Palliative care in intensive care units: why, where, what, who, when, how

Sebastiano Mercadante, Cesare Gregoretti, Andrea Cortegiani, Sebastiano Mercadante, Cesare Gregoretti, Andrea Cortegiani

Abstract

Palliative care is patient and family-centered care that optimizes quality of life by anticipating, preventing, and treating suffering when "curative" therapies are futile. In the Intensive Care Unit (ICU), critically ill patients receive life-sustaining therapies with the goal of restoring or maintaining organ function. Palliative Care in the ICU is a widely discussed topic and it is increasingly applied in clinics. It encompasses symptoms control and end-of-life management, communication with relatives and setting goals of care ensuring dignity in death and decision-making power. However, effective application of Palliative Care in ICU presupposes specific knowledge and training which anesthesiologists and critical care physicians may lack. Moreover, logistic issues such protocols for patients' selection, application models and triggers for consultation of external experts are still matter of debate.The aim of this review is to provide the anesthesiologists and intensivists an overview of the aims, current evidence and practical advices about the application of palliative care in ICU.

Keywords: End-of-life care; ICU; Intensive care unit; Palliative care; Patient-centered care.

Conflict of interest statement

Ethics approval and consent to participate

Not applicable.

Consent for publication

Not applicable.

Competing interests

Dr. Sebastiano Mercadante is the Head of the Palliative Care and Cancer Pain Study Group of the Italian Society of Anesthesiology, Analgesia, Reanimation and Intensive Care (SIAARTI – Società Italiana di Anestesia, Analgesia, Rianimazione e Terapia Intensiva). Dr. Cesare Gregoretti declared to have no conflict of interest. Dr. Andrea Cortegiani is an Associate Editor for BMC Anesthesiology.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

