The Changing Practice of Critical Care

Incorporating Skills from Palliative Medicine

XXXVII ACP Annual Chapter MeetingPanama City, Republic of Panama

February 27, 2015

Thomas J. Prendergast, MDClinical Professor of Medicine, OHSU

Senior Scholar, Center for Ethics in HealthcareSection Chief, PCCM, Portland VAMC

Director, Respiratory Care and PFT Lab

Summary

• There are significant, potentially beneficial cultural differences between critical care and palliative care

• To practice critical care is to practice end-of-life care; this indigenous practice continues to change and develop

• Research shows many opportunities to improve patient care in domains often associated with palliative care

• Effective communication is central to both critical care and palliative care; this set of skills is teachable

Nature of Critical Care

• Acute, severe illness with high short-term mortality

• Stabilize physiology, reverse organ failure, prevent death

• Short-term goals: Discharge from ICU

• Technology intensive, pushing limits

WHO Definition of Palliative Care

“The active total care of patients whose disease is not responsive to curative treatment.”

Clash of cultures

Palliative Care• Rooted in oncology• Predictable disease course• Patient able to speak for

himself• Longitudinal patient-provider

relationship• Work together over weeks

toward normative goals

Critical Care

• Rooted in physiology • Unpredictable disease course• Patient unable to speak for

himself• Rare to have met patient

prior to acute illness• Work together over hours to

stabilize

“Not responsive to curative treatment”

60-95% of ICU patients survive. Should we focus on dying ICU patients?

ICU Pall Care

Integrating Palliative Care into Critical Care

It is difficult to focus on dying ICU patients.

Problem:1. The dying are hard to identify

prospectively

Ante-mortem median 6 mo predicted survival

Lynn J et al. New Horizons 1997;5(1):56-61

One day One week

All deaths – SUPPORT

7% 35%

CHF 42% 62%

COPD 21% 41%

COMA 11% 27%

MOSF & malignancy 5% 26%

Saving a life

Predicted MortalityAlive/dead/NNT*

50% 1 / 1 / 275% 1 / 3 / 490% 1 / 9 / 1099% 1 / 99 / 100

*number needed to treat

Fundamentals of critical care

• A high percentage of ICU patients die but individual ICU patients are difficult to identify as dying.

• ICU deaths are not (necessarily, always) a failure of perspective but a consequence of imperfect prognostic skills.

• It is not (necessarily, always) suspect practice to treat people who die in the ICU. In fact, it is necessary.

Integrating Palliative Care into Critical Care, II

By focusing only on dying ICU patients, we may miss opportunities.

Problems:1. The dying are hard to identify

prospectively2. Offering palliation only to the dying is an

in-complete description of Palliative Care

Palliative Care skills

Palliative care is more than caring for the actively dying:

• Expert symptom management

• Skillful communications

• Emphasis on multidisciplinary teams and the need for provider support

• Focus on family and community

Interim conclusions

1. The reality of imperfect prognostication is a critical reason why palliative care belongs in the ICU.

Interim conclusions

1. The reality of imperfect prognostication is a critical reason why palliative care belongs in the ICU.

2. To transform cultural differences into a balanced approach, an institution needs visible champions who model respectful understanding.

Integrating Palliative Care into Critical Care, III

Who actually gets palliative care in the ICU?

Retrospective chart and EMR review

DHMC Project Impact

Total ICU Admissions 3,953Total ICU Deaths 793 (20%) 11,239

Death occurring<24 hours 222 (28%) 3,446 (31%)>24 hours 571 (72%) 7,793 (69%)

Data from April 1, 2001 through June 30, 2005

Status at time of death in <24h group

DHMC (n=222) PI (n=3446)

