Palliative Care

Published on 10/03/2015 by admin

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Last modified 10/03/2015

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Chapter 85 Palliative Care

Ursula McVeigh, MD , Allan Ramsay, MD

1 What are the elements of palliative care that are important in the care of critically ill patients?

Palliative care is support provided by an interdisciplinary team that focuses on relief of suffering in the physical, emotional, and spiritual domains of health. In the intensive care unit (ICU), coincident with aggressive disease-directed therapies, a multidisciplinary team provides this support to patients and families as they face what can be an emotional and tumultuous journey. This care is provided by physicians, nurses, social workers, and chaplains.

Specific elements of palliative care in the ICU:

image Communication skills including running a family meeting, delivering bad news, empathetic communication, eliciting patient preferences, and discussing goals of care

image Decisional support for patients or surrogates

image Prognostication

image Symptom management

image Psychosocial and spiritual support for patients, family, and staff

image Decisions to withhold or withdraw life-supporting therapies based on goals of care

image End-of-life care

2 What are the goals of the ICU family conference?

image Exchange medical information between the patient and family and the medical team

image Engage in complicated medical decision making, frequently with surrogate decision makers

image Provide emotional support to families

3 What are the steps of a family meeting?

image Preparation

image Invite invested participants; plan agenda, time, and space.

image Premeeting

image Discuss among team members to reach consensus on goals of the meeting, medical condition, prognosis, and treatment options.

image Introductions

image Identify family, team members, roles, and goals of the meeting.

image Perceptions

image Ask family members what they hope to have addressed in the meeting.
image Ask what the family members know about the illness and what they expect or hope for.

image Information

image Provide medical information about condition, prognosis, and treatment options.
image Explain aspects of surrogate decision making.

image Exploration

image Elicit questions, concerns, and values, and explore how these influence decisions.

image Recommendation

image Provide medical guidance and recommendations based on stated goals and values and the clinician’s professional knowledge and experience.

image Summary

image Review medical plan, next steps, and follow-up.
image Document.

4 What components of the family meeting are associated with better outcomes?

Research has identified specific elements of family meetings that are associated with increased quality of care, decreased negative psychological symptoms during bereavement, and improved family satisfaction with communication. See Box 85-1.

Box 85-1 Important components of intensive care unit family conference

image Hold family meeting within 72 hours of ICU admission.

image Listen more, speak less.

image A higher proportion of time providers spend listening to families rather than speaking is associated with increased family satisfaction with the meeting.

image Make empathetic statements acknowledging the difficulty of:

image Having an ill loved one
image Surrogate decision making
image Impending loss of loved one

image Make statements of nonabandonment and support for the decisions made.

image Explore patient values and treatment preferences.

image Explain principle of surrogate decision making.

image Reassure that the patient will be comfortable and not suffer.

Modified from Curtis J, White D: Practical guidance for evidence-based ICU family conferences. Chest 134:835–843, 2008.

5 What communication tool has been shown to be beneficial in improving communication in the ICU family meeting?

Incorporating the VALUE mnemonic has been shown to significantly reduce family symptoms of anxiety, posttraumatic stress disorder, and depression measured 3 months after the patient’s death:

image Value what the family says.

image Acknowledge expressed emotions.

image Listen.

image Understand the patient as a person; ask questions that elicit this information.

image Elicit family questions.

6

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