References

    1. Angus DC, Truog RD. Toward better ICU use at the end of life. JAMA. 2016;315:255–256. doi: 10.1001/jama.2015.18681.
    1. Angus DC, Barnato AE, Linde-Zwirble WT, Weissfeld LA, Watson RS, Rickert T, Rubenfeld GD. Use of intensive care at the end of life in the United States: an epidemiologic study. Crit Care Med. 2004;32:638–643. doi: 10.1097/01.CCM.0000114816.62331.08.
    1. Vincent J-L, Marshall JC, Namendys-Silva SA, François B, Martin-Loeches I, Lipman J, Reinhart K, Antonelli M, Pickkers P, Njimi H, Jimenez E, Sakr Y. Assessment of the worldwide burden of critical illness: the intensive care over nations (ICON) audit. Lancet Respir Med. 2014;2:380–386. doi: 10.1016/S2213-2600(14)70061-X.
    1. Teno JM, Gozalo PL, Bynum JPW, Leland NE, Miller SC, Morden NE, Scupp T, Goodman DC, Mor V. 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. 2013;309:470–477. doi: 10.1001/jama.2012.207624.
    1. Ho A, Tsai DF-C. Making good death more accessible: end-of-life care in the intensive care unit. Intensive Care Med. 2016;42:1258–1260. doi: 10.1007/s00134-016-4396-2.
    1. Cook D, Rocker G. Dying with dignity in the intensive care unit. N Engl J Med. 2014;370:2506–2514. doi: 10.1056/NEJMra1208795.
    1. Myburgh J, Abillama F, Chiumello D, Dobb G, Jacobe S, Kleinpell R, Koh Y, Martin C, Michalsen A, Pelosi P, Torra LB, Vincent J-L, Yeager S, Zimmerman J. End-of-life care in the intensive care unit: report from the task force of world Federation of Societies of intensive and critical care medicine. J Crit Care. 2016;34:125–130. doi: 10.1016/j.jcrc.2016.04.017.
    1. Edwards JD, Voigt LP, Nelson JE. Ten key points about ICU palliative care. Intensive Care Med. 2017;43:83–85. doi: 10.1007/s00134-016-4481-6.
    1. Aslakson RA, Reinke LF, Cox C, Kross EK, Benzo RP, Curtis JR. Developing a research agenda for integrating palliative care into critical care and pulmonary practice to improve patient and family outcomes. J Palliat Med. 2017;20:329–343. doi: 10.1089/jpm.2016.0567.
    1. Downar J, Delaney JW, Hawryluck L, Kenny L. Guidelines for the withdrawal of life-sustaining measures. Intensive Care Med. 2016;42:1003–1017. doi: 10.1007/s00134-016-4330-7.
    1. Truog RD, Campbell ML, Curtis JR, Haas CE, Luce JM, Rubenfeld GD, Rushton CH, Kaufman DC. Recommendations for end-of-life care in the intensive care unit: a consensus statement by the American college [corrected] of critical care medicine. Crit Care Med. 2008;36:953–963. doi: 10.1097/CCM.0B013E3181659096.
    1. Mercadante S, Giarratano A. The anesthesiologist and end-of-life care. Curr Opin Anaesthesiol. 2012;25:371–375. doi: 10.1097/ACO.0b013e3283530e7d.
    1. Mercadante S, Giarratano A, Cortegiani A, Gregoretti C. Application of palliative ventilation: potential and clinical evidence in palliative care. Support Care Cancer. 2017;25:2035–2039. doi: 10.1007/s00520-017-3710-z.
    1. Choi J, Hoffman LA, Schulz R, Tate JA, Donahoe MP, Ren D, Given BA, Sherwood PR. Self-reported physical symptoms in intensive care unit (ICU) survivors: pilot exploration over four months post-ICU discharge. J Pain Symptom Manag. 2014;47:257–270. doi: 10.1016/j.jpainsymman.2013.03.019.
    1. Puntillo KA, Arai S, Cohen NH, Gropper MA, Neuhaus J, Paul SM, Miaskowski C. Symptoms experienced by intensive care unit patients at high risk of dying. Crit Care Med. 2010;38:2155–2160. doi: 10.1097/CCM.0b013e3181f267ee.
    1. Puntillo K, Nelson JE, Weissman D, Curtis R, Weiss S, Frontera J, Gabriel M, Hays R, Lustbader D, Mosenthal A, Mulkerin C, Ray D, Bassett R, Boss R, Brasel K, Campbell M. Palliative care in the ICU: relief of pain, dyspnea, and thirst--a report from the IPAL-ICU advisory board. Intensive Care Med. 2014;40:235–248. doi: 10.1007/s00134-013-3153-z.
    1. Mercadante S, Aielli F, Adile C, Valle A, Fusco F, Ferrera P, Caruselli A, Cartoni C, Marchetti P, Bellavia G, Cortegiani A, Masedu F, Valenti M, Porzio G. Epidemiology and characteristics of episodic breathlessness in advanced Cancer patients: an observational study. J Pain Symptom Manag. 2016;51:17–24. doi: 10.1016/j.jpainsymman.2015.07.020.
    1. Mercadante S, Aielli F, Adile C, Ferrera P, Valle A, Cartoni C, Pizzuto M, Caruselli A, Parsi R, Cortegiani A, Masedu F, Valenti M, Ficorella C, Porzio G. Sleep disturbances in patients with advanced Cancer in different palliative care settings. J Pain Symptom Manag. 2015;50:786–792. doi: 10.1016/j.jpainsymman.2015.06.018.
    1. Desai SV, Law TJ, Needham DM. Long-term complications of critical care. Crit Care Med. 2011;39:371–379. doi: 10.1097/CCM.0b013e3181fd66e5.