Full resuscitation 13.1%23.9%CPR performed at time of death 12.2%23.0%

Full support, no CPR 7.7%35.5%

Withdrawal of LS 63.1%30.8%

Withholding of LS 6.8% 7.6%

Brain dead/organ donor 10.4% 4.9%

Unknown 0.0% 0.3%

Data from April 1, 2001 through June 30, 2005

Changing resuscitation status, <24h

DHMC (n=222) PI (n=3446)admission / dc

admission / dc Full resuscitation 91.9% / 13.1% 82.4% /

23.9%Full support, no CPR 5.0% / 7.7%

12.9% / 35.5%Withdrawal of LS 0.5% / 63.1% 0.8% /

30.8%Withholding of LS 2.3% / 6.8% 4.6% /

7.6%Brain dead/organ donor 0.0% / 10.4% 0.0% /

4.9%Unknown 0.5% / 0.0% 0.4% /

0.3%

Data from April 1, 2001 through June 30, 2005

Indications for ICU admission

What reasons and objectives lead to ICU admission?

Indications for ICU admission

1. Diagnostic evaluation or therapeutic intervention

2. Focused communication and to facilitate decision making (the default in a dying patient with no AD)

3. Intensive palliative care of a dying patient

4. Supportive care of a brain dead patient pending organ harvest

5/6. Difficult communications: Pt/family or Outside MD/RN insistence against clinician advice

7. Difficult communications: Immediate revision of OSH transfer plan

1. Intensive therapeutic trial

40 male alcoholic with cirrhosis and variceal hemorrhage, admitted to the ICU through ED for resuscitation. Despite aggressive efforts, critical care was unable to keep up with the blood loss.

The patient suffered PEA arrest secondary to exsanguination and died in the ICU after failed CPR.

No family available.

2. To facilitate communication

59 woman with end-stage emphysema and an enlarging 9 cm lung mass for which she serially refused evaluation. Found unresponsive by neighbor at home, brought by EMS to ED with pCO2 164. Patient unable to participate in discussion.

Placed on CPAP/BiPAP in ED and transferred to ICU on non-invasive ventilation. Family meeting in ICU confirmed that patient would not want intubation.

Ventilatory support immediately withdrawn.

3. Intensive palliative care

87 woman transferred from OSH ER for SBO due to endometrial CA. Brought through DHMC ER directly to the OR for ex lap where the surgeons found diffuse peritoneal carcinomatosis, in addition to multiple bowel perforations.

The attending surgeon left the OR to inform the family that this was not a curable problem. All agreed to bring the patient out to ICU for comfort care and to allow her to die in the company of her family.

5. Difficult communications:Patient insistence against clinician

advice

70 woman with metastatic ovarian cancer admitted in transfer from community hospital for evaluation of mild confusion and gait instability. On inpatient ward for 22 days, then had massive aspiration causing respiratory failure, was intubated and transferred to the ICU where family immediately WD support.

During 22 day inpatient hospitalization, multiple attempts to address goals of care and, specifically, DNR/DNI status. The patient consistently refused to discuss end of life care issues, the family deferred to the patient and the ward team was paralyzed.

5. Difficult communications: Immediate revision of transfer plan

55 man with colon cancer including pulmonary and hepatic metastases, receiving chemotherapy at the local VA hospital, presented there with febrile neutropenia progressing overnight to septic shock and multi-organ failure.

Patient transferred VA -> DHMC whereupon support immediately withdrawn following discussion with family.

The only critical care intervention was a conversation with the family.

Therapeutic intent motivating ICU admission

n = 222Intensive diagnostic evaluation or therapeutic trial 66

(30%)

Intensive communications to facilitate decision making 84 (38%)

Intensive supportive care 59(27%)Explicit palliative intent 27Physiologic support of potential organ donor 32

Difficult communications 13 (6%)Patient/family insistence against clinician advice 7Immediate revision of OSH transfer plan 6

Prendergast TJ, unpublished data

Advance directives

Patient able to participate in his/her own decision making 9 (4%)

Existing DNR 21 (9%)

Followed 12Ignored 7Ignored (BiPAP) 2

AD completed 56 (25%)

Available 38 (17%)Not available 18

AD not completed 136 (61%)No reason to have an AD 60Clear indication for AD 36Compelling indication for AD40

