity of Care • Maximize continuity of care across clinicians • Orient new clinicians regarding patient and family status • Prepare patient/family for change in clinicians

20. Continuity of Care • Situational, Background, Assessment,and Recommendation (SBAR) • Used by US Navy to insure critical information is communicated • Situation and background are objective • Assessment and recommendation allow delivery of subjective information • Creates redundancy Hoffman LA. Crit Care Alert 2006; 7:49-50

21. Continuity of Care • Implementation of SBAR • 98% of nurses using SBAR • Reduction of adverse rate from 89.9 to 39.6 per 1000 patient days Landro L. The Wall Street Journal. June 26, 2006:D1-2

22. Emotional and Practical Support for Patient/family • Waiting Room Program • Family assistance • Clinician support • Privacy/sleeping quarters • Open visiting hours Critical Care Family Assistance Program, Chest Foundation; http://www.chestnet.org/

23. Emotional and Practical Support for Patient/family • Society of Critical Care Medicine: www.icu-usa.com • Web-based program for ICU waiting rooms • Customized for processes in each ICU • Provides educational material for families related to common procedures and diagnosis in ICU • Satisfaction survey

24. Emotional and Practical Support for Patient/family • No One Dies Alone (NODA) http://www.peacehealth.org/Oregon/NoOneDiesAlone.htm • Volunteer program to be present during a patient’s death • Bereavement Services

25. Symptom Management • Development of protocols and guidelines • “Make it easy to do the right thing, at the right time, in the right way” • Delirium/agitation protocol • Comfort Measures only protocol • Ventilator withdrawal protocol • Bowel regimen guideline • Neuromuscular blockade protocol • Family meeting within 48hrs

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27. Effect of Sedation Protocol on Outcome • Randomized control trial • Intervention: daily sedative interruption • Outcome: • Decrease in duration of mechanical ventilation (55.9 hrs vs. 117 hrs) • Length of stay (5.7d vs. 7.5d) • Need for tracheostomy (6.2% vs. 13.2%) • Reduction in symptoms of PTSD Brook et al. CCM 1999; 27:2609-2614 Kress et al. AJRCCM 2003; 168:1457-1461

28. Spiritual Support • Provide strong pastoral care (spiritual care) presence in the ICU • Attendance in inter-disciplinary rounds • Formal consultation with spiritual assessment and plan of care • Look for ‘moral distress’ • Venue for discussion (M&M, grief rounds, death rounds, end-of-life rounds)

29. Spiritual Support • ‘Death Rounds’ • Monthly discussion of the issues and emotions surrounding the care of dying patients • 76% or residents felt worthwhile • 76% felt it should incorporated into all ICU rotations • Schwartz Rounds www.theschwartzcenter.org Hough CL et al. Journ Crit Care 2005; 20:20-5

30. Organizational Support for Clinicians • Needs assessment of clinical providers • Unit specific and department wide • Nurse education • 6-hour in-service • Overview/definition of palliative care • Pain management/adjunctive therapy • Spirituality • Ethical principles • Communication: how to deliver bad news • Annual competency training

31. Organizational Support for Clinicians • Physician education • Monthly lecture in communication skills • Delivering bad news and holding family meetings • Spirituality • Inter-disciplinary ICU morbidity & mortality • Medical Staff Progress Notes (Fast Facts; http://www.eperc.mcw.edu ) • Regional Symposium • Symptom management • Spirituality • Ethical Principles

32. Organizational Support for Clinicians • Local champions and academic detailing • Institutional feedback (Treece PD et al. Crit Care Med 2006; 34:S380-7) • ICU peer review for end-of-life care (Mosenthol AC et al. Crit Care Med 2006; 34:S399-403)

33. Pearls and Pitfalls • Culture change takes time • Value patient and family as unit of care • Link with existing resources • Be prepared for misfires • Be persistent

34. Web Resource Links • Lehigh Valley Hospital: http://www.lvh.org/pcinicu • No One Dies Alone Program: http://www.peacehealth.org/Oregon/NoOneDiesAlone.htm • Schwartz Rounds: www.theschwartzcenter.org • University of Washington http://depts.washington.edu/eolcare/ • Get To Know Me Poster www.massgeneral.org/palliativecare/palliative-micuproject.htm • Center to Advance Palliative Care www.capc.org

35. Questions