palliative care in the critical care environment · references o references o o aherns, t., yancey,...
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Palliative Care in the Critical Care Environment
Lori Lupe DNP, CCRN
10/14/11
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The Statistics
O There are greater than 2.4 million death
annually
O 80% of patients who die are >65 years of age
O 11% of patients on Medicare spend more than 7
days in the ICU within 6 months of death
O 1/5 of ICU patients die while hospitalized
O (Beckstand, R.L., et. al. 2005)
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Standards?
O IPAL-ICU (2010)
O Improving Palliative Care in the ICU
O Mt. Sinai School of Medicine
O Support from NIH and Center to Advance
Palliative Care
O Provides domains, frameworks, clinical
recommendations, and measures for
improving palliative care in the ICU
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Domains
O Symptom management
O Communication within the team and with patients and families
O Patient-and family-centered decision making
O Emotional and practical support for patient and families
O Spiritual support for patients and families
O Continuity of care
O Emotional and organizational support for ICU clinicians
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Quality Indicators
O Selected from a sample of 50
O Symptom assessment scales
O Documentation that pain and symptom assessment is part of all members of the critical care team orientation
O Written referenced ICU protocols for management
O Referenced analgesic/benzodiapine equivalency charts at the bedside
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VHA – Care and Compassion Bundle
O Identify the patient’s health care surrogate
O Determine whether the patient has an advanced directive
O Clarify the patient’s resuscitation status
O Assess pain regularly using an appropriate pain scale
O Manage pain optimally
O Offer social work support to patient/family
O Conduct a meeting of interdisciplinary team with the family
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Lee Memorial Health System- Qlife
Palliative Care Service O Adapted from VHA
O Expected transition from curative to comfort care
O Older than age 70 with co-morbidities
O Two or more hospital admissions in the last 6 months for same symptoms
O Address code status/advance directives
O Withdrawal/withhold treatment/discuss artificial nutrition or hydration
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LMH- Qlife
O Terminal extubation
O Gold setting
O End stage lung, cardiac, renal, hepatic disease
O Advanced or stage 3 or 4 cancer
O Sudden acute event (CVA, ICH)
O Disease Triggers: aspiration, pneumonia, COPD, CHF, septicemia
O Pain and Symptom Management
O (Provided by Karen Washburn – Director Qlife/Palliative Care LMHS)
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Quality of Death
O 7 broad domains
O Physical
O Psychological
O Social
O Spiritual and existential
O Nature of health care
O life closure and death preparation
O Circumstance of the death
O (Hales, S., Zimmerman, C., Rodin, G., 2010)
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Realities of Death Experience
O There is a high prevalence of pain and other
symptoms in the last days of life
O There is frequent use of life-sustaining
interventions
O A high portion of death occur in the hospital
– that is where culturally many people turn
to die
O (Hales, S., Zimmerman, C., Rodin, G., 2010)
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WHY????????
O We have standards
O We have literature
O Why is the death experience not managed
better?
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How Do We Identify Who Needs It?
O Palliative Care Assessment Components
O Are there distressing physical or psychological symptoms?
O Are there significant social or spiritual concerns affecting daily life?
O What are the goals for care identified by patient, family, surrogate?
Does the patient have an advanced directive?
(Weissman, D.E., Meier, D.E., 2011)
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The Living Will
O From Florida Bar Association – Florida
Statute 765.303
O Declaration made this _____day of ______I
____Willfully and voluntarily make known my
desire that my dying not be artificially
prolonged under the circumstances set forth
below, and I do hereby declare that, if at any
time I am incapacitated and
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The Choices
O I have a terminal condition
O I haven an end-stage condition
O I am in a persistent vegetative state
O And if my attending or treating physician and another consulting physician determine there is no reasonable medical probability of my recovery from such condition, I direct that life-prolonging procedures be withheld or withdrawn when the application of such procedures would serve
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Living Will cont
O Only to prolong artificially the process of
dying, that I be permitted to die naturally
with on the administration of medication or
performance of any medical procedure
deemed necessary to provide me with
comfort care or to alleviate pain.
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How Do We know?
O What conditions would be terminal?
O What condition would be end stage?
O What is a persistent vegetative state?
O What is artificially prolong?
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Real Cases
O Alzheimer's patient in Alzheimer's unit with
pneumonia – should we intubate?
O Patient with sepsis in ICU for 4 weeks on
vasopressors, ventilator, CVVHD
O End-stage CHF patient in pulmonary edema
– do we intubate?
O Ima – surgical patient with rough post
operative course
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Hastening Death?
Euthanasia – the intentional ending of the life of a person suffering from an incurable or painful disease.
Balance with decisions by health care providers to withhold or withdraw life support.
Terminal weans? D/C inotropes?
(Kuschner, W.G., et al 2009)
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Patient A
O Late 50s
O Lung cancer for 14 months with mets to the
brain
O Presents with arterial embolism to leg resulting
in a BKA
O Develops hemorrhagic stroke
O On mechanical ventilator 2 weeks –
unresponsive with no sedating meds
O Physician orders 30 mg/hr morphine for wean
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Patient B
O Mid 60’s
O Wide spread metastases treated with
chemotherapy
O Develops renal failure, ARDS, Sepsis
O Physician orders discontinuation of
vasopressors
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Patient C
O Mid 60’s
O Advanced lung cancer
O Respiratory distress, pneumonia, and sepsis
O Family requested comfort care only
O Stop vasopressors, decreased oxygen but
maintained vent, sedating with fentanyl and
midazolam infusions.
