Transcript End of Life Care

End of Life Care in the ICU
Goals in Critical Care and
Medicine
• Save the lives of salvageable patients,
restore health, relieve suffering and
offer the dying a peaceful and
dignified death.
• Patients should expect excellence in
all treatments, humanity and
compassion, respect for autonomy.
End-of-life in the ICU
Use of intensive care at the end of life in the U.S. RWJ
ICU End-of-Life Peer Group. Crit Care Med 2004
– Projection: 540,000 people die after receiving ICU care each
year. Of hospital deaths, half associated with ICU
– 1 in 5 Americans die in/after ICU hospitalization
• Deaths in ICU: majority of deaths expected
– >70% are preceded by withholding or withdrawing of life
support
– Intensivists actively manage deaths in ICU
• Institute of Medicine – national priority
• Society of Critical Care Medicine supports palliative
model
Palliative Care
• Patient and family-centered
• Alleviate suffering caused by illness - control
symptoms
• Communicate effectively about appropriate goals
of treatment
• Promote concordance of treatment with patient
preferences
• Promote quality of life
– Quality of life as the outcome rather than
morbidity/mortality
– Does not hasten or prolong death, affirms life
Quality of ICU Dying Experience
Fixed patient characteristics:
Clinical status, demographics
Modifiable dimensions:
Symptoms (pain), social/family support, spiritual,
moment of death/autonomy
Care system interventions:
Aggressiveness, palliative, communication,
social – dignity/respect
Mularski. Crit Care Med 2006
What are appropriate measures for
quality in EOL Care?
• Outcome:
– Utilization of ICU
• SUPPORT Study
– ICU length of stay
– Mortality
• Holloway, Quill. JAMA 2007
– Scoring, symptoms
• Quality of Death and Dying: Crit Care Med 2004, Chest 2005
– Family satisfaction
• JAMA 2004
• Process quality indicators:
– Decision-making, communication
– Symptom management
End-of-life care for the critically ill:
a national intensive care unit survey
Nelson et al. Crit Care Med 2006
Survey of 428 ICUs, 590 ICU directors
Greatest Barriers to EOL Care
• Unrealistic patient/family expectation
• Lack of advance directives
• Insufficient physician training in communication
• Competing demands on physicians’ time
• Suboptimal space for family meeting
• Unrealistic MD expectations
• Lack of palliative care service
End-of-life care for the critically ill:
a national intensive care unit survey
Crit Care Med 2006
Strategies to improve EOL care
• Role modeling by experienced clinicians
• Training in communication
• Training in symptom management
• Regular family meetings
• Bereavement programs
• End-of-life care quality monitoring
• Access to palliative care, ethics consultants
• Regular pastoral care visits
Clinical practice guidelines for support of the family in
the patient-centered ICU: American College of Critical
Care Medicine Task Force
Crit Care Med 2007
• Families support shared decision-making
• Recommend:
– Shared decision-making
– ICU team informs about status and prognosis
– ICU team strive to understand wishes about lifesustaining therapies
– Family meetings
– Training in communication
Decision making depends on
communication
• Goal is to use patient preferences in order to
establish goals of care
• The physician must provide information
about the illness, treatments, and prognosis
• Decisions depend on the patient’s values
attached to life-prolongation, functioning,
and comfort
Communication with Family
• Communication with family: informal, family
meetings
• Provide information, understanding patient
preferences, setting goals
• Families: information, understanding
– Crit Care Med 2000. over 50% of 102 ICU families
failed to identify 1 failing organ, any treatment or
prognosis
– Chest 2006. 440 hospitalized patients, 160 caregivers.
Poor knowledge of CPR – treatments and outcome
Communication - Family conferences
• Study of family conferences, Seattle, 2000-2002,
Curtis et al
– 51/111 eligible conferences- audiotaped, family
questionnaire
– Mainly white patient/family and physicians, Englishspeaking
– 80% of patients died, WH/WDLS discussed in 86% of
conferences
• Family satisfaction with family conferences about
end-of-life care in the ICU. Crit Care Med 2004
– Conference time 32 minutes, clinicians 70% of time
talking. Increased proportion of family speech was
associated with increased satisfaction
Communication - Family conferences
• Missed opportunities during family conferences about
end-of-life care in the ICU. Am J Respir Crit Care Med
2005
– 29% missed: listening/respond to question, inform about illness,
ethics/palliative care, preferences, surrogate decision-making,
nonabandonment, compassion
• Clinician statements and family satisfaction with
family conferences in the ICU. Crit Care Med 2006
• Increased family satisfaction - 3 types of clinician statements:
– Assurances that patient will not be abandoned before death
– Assurances that patient will be comfortable and will not suffer
– Support for the family’s decision about EOL, including withdrawing or
not withdrawing life support
Prognostication during physician-family
discussions about limiting life support in
ICUs. Crit Care Med 2007
• Understanding Cardiopulmonary
Resuscitation Decision Making. Chest 2006
– Questionnaire to 440 patients with end-stage
cancer and advanced diseases
– Poor knowledge of CPR treatments (11% could
identify 2 treatments) and outcome (2% thought
success < 10%)
– Many did not want to discuss preferences with
doctor
– Variable preferences for role in decision making.
