Incorporating Palliative Practices Into Critical Care

In 2002, I returned to work at my prior hospital of employment and found many examples of forward-thinking in place. One seemed like an oxymoron. A palliative care nurse practitioner was now employed within the Medical Intensive Care Unit (ICU). I wasn’t sure what to make of this addition at the time, but years later, I’ve realized the very appropriate allocation of this advanced practice nurse within this setting.

The overall death rate in the ICU is high: 20%-35% of patients admitted to intensive care die.¹ In addition, admissions to the ICU in the last month of life have increased to nearly 30%.² Within cancer care, contemporary data confirms the importance of addressing the needs of patients with cancer within the critical care setting. Consider the following:

• In the past decade, up to a third of patients admitted to ICU have a cancer diagnosis.
• Overall, 1 in 10 patients experience a life-threatening condition that requires the supportive technologies and monitoring rendered within the ICU setting.
• The use of aggressive cancer therapies heightens the prevalence of emergent scenarios; this is especially the case in the treatment of hematologic malignancies and with the use of hematopoietic stem cell transplantation.³

Associated with the increased prevalence of oncology patients within critical care settings are other corollaries.

Within the context of patients being unable to speak on their own behalf, surrogate or proxy decision-making has a plethora of problems and controversies.⁴ The prevalence of considerable symptom distress is another issue. In addition to cancer treatment-related sequelae, palliative care-related symptoms (i.e., thirst, anxiety, sleep disturbance, dyspnea) also require management.⁵ Lastly, poor communication amongst numerous physician specialists and with family members is pervasive.^3,6-9

There are several interventions to be considered to address these issues. They require implementation within the critical care and oncology unit settings. Consider the following:

• Establish a routine schedule for rounding with the palliative care team in both the oncology unit and intensive care settings. This includes developing a proactive approach to identifying patients who could benefit from palliative care interventions with the delineation of triggers for palliative care consults.
• In the ICU setting, have a plan for routine family meetings based on the projected or estimated length of stay.
• Create comfort care protocols for the management of common distress sequelae.
• Consider the development of family education approaches to enhance their awareness of common sequelae they are likely to encounter in critical care.
• Mandate communication training opportunities that address common scenarios likely to be encountered within critical care.³

I had the opportunity to work with a research initiative within the 5 University of California hospitals to train critical care nurses in communication skills.^10,11 The program’s goal was to provide needed instruction in the clinical setting about how to speak with the families of ill patients and the training consisted mostly of role-playing communication strategies with families, physicians, and family meetings.

Oncology nurses are one of many nurse specialties that care for patients with cancer. Emergency Department, PACU, surgical, rehabilitation, home care, dialysis, medical, and critical care nurses care for our patients at various phases of their cancer experience. The inevitability of oncology patients being cared for, and possibly dying, in the critical care setting is a real one in today’s acute care environment. Because of the prominence of cancer today, all nurses need to ensure they have the expertise and confidence to care for oncology patients at varied points along the cancer continuum.

References:

• Angus DC & Truog RD (2016). Toward better ICU use at the end of life. JAMA, 315: 255-256.
• Teno JM, Gozalo PL, Bynum JP et.al. (2013). Change in end of life care for Medicare beneficiaries: Site of death, place of care, and health care transitions in 2000, 2005, and 2009. JAMA, 309: 470-477.
• Boyle DA, Barbour S, Anderson W et.al. (2017). Palliative care communication in the ICU: Implications for an oncology-critical care nursing partnership. Sem Oncol Nurs, 33(5): 544-554.
• Mercadente S, Gregoretti C, Cortegiani A (2018). Palliative care in intensive care units: Why, where, what, who, when, how. BMC Anesthesiology, 18:106.
• Puntillo KA, Arai S, Cohen NH et.al. (2010). Symptoms experienced by intensive care unit patients at high risk of dying. Crit Care Med, 38: 2155-2160.
• Oh YS (2017). Communication with health professionals and psychological distress in family caregivers to cancer patients: A model based on stress-coping theory. Appl Nurs Res, 33: 5-9.
• Milic MM, Puntillo K, Turner K et.al. (2015). Communicating with patients’ families and physicians about prognosis and goals of care. Am J Crit Care, 25: e56-e64.
• Fumis RR, Martins P, Schettino G (2015). The impact of poor prognostic patients admitted to the intensive care unit on family members emotional disorders. J Int Crit Care, 2: 1-6.
• Wright AA, Keating NL, Ayanian JZ et.al. (2016). Family perspectives on aggressive cancer care near the end of life. JAMA, 315: 284-292.
• Anderson WG, Puntillo K, Boyle D, Barbour S, Turner K, Cimino J, Moore E, … Pantilat S. ICU bedside nurses’ involvement in palliative care communication: A multicenter survey. J Pain Sympt Man, 51: 589-596, 2016.
• Boyle D & Anderson WG. Enhancing communication skills of critical care nurses: Focus on prognosis and goals of care decision-making. J Clin Outcomes Manag, 22(12): 543-549, 2015.