Preliminary report of the integration of a palliative care team into an intensive care unit

Objectives: We conducted a pilot quality improvement (QI) project with the aim of improving accessibility of palliative care to critically ill neurosurgical patients. Methods: The QI project was conducted in the neurosurgical intensive care unit (NS-ICU). Prior to the QI project, referral rates to palliative care were low. The ICU-Palliative Care collaborative comprising of the palliative and intensive care team led the QI project from 2013 to 2015. The interventions included engaging key stake-holders, establishing formal screening and referral criteria, standardizing workflows and having combined meetings with interdisciplinary teams in ICU to discuss patients’ care plans. The Palliative care team would review patients for symptom optimization, attend joint family conferences with the ICU team and support patients and families post-ICU care. We also collected data in the post-QI period from 2016 to 2018 to review the sustainability of the interventions. Results: Interventions from our QI project and the ICU-Palliative Care collaborative resulted in a significant increase in the number of referrals from 9 in 2012 to 44 in 2014 and 47 the year later. The collaboration was beneficial in facilitating transfers out of ICU with more deaths outside ICU on comfort-directed care (96%) than patients not referred (75.7%, p < 0.05). Significantly more patients had a Do-Not-Resuscitation (DNR) order upon transfer out of ICU (89.7%) compared to patients not referred (74.2.%, p < 0.001), and had fewer investigations in the last 48 hours of life (p < 0.001). Per-day ICU cost was decreased for referred patients (p < 0.05). Conclusions: Multi-faceted QI interventions increased referral rates to palliative care. Referred patients had fewer investigations at the end-of-life and per-day ICU costs.

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Palliative medicine in the intensive care unit: needs, delivery, quality

BMJ Supportive & Palliative Care ◽

10.1136/bmjspcare-2020-002795 ◽

2021 ◽

pp. bmjspcare-2020-002795

Author(s):

Stephanie A Hill ◽

Abdul Dawood ◽

Elaine Boland ◽

Hannah E Leahy ◽

Fliss EM Murtagh

Keyword(s):

Palliative Care ◽

Intensive Care ◽

Length Of Stay ◽

Care Delivery ◽

Multiorgan Failure ◽

Symptom Control ◽

Palliative Care Team ◽

Care Team ◽

Specialist Palliative Care ◽

Treatment Limitation

Background15%–20% of critical care patients die during their hospital admission. This service evaluation assesses quality of palliative care in intensive care units (ICUs) compared with national standards.MethodsRetrospective review of records for all patients who died in four ICUs (irrespective of treatment limitation) between 1 June and 31 July 2019. Descriptive statistics reported for patient characteristics, length of stay, admission route, identification triggers and palliative care delivery.ResultsForty-five patients died, two records were untraced, thus N=43. The dying process was recognised in 88% (n=38). Among those where dying was recognised (N=35), 97% (34) had documented family discussion before death, 9% (3) were offered religious/spiritual support, 11% (4) had review of hydration/nutrition and 6% (2) had documented preferred place of death. Prescription of symptom control medications was complete in 71% (25) opioids, 34% (12) haloperidol, 54% (19) midazolam and 43% (15) hyoscine. Combining five triggers—length of stay >10 days prior to ICU admission 7% (3), multiorgan failure ≥3 systems 33% (14), stage IV malignancy 5% (2), post-cardiac arrest 23% (10) and intracerebral haemorrhage requiring mechanical ventilation 12% (5)—identified 60% (26) of patients. Referral to the palliative care team was seen in 14% (5), and 8% (3) had specialist palliative care team review.ConclusionsRecognition of dying was high but occurred close to death. Family discussions were frequent, but religious/spiritual needs, hydration/nutrition and anticipatory medications were less often considered. The ICUs delivered their own palliative care in conjunction with specialist palliative care input. Combining five triggers could increase identification of palliative care needs, but a larger study is needed.

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The Truth, the Whole Truth, and Nothing but the Truth: Therapeutic Privilege

10.21203/rs.3.rs-847469/v1 ◽

2021 ◽

Author(s):

Manar Shalak ◽

Masood Shariff ◽

Varun Doddapanini ◽

Natasha Suleman

Keyword(s):

Intensive Care Unit ◽

Mechanical Ventilation ◽

Palliative Care ◽

Intensive Care ◽

Respiratory Failure ◽

Palliative Care Team ◽

Medical Field ◽

Ethical Implications ◽

Therapeutic Privilege ◽

To Receive

Abstract The term therapeutic privilege is unfamiliar in the medical field and often sparks questions and discomfort about its ethical implications. Therapeutic privilege refers to the act of withholding of information by a clinician, with the underlying notion that the disclosure of this information would inflict harm or suffering upon the patient1. This is a case of a 56-year-old woman who presented to our facility in critical condition: sepsis with acute respiratory failure requiring intubation and mechanical ventilation. Prior to her admission, her husband had been admitted at our facility and was being cared for in the intensive care unit. On the same day that our patient was extubated, her husband had died. The palliative care team was consulted to assist with disclosing this information to the patient in light of her emotional fragility, her anxiety and concerns for her ability to receive such news given her own active illnesses.

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Access to Palliative Care for Critically Ill Cancer Patients in Mexico

Journal of Palliative Care ◽

10.1177/08258597211014365 ◽

2021 ◽

pp. 082585972110143

Author(s):

Silvio A. Ñamendys-Silva ◽

Adán R. López-Zamora ◽

Bertha M. Córdova-Sánchez ◽

Luis A. Sánchez-Hurtado ◽

Francisco J. García-Guillén ◽

...

Keyword(s):

Palliative Care ◽

Risk Factor ◽

Intensive Care ◽

Cancer Patients ◽

Critically Ill ◽

Palliative Care Team ◽

Care Team ◽

Incurable Cancer ◽

Qsofa Score

Objective: To determine the outcomes of hospitalized cancer patients requiring intensive care unit (ICU) intervention and receiving palliative care. Materials and Methods: An observational retrospective study was completed at a single academic critical care unit in Mexico City. All hospitalized cancer patients who were evaluated by the intensive care team to assess need for ICU were included between January and December 2018. Results: During the study period, the ICU group made 408 assessments of critically ill cancer patients in noncritical hospitalized areas. In total, 24.2% (99/408) of the patients in this population were consulted by the palliative care team. Of the patients evaluated, 46.5% (190/408) had advanced stage, but only 28.4% were receiving care by the palliative care team. The only risk factor for hospital mortality in the multivariate analysis was the quick Sequential Organ Failure Assessment (qSOFA) score at the time of the consultation by the ICU group (HR = 2.10, 95% CI = 1.34-3.29, p = 0.001). The median time between palliative care consultation and death was 3 days (IQR = 2-22). A total of 63% (37/58) of patients who were discharged from the hospital died during follow-up. The median follow-up time was 55 days (95% CI = 26.9-83.0). The overall mortality rate for the entire group during hospitalization and after hospital discharge was 80.8% (80/99). Conclusion: Fewer than 3 out of 10 hospitalized cancer patients requiring admission to the ICU were evaluated by the palliative care team despite having incurable cancer. The qSOFA score of patients at the time of the ICU consultation was the only risk factor for mortality during hospitalization. Future research efforts in Mexico should focus on earlier integration of palliation care with usual oncology care in incurable cancer patients.

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