Andrew Stephen, MD
Background
Less than 50% of American have a “living will” or advanced directive establishing what level of support they want if critically ill or what their long-term post-ICU goals would be. Soon after a critically ill patient is admitted to the ICU a meeting should be held with the patient’s representatives in order to establish goals of care. The need for this meeting is even more urgent if the patient is unstable and a negative outcome is expected. Mortality in the ICU is up to 20-33% in some series affirming the need for these communications to occur early. Consider a palliative care consult early.
What is palliative care?
Palliative care and use of ICU resources to promote survival can seem at odds with each other but the two can be used concurrently to improve outcomes. This can be seen in the definition of palliative care provided by the NEJM in a 2014 review:
“Palliative care is the interdisciplinary specialty focused on improving quality of life for persons with serious illness and their families.”
Palliative care does not preclude ongoing use of lifesaving treatments, technology or operations. Palliative medicine is a formal field among the American Board of Medical Specialties.
Key aspects of palliative care:
- -assessment and treatment of physical symptoms
- -assessment and treatment of psychological symptoms
- -supporting spiritual distress
- -assisting with medical decision making
- -expert communication
- -coordinating care
Improved outcomes shown with palliative care:
- -reduce symptom distress
- -reduced spiritual distress
- -better quality of life
- -reduced cost
- -reduced resource utilization
- -reduced mortality in the ICU
A systematic review of 8 studies in terminally ill ICU patients
A NEJM review of palliative care
What is hospice?
Hospice was first well described in the 1960’s as a concept to care for patients with advanced cancer at the end of life. There are often insurance benefits and federally supported hospice programs for those patients with expected survival less than 6 months. Hospice provides palliative care services to the dying in the last months of life.
What are the longterm outcomes of ICU patients?
In a 2011 prospective longitudinal study 1/3 of patients admitted to the ICU died within 6 months and that the oldest survivors had the poorest results on quality of life questionnaires. A number of other negative outcomes have been described in a growing body of literature:
-Mortality at 1-year following ICU discharge for sepsis is high as is the presence of lasting cognitive impairment
-In comparison to age matched healthy controls, ICU patients that survive to 6 months after discharge have demonstrated worse physical function, general health, social functioning compared to baseline
-Need for renal replacement therapy(RRT) after ICU discharge associated with truly dismal results with near uniform mortality at 3 months in non-surgical patients over the age of 75.
-Patients with ARDS during the ICU stay have been shown to have lasting difficulties with muscle weakness, depression and significant physical limitations, but surprisingly little pulmonary limitations.
A recent multicenter cohort study looks at patient factors and aspects of their ICU course and how they relate to mortality at one year after ICU discharge.
What is chronic critical illness?
Between 5 and 10% of patients who require mechanical ventilation for acute conditions develop chronic critical illness(CCI). Many patients with sepsis develop CCI as well. There are many different definitions of CCI but most involve some combination of the following issues:
- -decreased physical function
- -ongoing cognitive dysfunction
- -emotional disturbances
- -malnutrition
- -skin breakdown
- -dependence on mechanical ventilation
For a thorough review with good references: