The Exchange

Commentary and Observations from
the Medical Front Lines

Palliative Care Starts Sooner Than You Think!

Palliative Care Starts Sooner Than You Think!

Last year, I transitioned from being an ER PA to a critical care PA, now working in our hospital's ICU. It was not the hardest job change I have ever made: I had an entire career as a rescue paramedic and firefighter prior to being a PA, followed by 7 years in the ER. That said, there has been a lot of critical care laced through my medical professional life, but 1 thing I find new and challenging in the ICU environment is the concept of palliative care.

We all know about advanced directives, living wills, and DNRs, but in the ICU, those documents take on a whole new meaning. Imagine that a patient arrives to your ICU intubated, sedated, and on mechanical ventilation. The patient had arrived to the ER by EMS and they did not have a clear history; the patient was altered due to sepsis. Because the ER team had concerns that he was no longer protecting his airway, they intubated him. Going through what you can of his medical history, you find that he has stage IV prostate cancer with metastatic disease to multiple organs.

Now, he is on full life support in your ICU and his family is driving in from another town to be with him. The question you should ask now is: What would this patient want for himself if he could speak?

In our ICU, we are blessed to have a team of palliative care specialists who help us communicate with families and patients in order to make the most ethical decision that best represents the wishes of the family. In the case above, we would consult palliative care to assist with developing goals of care for this patient. This would entail an extensive conversation with his family that includes the patient's standard of living prior to his critical turn, his prior medical conditions, our best guesses about what his standard of living would look like if he survives his illness, and, ultimately, what the patient would want regarding prolonged life support.

These are often difficult conversations to have with families, especially when a patient cannot participate. Options may include:

  1. Do everything

    Continue to do everything for the patient and escalate care until the patient dies or gets better—no matter how long it takes. This would include CPR, multiple vasopressors, paralytics, etc.

  2. Classify the patient as DNR

    This means that we continue to do everything for the patient, including escalating all measures of care. But if the patient's heart were to stop, we would not initiate CPR. If the patient was not already intubated, it would also mean no intubation in respiratory failure. One of the trickiest things we run into is the "code status" changes that include DNI (do not intubate), chemical code only, soft code only, etc. These are vague and can lead to confusion in the middle of the night. Each hospital's environment is a little different and you must clearly understand yours when dealing with code status.

  3. Do not escalate care

    This goal of care is often used when a patient is critically ill and already on significant life support. The family may already be in discussions with palliative care or another specialist about withdrawing life support. A "do not escalate care" order helps the team when dealing with new clinical changes, such as a falling blood pressure, spontaneous pneumothorax, new infectious process, etc.

  4. Withdraw life support

    This is probably the most complicated decision a family can make for an intubated patient on life support. It involves weighing the objective information from the critical care team and other specialists involved in the care of the patient. It also involves the family's faith and belief systems. But most importantly, it involves the family doing what they believe the patient would want. In our ICU, we work as a coordinated team with palliative care to follow a specific set of guidelines and protocols that ensure compassionate, respectful, and painless withdrawal of life-sustaining measures. This also may include inpatient hospice, depending on the patient.

As you can imagine, these goals of care and palliative discussions are made even more complex if patients have not expressed their wishes prior to the critical illness. For this reason, palliative care and goals of care should be discussed with all patients prior to their arrival in an ICU. If you work in primary care, please consider including a discussion of goals of care and advanced directives with each of your patients during an annual visit.

They do not have to have a critical illness or terminal diagnosis to have these discussions: Consider the young, healthy patient who is involved in a motor vehicle collision. Even if the patient just has a conversation with family members at some point, this is immensely helpful to the critical care team. If you work in an ER or EMS, please take a moment prior to intubating a patient to determine if the patient actually wants to be on life support and if there are any temporary adjuncts you can use to buy some time for a goals of care discussion with the patient and/or family.

The world of palliative care is much more expansive, but my hope is to reach some of us who have not given advanced directives and goals of care significant thought. Prior to my arrival in the ICU, these issues were in the background; I did not realize how important they would become when a patient reaches the ICU. I encourage everyone to visit and meet with your hospital's palliative care and critical care teams if you have an opportunity.

Filed under: Curbside Consultations, Miscellaneous

Development Widget