Intensive Care Unit
Intensive Care Units (ICUs) provide sophisticated, state-of-the-art care to seriously ill patients. Patients are living longer with serious, complex illness, which for many means multiple ICU admissions over the course of their illness. Unfortunately, there are many barriers to providing effective palliative care in this setting. According to a study presented at the 2003 American Thoracic Society International Conference, lead researcher Judith Nelson, M.D., J.D. noted these barriers include: insufficient communication skills about end-of-life issues among health care providers, inability of patients to participate in discussions about their treatment, unrealistic expectations on the part of patients and families about the prognosis of patients or the effectiveness of ICU treatment, and lack of advance directives from patients about how they wish their care to be handled at the end of life.
Palliative care programs excel at integrating vigorous pain and symptom management whether life-prolonging or curative treatment is being provided or is being withheld or withdrawn. Palliative care programs also ease case management burdens on primary physician and staff and provide assistance with care coordination and time-intensive patient-family communication.
The following materials are suggested as a starting point for those who are exploring opportunities to provide palliative care services in the intensive care unit.
Arnold RM, Kellum J. Moral justifications for surrogate decision making in the intensive care unit: implications and limitations. Crit Care Med. 2003, May; 31 (5 Suppl): S347-353.
Baggs JG. End-of-life care for older adults in ICUs. Annu Rev Nurs Res. 2002;20:181-229. Review.
Campbell ML, Guzman JA. Improving the end-of-life experience of MICU patients through a proactive approach to palliative care consultation. Unpublished.
Campbell ML, Guzman JA. Impact of a proactive approach to improve end-of-life care in a medical ICU. Chest, 2003; 123:266-127.
Dickie H, Vedio A, Dundas R. Treacher DF, Leach RM. Relatonship between TISS and ICU cost. Intensive Care Medicine 1998; 24:1009-17.
Dowdy MD, Robertson C, Bander JA. A study of proactive ethics consultation for critically and terminally ill patients with extended lengths of stay. Crit Care Med. 1998;26:252-259.
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.
Mosenthal AC, Lee KF, Huffman J. Palliative care in the surgical intensive care unit. J Am Coll Surg. 2002 Jan;194(1):75-83; discussion 83-5
Nelson JE, Meier DE. Palliative care in the intensive care unit: Part I. Journal of Intensive Care Medicine 1999; 14(3):130-139.
Nelson JE, Danis M. End-of-life care in the intensive care unit: where are we now? Crit Care Med. 2001 Feb;29(2 Suppl):N2-9. Review.
Nelson-Marten P, Braaten J, English NK. Critical caring. Promoting good end-of-life care in the intensive care unit. Crit Care Nurs Clin North Am. 2001 Dec;13(4):577-85.
Rubenfeld JD, Curtis JR. Beyond ethical dilemmas: improving the quality of end-of-life care in the intensive care unit. Crit Care. 2003 Feb;7(1):11-2.
Truog RD, Cist AF, Brackett SE, Burns JP, Curley MA, Danis M, DeVita MA, Rosenbaum SH, Rothenberg DM, Sprung CL, Webb SA, Wlody GS, Hurford WE. Recommendations for end-of-life care in the intensive care unit: The Ethics Committee of the Society of Critical Care Medicine. Crit Care Med. 2001 Dec;29(12):2332-48.
Danis M, Federman D, Fins JJ, et al. Incorporating palliative care into critical care education: principles, challenges, and opportunities. Crit Care Med 1999; 27:2005-13.
Mularski RA, Bascom P, Osborne ML. Educational agendas for interdisciplinary end-of-life curricula. Crit Care Med 2001; 29:N16-23.
Schneiderman , L, Gilmer, T, Teetzel, H, Dugan, D, Blustein, J, Cranford, R, Briggs, K, Komatsu, G, Goodman-Crews, P, Cohn, F, Young, E. Effect of Ethics Consultations on Nonbeneficial Life-Sustaining Treatments in the Intensive Care Setting: A Randomized Controlled Trial JAMA 2003;290:1166-1172.