    1. Saczynski JS, Marcantonio ER, Quach L, Fong TG, Gross A, Inouye SK, Jones RN. Cognitive trajectories after postoperative delirium. N Engl J Med. 2012;367:30–39. doi: 10.1056/NEJMoa1112923.
    1. Pandharipande PP, Girard TD, Jackson JC, Morandi A, Thompson JL, Pun BT, Brummel NE, Hughes CG, Vasilevskis EE, Shintani AK, Moons KG, Geevarghese SK, Canonico A, Hopkins RO, Bernard GR, Dittus RS, Ely EW. Long-term cognitive impairment after critical illness. N Engl J Med. 2013;369:1306–1316. doi: 10.1056/NEJMoa1301372.
    1. Treece PD, Engelberg RA, Crowley L, Chan JD, Rubenfeld GD, Steinberg KP, Curtis JR. Evaluation of a standardized order form for the withdrawal of life support in the intensive care unit. Crit Care Med. 2004;32:1141–1148. doi: 10.1097/01.CCM.0000125509.34805.0C.
    1. Davidson JE, Aslakson RA, Long AC, Puntillo KA, Kross EK, Hart J, Cox CE, Wunsch H, Wickline MA, Nunnally ME, Netzer G, Kentish-Barnes N, Sprung CL, Hartog CS, Coombs M, Gerritsen RT, Hopkins RO, Franck LS, Skrobik Y, Kon AA, Scruth EA, Harvey MA, Lewis-Newby M, White DB, Swoboda SM, Cooke CR, Levy MM, Azoulay E, Curtis JR. Guidelines for family-centered Care in the Neonatal, pediatric, and adult ICU. Crit Care Med. 2017;45:103–128. doi: 10.1097/CCM.0000000000002169.
    1. Davidson JE, Jones C, Bienvenu OJ. Family response to critical illness: postintensive care syndrome-family. Crit Care Med. 2012;40:618–624. doi: 10.1097/CCM.0b013e318236ebf9.
    1. Schmidt M, Azoulay E. Having a loved one in the ICU: the forgotten family. Curr Opin Crit Care. 2012;18:540–547. doi: 10.1097/MCC.0b013e328357f141.
    1. Choi J, Tate JA, Hoffman LA, Schulz R, Ren D, Donahoe MP, Given BA, Sherwood PR. Fatigue in family caregivers of adult intensive care unit survivors. J Pain Symptom Manag. 2014;48:353–363. doi: 10.1016/j.jpainsymman.2013.09.018.
    1. Byock I. Improving palliative care in intensive care units: identifying strategies and interventions that work. Crit Care Med. 2006;34:S302–S305. doi: 10.1097/01.CCM.0000237347.94229.23.
    1. McAdam JL, Dracup KA, White DB, Fontaine DK, Puntillo KA. Symptom experiences of family members of intensive care unit patients at high risk for dying. Crit Care Med. 2010;38:1078–1085. doi: 10.1097/CCM.0b013e3181cf6d94.
    1. Mularski RA, Heine CE, Osborne ML, Ganzini L, Curtis JR. Quality of dying in the ICU: ratings by family members. Chest. 2005;128:280–287. doi: 10.1016/S0012-3692(15)37958-7.
    1. Hua MS, Li G, Blinderman CD, Wunsch H. Estimates of the need for palliative care consultation across United States intensive care units using a trigger-based model. Am J Respir Crit Care Med. 2014;189:428–436. doi: 10.1164/rccm.201307-1229OC.
    1. Braus N, Campbell TC, Kwekkeboom KL, Ferguson S, Harvey C, Krupp AE, Lohmeier T, Repplinger MD, Westergaard RP, Jacobs EA, Roberts KF, Ehlenbach WJ. Prospective study of a proactive palliative care rounding intervention in a medical ICU. Intensive Care Med. 2016;42:54–62. doi: 10.1007/s00134-015-4098-1.
    1. Hinkle LJ, Bosslet GT, Torke AM. Factors associated with family satisfaction with end-of-life care in the ICU: a systematic review. Chest. 2015;147:82–93. doi: 10.1378/chest.14-1098.
    1. Unger KM. Withdrawal of Ventilatory support at home on hospice. J Pain Symptom Manag. 2016;52:305–312. doi: 10.1016/j.jpainsymman.2016.03.004.
    1. Nelson JE, Bassett R, Boss RD, Brasel KJ, Campbell ML, Cortez TB, Curtis JR, Lustbader DR, Mulkerin C, Puntillo KA, Ray DE, Weissman DE. Models for structuring a clinical initiative to enhance palliative care in the intensive care unit: a report from the IPAL-ICU project (improving palliative care in the ICU) Crit Care Med. 2010;38:1765–1772. doi: 10.1097/CCM.0b013e3181e8ad23.
    1. Quill TE, Abernethy AP. Generalist plus specialist palliative care--creating a more sustainable model. N Engl J Med. 2013;368:1173–1175. doi: 10.1056/NEJMp1215620.
    1. Nelson JE, Curtis JR, Mulkerin C, Campbell M, Lustbader DR, Mosenthal AC, Puntillo K, Ray DE, Bassett R, Boss RD, Brasel KJ, Frontera JA, Hays RM, Weissman DE. Choosing and using screening criteria for palliative care consultation in the ICU: a report from the improving palliative care in the ICU (IPAL-ICU) advisory board. Crit Care Med. 2013;41:2318–2327. doi: 10.1097/CCM.0b013e31828cf12c.
    1. Wysham NG, Hochman MJ, Wolf SP, Cox CE, Kamal AH. Performance of consultative palliative care model in achieving quality metrics in the ICU. J Pain Symptom Manag. 2016;52:873–877. doi: 10.1016/j.jpainsymman.2016.05.026.
    1. Saunders C. The evolution of palliative care. J R Soc Med. 2001;94:430–432. doi: 10.1177/014107680109400904.