Most preferred including family member
Advance Directives
• Health care proxy, living will
• Permit patients to make informed decisions about
their health care
• Promote patient autonomy: patients have the right
to make decisions and this right is protected when
conscious capacity is lost.
• The Patient Self-Determination Act of 1991
requires hospitals to ask patients whether they
have an advance directive
• Patient with capacity to make health care decisions
has the authority to decline life-sustaining
treatment or ask that such treatment be withdrawn
• Surrogate decision maker: patient’s representative
to make decisions when the patient is incapable of
making health care decisions
• Substituted judgment: learn what the patient
would have wanted if he or she had been able to
understand and participate in the decisions
Do Not Resuscitate Order
• A “Do Not Resuscitate (DNR)” order is
one advance directive that concerns
interventions in the setting of a
cardiopulmonary arrest
• A DNR order means that if the patient
suffers a cardiopulmonary arrest, the
interventions of intubation, CPR and ACLS
will be withheld
Decision to Withdraw Life Support
• Patient’s expressed wishes
• Health care proxy or living will
• Oral advance directive – requires Ethics
Consultation
Withholding and Withdrawing LifeSustaining Treatments
• Based on the individual patient’s goals of therapy,
withholding an intervention may be appropriate
• As well, a trial of therapy with clear goals may be
undertaken. If the goals are not achieved,
withdrawing an intervention is acceptable
• The motivation must be respect for patient
preferences and avoiding burdensome
interventions
Withdrawal of Life Support
• Majority of physicians withdraw/withhold
life support Am J Respir Crit Care Med 1995
• Life-sustaining treatments: ventilation,
vasopressors, dialysis, blood products,
nutrition, hydration
• >70% of ICU deaths are preceded by
decision to WH/WD
– Am J Respir Crit Care Med 1998
Withdrawal of Mechanical Ventilation in
Anticipation of Death in the ICU
Cook et al. N Engl J Med 2003
• 15 medical-surgical ICUs, 851 patients receiving
mechanical ventilation
• 63% weaned, 17% died while receiving MV
• 19.5% died after withdrawal of MV
Determinants of withdrawal
• Physicians’ perception of patient preference
• Physician prediction of low likelihood of ICU
survival and high likelihood of poor cognitive
function
• Dependency on inotropes and vasopressors
Symptoms in the Critically Ill
• Patients die with treatable pain
• The symptom burden of chronic critical
illness. Crit Care Med 2004
– Patient report: 50 patients with tracheostomy
– 40-50% of patients experienced pain at the
highest levels of intensity, 60% dyspnea
– Studied communicative patients so likely
underestimate symptoms and relief
– Half of patients died by 3 months
Nursing - Front Line
• Nurse is the main caregiver – ICU, Palliative unit
• Improve EOL care – MD/RN Communication
• Differences in ideas of EOL, processes, good
death, predicting outcomes of critically ill patients
– Crit Care Med 2003: 1900 judgments by MD and RNs,
disagreements in 63% of dying patients
• MD and RN: Different experiences and burdens
Factors associated with nurse assessment of
the quality of dying and death in the
intensive care unit. Crit Care Med 2004.
• 178 patients
• QODD: Control of pain, situation, breathing,
dignity, time with family, spiritual/religious,
someone present at death, on ventilator, proper
amount of sedation
• Independent predictors of QODD score:
– CPR performed in last 8 hours of life – negative
– Someone present at moment of death – positive
Quality of Dying in the ICU
Chest 2005
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Ratings by families of 38 decedents, QODD
<50% had pain controlled
3% breathing comfortably
32% kept dignity and self-respect
Family Perspectives
• Family perspectives on end-of-life care at
the last place of care. JAMA 2004
• Family follow-up after 1578 deaths
• 67% institution, 32% death at home
• Unmet needs in institutions (more than 1/3
reported): inadequate treatment for pain or
dyspnea, emotional support, respect,
physician communication
How we can improve EOL care
• Recognize end of life, preferences, goals of care
for the patient
• Process of ICU care: decision-making,
communication, symptom management
• Education, teaching communication skills
• For ICU Nurses: involvement in EOL decisions
• Communicate - MD, RN, family
• Use resources: Nursing, Palliative, Critical Care,
Geriatrics, Pastoral Care, Ethics, Social Work