Palliative Care

OVERVIEW

  • “Palliative care is an approach that improves the quality of life of patients and their families facing the problem associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual.” (WHO Definition)
  • Palliative care is distinct from curative care, which is primarily disease-specific and focused on restoration of health
  • Palliative care is not synonymous with end of life care, but is an important part of end of life care
  • As 10-20% of ICU patients will die, the transition from cure to comfort is a common and important decision to make

Summary of key principles of palliative care in the ICU

  • good communication
  • don’t hasten death but allow it to take place
  • drug therapy
  • adhere to ethical principles

GENERAL PRINCIPLES

Good communication

  • patient/family centred
  • complete and open discussion
  • open disclosure
  • provide sufficient information
  • sensitive but clear language
  • listen
  • value their input
  • support their emotions
  • support the family’s decision making process
  • respect

Conflict resolution

  • conflict usually prevented by good communication
  • occasionally will require other ICU clinician input
  • allow time

Autonomy

  • patient’s right to choose or refuse therapies
  • in critical care the family’s understanding of patients wishes are used as a surrogate

Beneficence

  • obligation to act in patient best interests

Non-maleficence

  • obligation to do no harm
  • this includes refraining from interventions which are more likely to harm than benefit

Justice

  • fair allocation of societal resources

SPECIFICS

  • cover what is involved in the transition to palliative care
  • plans regarding interventions (analgesics, removal of lines/ETT, not for futile procedures/therapies (ie CPR))
  • extubation: stop fluids 6 hours prior to extubation, dexamethasone, buscopan, suction
  • explain: difference between withdrawing active treatment and transition to palliative care
  • explain: difference between allowing to die vs actions of hastening death
  • have an explicit plan
  • discontinue monitoring
  • provide a quite room
  • reassure that clinical care will be maintained
  • offer bereavement and support services
  • make sure you are treating the symptoms of the patient rather than the concerns of the family/nursing staff

DRUG THERAPY

  • SC and IV doses are the same
  • death does not required an infusion of medication
  • need to make the distinction between the conscious and unconscious patient
  • if patient on chronic benzodiazepines or opioids then we need to continue them (also try to prevent withdrawal of they have been on sedation for a prolonged period of time in ICU ie. > 3 weeks)

Conscious

  • can be very specific with PRN medication for symptom control
  • assess usage over 12 or 24 hours and then increase infusion as required

Unconscious

  • often not in pain thus don’t require analgesia
  • look for facial grimacing, moaning not associated with breathing or localizing signs
  • noisy breathing and secretions are common and aren’t distressing to patients (may require explanation to families)
  • if unconscious because of sedation but patient is having active withdrawal -> we often will have to negotiate with family the continuation of sedation so patient doesn’t become distressed
  • gentle suction generally OK
  • no real place for nasopharyngeal or Guedel airways

Drug Therapy for Symptoms

Pain and SOB

  • opioids
  • morphine 2.5mg Q1hrly
  • fentanyl 12.5-25mcg Q30min (in renal impairment to avoid delirium, myoclonus and neuroexcitation with morphine)

Secretions

  • muscarinic anticholinergic
  • buscopan 20mg Q2 hrly (max 120mcg/24 hrs) – doesn’t cross the BBB

Anxiety/Distress

  • benzodiazepines
  • midazolam 1-2.5mg Q30 min
  • may develop tolerance quickly

N+V and Delirium

  • D2 antagonists
  • haloperidol 0.5mg Q1 hrly (max 5mg)
  • levomepromazine 6.25mg Q4hrly (max 25mg) – increased sedating effects

PEACE Tool

  • Physical symptom control (pain, nausea, SOB, delirium)
  • Emotive and cognitive symptoms (anxiety)
  • Autonomy (sense of control and participation in decision making)
  • Closure of life affairs (spent time with family and others)
  • Economic issues (assistance, arrangements, insurance) and Existential issues (religious, spiritual)

CONSIDER STAFF

  • some deaths can be particularly difficult for staff:
    • paediatrics
    • staff member
    • death from an error in medical management
  • important to recognize and support staff:
    • debriefing
    • professional counselling
    • teaching
    • morbidity and mortality meetings
    • discuss with senior staff

PATTERNS OF DECLINE AT THE END OF LIFE

  • Many patients die from acute complications of an otherwise chronic condition, most likely without a discrete terminal illness phase
  • Classically described trajectories of dying include:
    • abrupt, surprise deaths
    • short-term expected deaths (terminal illness)
    • lingering expected deaths (frailty)
    • entry-reentry deaths (individuals slowly decline but return home between stays in the hospital)
  • Good end-of-life care takes into account the unpredictable timing of most deaths (e.g. the frail patient)

References and Links

Journal articles and Textbooks

  • Lukin W, Douglas C, O’Connor A. Palliative care in the emergency department: an oxymoron or just good medicine? Emerg Med Australas. 2012 Feb;24(1):102-4. PMID: 22313567. [article]
  • Lunney JR, Lynn J, Foley DJ, Lipson S, Guralnik JM. Patterns of functional decline at the end of life. JAMA. 2003 May 14;289(18):2387-92. PMID: 12746362. [article]
  • Myatra SN, Salins N, Iyer S, et al. End-of-life care policy: An integrated care plan for the dying: A Joint Position Statement of the Indian Society of Critical Care Medicine (ISCCM) and the Indian Association of Palliative Care (IAPC). Indian J Crit Care Med. 2014;18(9):615-35. PMID: 25249748 [article]

FOAM and Web Resources


CCC 700 6

Critical Care

Compendium

Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also the Innovation Lead for the Australian Centre for Health Innovation at Alfred Health and Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.

After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.

He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE.  He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.

His one great achievement is being the father of two amazing children.

On Twitter, he is @precordialthump.

| INTENSIVE | RAGE | Resuscitology | SMACC

Leave a Reply

This site uses Akismet to reduce spam. Learn how your comment data is processed.