    1. WHO Definition of Palliative Care. . Accessed 25 May 2018.
    1. Azoulay E, Chaize M, Kentish-Barnes N. Involvement of ICU families in decisions: fine-tuning the partnership. Ann Intensive Care. 2014;4:37. doi: 10.1186/s13613-014-0037-5.
    1. Lilly CM, De Meo DL, Sonna LA, Haley KJ, Massaro AF, Wallace RF, Cody S. An intensive communication intervention for the critically ill. Am J Med. 2000;109:469–475. doi: 10.1016/S0002-9343(00)00524-6.
    1. Lobo SM, De Simoni FHB, Jakob SM, Estella A, Vadi S, Bluethgen A, Martin-Loeches I, Sakr Y, Vincent J-L. Decision-making on withholding or withdrawing life support in the ICU: a worldwide perspective. Chest. 2017;152:321–329. doi: 10.1016/j.chest.2017.04.176.
    1. Mark NM, Rayner SG, Lee NJ, Curtis JR. Global variability in withholding and withdrawal of life-sustaining treatment in the intensive care unit: a systematic review. Intensive Care Med. 2015;41:1572–1585. doi: 10.1007/s00134-015-3810-5.
    1. Connolly C, Miskolci O, Phelan D, Buggy DJ. End-of-life in the ICU: moving from “withdrawal of care” to a palliative care, patient-centred approach. Br J Anaesth. 2016;117:143–145. doi: 10.1093/bja/aew109.
    1. Thellier D, Delannoy PY, Robineau O, Meybeck A, Boussekey N, Chiche A, Leroy O, Georges H. Comparison of terminal extubation and terminal weaning as mechanical ventilation withdrawal in ICU patients. Minerva Anestesiol. 2017;83:375–382.
    1. Gregoretti C, Pisani L, Cortegiani A, Ranieri VM. Noninvasive ventilation in critically ill patients. Crit Care Clin. 2015;31:435–457. doi: 10.1016/j.ccc.2015.03.002.
    1. Mazer MA, Alligood CM, Wu Q. The infusion of opioids during terminal withdrawal of mechanical ventilation in the medical intensive care unit. J Pain Symptom Manag. 2011;42:44–51. doi: 10.1016/j.jpainsymman.2010.10.256.
    1. Epker JL, Bakker J, Lingsma HF, Kompanje EJO. An observational study on a protocol for withdrawal of life-sustaining measures on two non-academic intensive care units in the Netherlands: few signs of distress, no suffering? J Pain Symptom Manag. 2015;50:676–684. doi: 10.1016/j.jpainsymman.2015.05.017.
    1. Kompanje EJO, van der Hoven B, Bakker J. Anticipation of distress after discontinuation of mechanical ventilation in the ICU at the end of life. Intensive Care Med. 2008;34:1593–1599. doi: 10.1007/s00134-008-1172-y.
    1. O'Mahony S, McHenry J, Blank AE, Snow D, Eti Karakas S, Santoro G, Selwyn P, Kvetan V. Preliminary report of the integration of a palliative care team into an intensive care unit. Palliat Med. 2010;24:154–165. doi: 10.1177/0269216309346540.
    1. Aslakson R, Cheng J, Vollenweider D, Galusca D, Smith TJ, Pronovost PJ. Evidence-based palliative care in the intensive care unit: a systematic review of interventions. J Palliat Med. 2014;17:219–235. doi: 10.1089/jpm.2013.0409.
    1. Aslakson RA, Curtis JR, Nelson JE. The changing role of palliative care in the ICU. Crit Care Med. 2014;42:2418–2428. doi: 10.1097/CCM.0000000000000573.
    1. Hsu-Kim C, Friedman T, Gracely E, Gasperino J. Integrating palliative care into critical care: a quality improvement study. J Intensive Care Med. 2015;30:358–364. doi: 10.1177/0885066614523923.
    1. Sihra L, Harris M, O'Reardon C. Using the improving palliative care in the intensive care unit (IPAL-ICU) project to promote palliative care consultation. J Pain Symptom Manag. 2011;42:672–675. doi: 10.1016/j.jpainsymman.2011.08.002.
    1. Villarreal D, Restrepo MI, Healy J, Howard B, Tidwell J, Ross J, Hartronft S, Jawad M, Sanchez-Reilly S, Reed K, Espinoza SE. A model for increasing palliative care in the intensive care unit: enhancing interprofessional consultation rates and communication. J Pain Symptom Manag. 2011;42:676–679. doi: 10.1016/j.jpainsymman.2011.07.004.
    1. Cortegiani A, Russotto V, Raineri SM, Gregoretti C, Giarratano A, Mercadante S. Attitudes towards end-of-life issues in intensive care unit among Italian anesthesiologists: a nation-wide survey. Support Care Cancer. 2017;26:1773–1780. doi: 10.1007/s00520-017-4014-z.
    1. Lanken PN, Terry PB, Delisser HM, Fahy BF, Hansen-Flaschen J, Heffner JE, Levy M, Mularski RA, Osborne ML, Prendergast TJ, Rocker G, Sibbald WJ, Wilfond B, Yankaskas JR. An official American Thoracic Society clinical policy statement: palliative care for patients with respiratory diseases and critical illnesses. Am J Respir Crit Care Med. 2008;177:912–927. doi: 10.1164/rccm.200605-587ST.

Source: PubMed

Sponsors and Collaborators

Medical Conditions

Drug Interventions

3
Subscribe