Prendergast TJ, unpublished data

Impact of advance directives

AD available No AD available

n=56 n=166

Failed resuscitation 6 (10.7%) 28 (16.9%)

Full Rx, no CPR 2 (3.6%) 4 (2.4%)Withdrawal of LS 42 (76.8%) 103

(62.0%)Withholding of LS 4 (7.2%) 3 (1.8%)Brain death 2 (3.6%) 28 (16.9%)

Prendergast TJ, unpublished data

Impact of surrogate decision makers

Family available No family available

n=196 n=26

Failed resuscitation 13 (6.6%) 21 (80.8%)*Full Rx, no CPR 6 (3.0%) 0Withdrawal of LS 144 (73.1%) 2

(7.7%)Withholding of LS 7 (3.6%) 0Brain death 26 (13.2%) 3

(11.5%)

* P < .0001Prendergast TJ, unpublished data

Study summary

• Death in the first 24 hours following ICU admission is common, comprising approximately one third of all deaths.

• Under 30% of patients had an available advance directive, but few patients underwent CPR, except those with no available family.

• 92% were “Full code” on admission, but one third of patients were admitted for supportive care, another third were admitted for intensive communications and less than half underwent a therapeutic or diagnostic evaluation prior to death.

Implications for Critical Care

• A significant minority of ICU patients is admitted for explicitly supportive care

• Advance directives remain uncommon

• Living wills have less impact on decision making than a person who can speak for the patient

Integrating Palliative Care into Critical Care, IV

What can we learn from palliative care to improve ICU practice?

1. Untreated pain and other symptoms

2. Unmet needs for family care

3. Minimizing conflict among clinicians/patients/families

4. Ineffective communication

1. Pain and symptom management

• Pain is under-recognized and undertreated• Desbiens NA et al, Crit Care Med 24:1953, 1996• Gelinas C, Intensive Crit Care Nurs 23:298, 2007

• Sources of pain/distress are underappreciated

• Nelson JE et al, Crit Care Med 29:277, 2001• Puntillo KA et al, Crit Care med 38:2155, 2010

• Sedation is overused• Payen JF et al Anesthesiology 106:687, 2007

• Protocol-driven assessment can improve pain mgmt, reduce sedation and shorten ventilation and ICU LOS• Kress JP et al, NEJM 342:1471, 2000• Payen JF et al, Anesthesiology 111:1308, 2009

2. Family’s experience

• Anxiety, depression, PTSD and complicated grief afflict 30-50% of family members of ICU patients who die

• Anderson WG et al. J Gen Intern Med 23:1872, 2008• Paparrigopoulos T et al. J Psychosom Res 61:719, 2006• Siegel MD et al. Crit Care Med 36:1722, 2008• McAdam JL et al, Crit Care Med 38:1078, 2010

• Surrogate decisionmakers are at increased risk, made worse in the presence of conflict or poor communications

• Wendler D and Rid A, Ann Intern Med 154:336, 2011

• Proactive, protocol-based ICU family meetings inc distri-bution of printed informational materials reduced sx

• Lautrette A et al, MEJM 356:469, 2007

3. Conflict among providers/patients/families

• Disagreement between providers and surrogates over goals of treatment occurs in 10-20% of dying ICU patients

• Prendergast and Luce, AJRCCM 155:15, 1997

• Multiple studies find conflict among providers in 30-70% of patients, principally between MDs and RNs

• Azoulay E et al. Am J Respir Crit Care Med 2009; 180:853. • Frick S et al. Crit Care Med 2003; 31:456. • Breen C et al. J Gen Intern Med 2001; 16:283.