O Patient dies within2 hours
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Patient D
O Mid 50’s
O Colon cancer metastasized to liver – chemo
O Presents with respiratory failure, neutropenia,
sepsis, hypotension, and extreme obesity
O Treated with antibiotics, vasopressors,
mechanical ventilation – paralyzed and sedated
O Family requests comfort care
O Withdrew vasopressors and paralysis and
extubated
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The Investigation
O US Department of Veterans Affairs
O OIG
O Office of Healthcare Inspections:
Organization and Mission
O Purpose – determine validity of allegations
of euthanasia.
O Was there pressure to hasten the deaths to
open the ICU beds for other patients?
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Findings
O None of the deaths were intentionally hastened
O The family members had requested comfort measures only
O The organization needed clearer policies and procedures for end-of-life care issues
O There was disagreement among the ICU care team on end-of-life issues
(Kuschner, W.G., et al. 2009)
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DNR does not mean No Care
O Provide meticulous hygiene care
O Offer family beverages, encourage breaks
O Visiting hours? Open? Liberal?
O Involve the multidisciplinary team
O Psychological support for the ICU team – flexible scheduling with release time after death
O Clear policies and procedure
O What to do when the bed is needed?
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Opportunities for Improvement
O Identify Bundles
O Care maps to outline activities by day
O Early identification of the health surrogate
O Early meetings with the families and team to
communicate
O Symptom management protocols for pain,
anxiety, family fatigue, family disagreement
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Considerations
O Explore ways to keep family informed that
facilitates care and does not take the nurse
from the bedside
O Educate physicians and nurses on how to
communicate effectively with families
O Develop education for families to facilitate
understanding of lifesaving measures and
terms
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How Do You Monitor
O “To improve palliative care, ICU caregivers
need feedback on performance from the
measures that are scientifically sound,
practical and relevant for daily use”
O (Nelson, J.E., Mulkerin,C.M., Adams, L.L,
Pronovost, P.J., 2006)
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References O References
O
O Aherns, T., Yancey, V., Kollef, M., (2003). Improving Family Communications at the End of Life: Implications for Length of Stay in the Intensive Care Unit and Resource Use, American Journal of Critical Care, 12(4), 317-324.
O Beckstand, R.L., Kirchloff, T., (2005). Providing End-of-Life Care to Patients: Critical Care Nurses’ Perceived Obstacles and Supportive Behaviors, American Journal of Critical Care, 14(5), 395-403.
O Byock, I., (2006). Improving Palliative Care in Intensive Care Units: Identifying Strategies and Interventions that Work, Critical Care Medicine, 34(11), 302-305.
O Fields, L., (2007). DNR Does Not Mean No Care, American Association of Neuroscience Nurses, 294-296.
O Kross, E.K., Engelber, R.A., Gries, J., Nielsen, E.L., Zatzick, D., Curtis, R., (2011). ICU Care Associated with Symptoms of Depression and Posttraumatic Stress Disorder Among Family Members of Patients Who Die in the ICU, Chest, 139(4), 795-801.
O Kross, E.K., ENgelberg, R.A., Shannon, S.E., Curtis, J.R., (2009). Potential Response Bias in Family Surveys About End-of-Live in the ICU, Chest, 136, pp. 1496-1502.
O Kuschner, W.G., D.A., Clum, N., Beal, A., Ezeji-Okoye, S.C.,(2009). Implementation of ICU Palliative Care Guidelines and Procedures: A Quality Improvement Initiative Following an Investigation of Alleged Euthanasia, Chest, 135(1), pp. 26-32.
O Lee Char,S.J., Evans, L.R., Malvar, G.L., White, D.B., (2010). A Randomized Trial of Two Methods to Disclose Prognosis to Surrogate Decision Makers in Intensive Care Units. Am J Respir Crit Care Med. 182, 905-909.
O Nelson, J.E., Mulkerin, C.M., Adams, L.L., Pronovost, P.J., (2006). Improving Comfort and Communication in the ICU: a Practical New Tool for Palliative Care Performance Measurement Feedback, Qual Saf Health Care, 15, 264-271
O Nelson, J.E., Bassett, R., Boss, R., Brasel, K.J., Campbell, M.L., Cortex, T., Curtis, R.J., Lustbader, D.R>, Mulkerin, C., Puntillo, K., Ray, D.E., Weissman,D.E., (2010). Models for Structuring a Clinical Initiative to Enhance Palliative Care in the Intensive Care Unit: A Report from the IPAL-ICU Project (Improving Palliative Care in the ICU), Critical Care Medicine, 38(9), pp 1765-1772.
O Nelson, J.E., Bassett, R., Boss, R., Brasel, K.J., Campbell, M.L., Cortex, T., Curtis, R.J., Lustbader, D.R>, Mulkerin, C., Puntillo, K., Ray, D.E., Weissman,D.E., (2010). Organizing an ICU Palliative Care Initiative: A technical Assistance Monograph from IPAL_ICU Project. www.capc.org/ipal-icu.
O Scheunemann, L.P., McDevitt, M., Carson, S.S., Hanson, L.C., (2010). Randomized, Controlled Trials of Interventions to Improve Communication in Intensive Care: A Systematic Review, Chest, 139, pp. 543-554.
O Weissman, D.E., Meier, D., (2011). Identifying Patients in Need of a Palliative Care Assessment in the Hospital Setting: A consensus Report from the Center to Advance Palliative Care, Journal of Palliative Care Medicine, 14(1), pp 1-7.
O