Promoting Excellence in End-of-Life Care is a national program of The Robert Wood Johnson Foundation (RWJF), providing grants and technical support to innovative programs to change the face of dying in America. http://www.promotingexcellence.org/navigate/intensive_care.html
The Society of Critical Care Medicine (SCCM) is the leading organization dedicated to ensuring excellence and consistency in the practice of critical care. The SCCM recognizes the unique needs of the critically ill patient of any age -- infant to adult -- and strives to secure the highest quality care for all patients facing life-threatening conditions. http://www.sccm.org/index.asp
The Promoting Excellence in End-Of-Life Care Program developed a “Critical Care Workgroup” composed of clinicians and researchers to extend palliative care to challenging domains and special populations of patients. The Critical Care Workgroup has created several resources including a comprehensive bibliography and resource page for critical care end-of-life issues and a list of 7 domains with quality indicators and interventions or behaviors that may improve the quality of end-of-life care in the ICU setting. These documents are downloadable in PDF format. http://www.promotingexcellence.org/content/workgroups.html
The End of Life Care Research Program at the University of Washington ( http://depts.washington.edu/eolcare/index.html ) is committed to the improvement of end-of-life care. One of the goals of the Program is to participate in education by providing the resources for medical students, medical residents, physician-fellows, and nurses to participate in these projects and conduct related research projects. Their web site includes an example of a physician orders form for withdrawal of life support in the ICU as well as instruments for assessing the quality of dying and death and the quality of patient-doctor communication. These documents are downloadable in PDF format.
The Program on the Medical Encounter and Palliative Care at Duke University conducts research and provides educational tools that help to improve the understanding of communication in the medical setting and the quality of care at the end of life. Available on their website is a survey instrument focusing on what patients consider to be important at the end of life and a coding manual for physician communication with patients.
Presentations and Audio Conferences:
Improving the Quality of Palliative Care for Patients in the ICU
J. Randall Curtis, MD, MPH, FCCP, Pulmonary and Critical Care Medicine, University of Washington
- epidemiology of death in the ICU
- communication with patients and families
- practice of withdrawing life support
- system-level interventions
Nursing Care for Patients Dying in the ICU
Kathleen Puntillo, RN, DNSc, FAAN, University of California, San Francisco.
This PowerPoint presentation discusses the nursing contribution to care of dying ICU patients. Three themes include: 1) families' perceptions of nursing care; 2) nurses' perceptions of their roles in DNR process; and 3) nursing actions. http://www.esicm.org/consensus/Puntillo%20slides.ppt
Managing Death in the ICU: Integrating Palliative Care and Critical Care
J. Randall Curtis, MD, MPH, FCCP.
During this CAPC audio conference, Dr. Curtis identifies problems with current end-of-life care and palliative care in the ICU setting; reviews the state of the art for communicating with critically ill patients and their families; examines the principles and practices of withdrawing life support in the ICU setting; reviews the state of the art for integrating palliative care in the ICU setting; and discusses systems level interventions used to improve palliative care in the ICU.
Books and Videos:
Campbell ML. Forgoing Life Sustaining Therapy. How to Care for the Patient who is Near Death. Aliso Viejo: American Association of Critical-Care Nurses Critical Care Publication, 1998.
Curtis JR, Rubenfeld GD, eds. Managing death in the intensive care unit. Oxford: Oxford University Press, 2001.
This book discusses the optimal management of patients dying in the ICU and their families. Topics include the changing attitudes and ethics regarding death in the ICU, the difficult decision to limit life-support therapy, the importance of advance directives, and the application of the principles and practices of palliative care.
The Medical Ethics Committee of the British Medical Association. Withholding and Withdrawing Life-Prolonging Medical Treatment. Guidance for Decision Making. London: BMJ Books, BMA House, 1999:84.
Compassionate Care in the ICU: Creating a Humane Environment
This video developed by the Promoting Excellence Program addresses common barriers to optimal end-of-life care and suggests strategies for improvement for caregivers and patients. Copies are available at no charge from the producer by contacting: David Comora, Davids Productions, Montville, NJ (973) 541-2201.