• An intensive communication effort can reduce conflict between surrogates and team over goals and LST

• Lilly CM et al, Am J Med 109:469, 2000

4. Communications in critical care

Time-pressured decisions under conditions of uncertainty naturally leads to differences of opinion and potential conflict

Patient/surrogate preferences

Domains of high-quality ICU care•Timely, clear, compassionate communication•Clinical decision making focused on patient

preferences, goals and values•Patient care, maintaining comfort, dignity,

personhood•Open access of families to patients•Interdisciplinary support of families during and

(for deceased patients) after the ICU stay

Nelson JE, Crit Care Med 38:808, 2010

Preferences: Need for control

Johnson SK et al, AJRCCM Epub 2010 Oct 29

1 2 3 4 50

5

10

15

20

25

30

35

40

45

50

LSTAbx

Physician practice

How do ICU physicians approach family meetings regarding decisions about life sustaining therapies?• 11% provided information but did not provide a recommendation or attempt to elicit values of preferences• 37% guided surrogate to focus on patient’s values without providing a direct recommendation• 51% shared in deliberations including making a recommendation• 2% told the family what s/he was going to do

White DB et al, Crit Care Med 38:743, 2010

Ineffective communication

• Families regard communication skills as equal to or more important than clinical skills, but

for many patients, no family meeting is held

physicians talk instead of listening missed opportunities to inform and to support

Heyland DK et al, Crit Care Med 30:1413, 2002 McDonagh JR et al, Crit Care Med 32:1484, 2004 Curtis JR et al, AJRCCM 171:803, 2005

Ineffective communication

• After discussion, half of families fail to comprehend basic information about illness, treatment and prognosis

• Azoulay E et al, Crit Care Med 28:3044, 2000

• 87% of surrogates want prognostic information but 37% of physicians fail to disclose likelihood of survival

• Evans LR et al, AJRCCM 179:48, 2009

• White, DB et al, Crit Care Med 35:442, 2007

Listening and emotional support

Positive correlation between empathic statements and surrogate satisfaction but 34% of physicians fail to make any empathic statement

Evans LR et al, AJRCCM 179:48, 2009

Only 2% of physicians checked to assess surrogates’ interest in prognosis and only 14% checked understanding of prognostic information after disclosure

• White, DB et al, Crit Care Med 35:442, 2007

Shared decision making

Nature of the decisionTreatment alternativesPro/con of choicesAddress uncertaintyAssess family understanding

Elicit patient valuesDiscuss family’s roleAssess need for others’ inputExplore the contextElicit family’s opinion

Charles C et al , Soc Sci Med 49:651, 1999

Shared decision making

Nature of the decisionTreatment alternativesPro/con of choicesAddress uncertaintyAssess family understanding

Elicit patient valuesDiscuss family’s roleAssess need for others’ inputExplore the contextElicit family’s opinion

Information sharing: 79% of conferences

White DB et al, Arch Intern Med 167:461, 2007

Shared decision making

Nature of the decisionTreatment alternativesPro/con of choicesAddress uncertaintyAssess family understanding

Elicit patient valuesDiscuss family’s roleAssess need for others’ inputExplore the contextElicit family’s opinion

Decision making process: 35% of conferences

White DB et al, Arch Intern Med 167:461, 2007

Observations

•Critical care is a challenging communications environment

•Both patients and physicians report that conversations around limiting life support are unsatisfactory

•Multiple studies demonstrate improved outcomes with improved communications

Integrating PC insights into critical care

By ICU d1 Identify medical decision maker Address AD and resuscitation status Provide family written information on ICU Assess and manage pain according to best practice

By ICU d3 Offer social work (emotional and practical) and spiritual support to family

By ICU d5 Conduct scheduled interdisciplinary family meeting

Nelson JE et al, Qual Safe Health Care 15:264, 2006

Improving communications

• ICU conferences within 72 hours -> decreased LOS and improved perception of quality of death

• Factors associated with improved family satisfaction: private space for communication consistent communication among providers more time spent listening than speaking empathic statements reassurance that the patient will not be abandoned

Conclusions

• There are significant, potentially beneficial cultural differences between critical care and palliative care

• To practice critical care is to practice end-of-life care; this indigenous practice continues to change and develop

• Research shows many opportunities to improve patient care in domains often associated with palliative care

• Effective communication is central to both critical care and palliative care; this set of skills is teachable