Transcript The Changing Practice of Critical Care Incorporating Skills from Palliative Medicine XXXVII ACP Annual Chapter Meeting Panama City, Republic of Panama February 27, 2015 Thomas.

The Changing Practice of Critical Care
Incorporating Skills from Palliative Medicine
XXXVII ACP Annual Chapter Meeting
Panama City, Republic of Panama
February 27, 2015
Thomas J. Prendergast, MD
Clinical Professor of Medicine, OHSU
Senior Scholar, Center for Ethics in Healthcare
Section 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
One day
One week
7%
35%
CHF
42%
62%
COPD
21%
41%
COMA
11%
27%
MOSF & malignancy
5%
26%
All deaths – SUPPORT
Lynn J et al. New Horizons 1997;5(1):56-61
Saving a life
Predicted Mortality
50%
75%
90%
99%
Alive/dead/NNT*
1/ 1 / 2
1/ 3 / 4
1 / 9 / 10
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 prospectively
2. Offering palliation only to the dying is an incomplete 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
Total ICU Admissions
Total ICU Deaths
Death occurring
<24 hours
>24 hours
DHMC
3,953
793 (20%)
222 (28%)
571 (72%)
Project Impact
11,239
3,446 (31%)
7,793 (69%)
Data from April 1, 2001 through June 30, 2005
Status at time of death in <24h group
Full resuscitation
CPR performed at time of death
Full support, no CPR
Withdrawal of LS
Withholding of LS
Brain dead/organ donor
Unknown
DHMC (n=222)
PI (n=3446)
13.1%
12.2%
7.7%
63.1%
6.8%
10.4%
0.0%
23.9%
23.0%
35.5%
30.8%
7.6%
4.9%
0.3%
Data from April 1, 2001 through June 30, 2005
Changing resuscitation status, <24h
Full resuscitation
Full support, no CPR
Withdrawal of LS
Withholding of LS
Brain dead/organ donor
Unknown
DHMC (n=222)
admission / dc
PI (n=3446)
admission / dc
91.9% / 13.1%
5.0% / 7.7%
0.5% / 63.1%
2.3% / 6.8%
0.0% / 10.4%
0.5% / 0.0%
82.4% / 23.9%
12.9% / 35.5%
0.8% / 30.8%
4.6% / 7.6%
0.0% / 4.9%
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 noninvasive 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
Intensive diagnostic evaluation or therapeutic trial
n = 222
66
(30%)
Intensive communications to facilitate decision making 84
(38%)
Intensive supportive care
59
(27%)
13
(6%)
Explicit palliative intent
Physiologic support of potential organ donor
27
32
Difficult communications
Patient/family insistence against clinician advice
Immediate revision of OSH transfer plan
7
6
Prendergast TJ, unpublished data
Advance directives
Patient able to participate in his/her own decision making
9 (4%)
Existing DNR
Followed
Ignored
Ignored (BiPAP)
21 (9%)
AD completed
Available
Not available
AD not completed
No reason to have an AD
Clear indication for AD
Compelling indication for AD
12
7
2
56 (25%)
38 (17%)
18
136 (61%)
60
36
40
Prendergast TJ, unpublished data
Impact of advance directives
Failed resuscitation
Full Rx, no CPR
Withdrawal of LS
Withholding of LS
Brain death
AD available
No AD available
n=56
n=166
6
2
42
4
2
(10.7%)
(3.6%)
(76.8%)
(7.2%)
(3.6%)
28 (16.9%)
4 (2.4%)
103 (62.0%)
3 (1.8%)
28 (16.9%)
Prendergast TJ, unpublished data
Impact of surrogate decision makers
Failed resuscitation
Full Rx, no CPR
Withdrawal of LS
Withholding of LS
Brain death
Family available
No family available
n=196
n=26
13 (6.6%)
6 (3.0%)
144 (73.1%)
7 (3.6%)
26 (13.2%)
21 (80.8%)*
0
2 (7.7%)
0
3 (11.5%)
* P < .0001
Prendergast 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 distribution 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 3070% 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
50
45
40
35
30
25
20
15
10
5
0
LST
Abx
1
2
3
4
5
Johnson SK et al, AJRCCM Epub 2010 Oct 29
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 decision
Elicit patient values
Treatment alternatives
Discuss family’s role
Pro/con of choices
Assess need for others’ input
Address uncertainty
Explore the context
Assess family understanding Elicit family’s opinion
Charles C et al , Soc Sci Med 49:651, 1999
Shared decision making
Nature of the decision
Elicit patient values
Treatment alternatives
Discuss family’s role
Pro/con of choices
Assess need for others’ input
Address uncertainty
Explore the context
Assess family understanding Elicit family’s opinion
Information sharing: 79% of conferences
White DB et al, Arch Intern Med 167:461, 2007
Shared decision making
Nature of the decision
Elicit patient values
Treatment alternatives
Discuss family’s role
Pro/con of choices
Assess need for others’ input
Address uncertainty
Explore the context
Assess family understanding Elicit 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