CHAPTER 104 PALLIATIVE CARE IN THE TRAUMA INTENSIVE CARE UNIT
Despite many recent advances in trauma resuscitation and surgery, surgeons continue to care for critically injured patients who will succumb to their injuries. The mortality rate for trauma patients who require admission to the intensive care unit (ICU) remains at 10%–20%, and an additional percentage of those who survive will be significantly disabled or functionally impaired. Appropriate and compassionate care for the dying trauma patient as well as management of pain and symptoms in all critically ill patients are now part of good-quality trauma care. Aggressive pain management or comfort measures causing physiologic hemodynamic derangements or masking symptoms in the critically injured are no longer of great concern. Newer information and selection of appropriate medications now make clear that attention to pain management and comfort can be successfully provided during ongoing resuscitation without ill effects. The skills of the trauma surgeon encompass basic palliative care principles as they apply to the critically ill trauma patient; facility with an interdisciplinary team approach, communication of bad news, pain and symptom management, and withholding and withdrawal of life support.
WHEN TO START PALLIATIVE CARE IN ICU
While mortality from injury is correlated with Injury Severity Score and increasing age, prognosis on admission to the ICU is not always clear for every patient. The majority of trauma deaths in the ICU occur in the first 48 hours secondary to traumatic brain injury or traumatic hemorrhage, while another significant proportion (20%–30%) will linger in the ICU only to die weeks later from sepsis and multiple organ failure. In the first group, catastrophic injuries have a rapid trajectory toward death, usually with prognostic certainty; here palliative care should be started early in the ICU course, shortly after admission. In this context, bereavement support and communication with the family while attending to patient care are crucial. This early support sets the stage for later decision making, minimizes conflict and has a salutary effect on family grief, bereavement, and even organ donation rates. For patients who have a protracted course and uncertain prognosis, waiting for death to be imminent before instituting palliative care means that many patients will receive end-of-life care late, have untreated suffering and symptoms, or remain on life support long after it is futile. Thus, palliative care in some form should start early in this group as well, regardless of ultimate outcome.
All trauma patients are admitted to the ICU with the hope and expectation for life-saving care, not only on the part of their families, but physicians and nurses as well. The transition in goals of care to palliative can seem daunting in the face of these hopes. This transition is best initiated on admission with a simple palliative care assessment for likely prognosis, even if the possible outcomes are uncertain. Assessment should include not just survival and mortality risk, but expected long-term quality of life and function. If a poor outcome is possible or expected, an interdisciplinary assessment should follow of pain and symptoms, family psychosocial needs, proxy decision makers, presence of advance directives or patient preferences regarding care, and spiritual issues (Table 1).
Table 1 Palliative Care Assessment on Admission to Trauma ICU
| Pain and symptom assessment |
| 1. Pain score_____ 2. Anxietyv_____ 3. Agitation score_____ 4. Dyspnea_____ |
| Outcome and prognosis assessment |
WHAT IS PALLIATIVE CARE IN THE ICU?
These four components of palliative care are essential for good quality care for trauma patients in the ICU. Evidence suggests that implementation of these components in a pathway or bundle improves many aspects of care. Integration of these four areas of assessment and management into standard critical care in a timed sequence ensures their application when appropriate. Assessment of patient, family, and prognosis is the first step, followed by appropriate family support, communication, and family meetings. From these steps, goals of care should be developed. This should be completed within 72 hours of admission (Table 2).
Table 2 Integrated Care Pathway: Essential Steps in Trauma ICU
| First 24 Hours | First 72 Hours | End-of-Life Care for Dying |
|---|---|---|
| Palliative care assessment: |
