We are delighted to introduce our new Palliative Care and Intensive Care blog series. For the first article in this series, Martin Neukirchen and colleagues tell us about combined initiatives established during the pandemic that have proved to have significant staff, patient and relative benefit.
At first sight, the two disciplines of intensive care and palliative care differ substantially in their goals. Intensive care is commonly associated with high-tech medicine to save lives, while palliative care alleviates symptom burden to maintain quality of life. However, both disciplines care for the seriously ill, often dying, patients and their relatives. Both have to deal with the fact that curation can sometimes no longer be achieved. In addition, intensive care, even more than palliative care, often faces the great challenge of treating patients with large prognostic uncertainty. Keeping hope alive for patients, and their often highly stressed relatives, and motivate them to fight against serious conditions on the one hand, while not raising unjustified hopes on the other hand remains deeply challenging.
Models for implementing palliative care structures in Intensive Care Units (ICUs) have been developed. However, they are implemented to a greater or lesser extent within Europe. Difficulties mainly exist in identifying ICU patients who could benefit from palliative care. For this purpose, trigger factors have been developed, that can be used as screening methods. These are factors which are commonly associated with patients who may have a life-threatening illness and so may have palliative care needs or need treatment to reduce symptom burden. A closer look at those trigger factors shows that they’re mainly prognostic factors, so depending on life expectancy. They include, for example, older age and comorbidities, history of cardiac arrest or stage IV tumors. However, trigger factors must encompass more than prognosis to be a meaningful tool to be used to determine patients’ outcomes and needs. For example, they should include nurses’ perspective as an integral part of interprofessional cooperation. As a rule of thumb, intensive care nurses spend more time at the patient’s bed and are therefore confronted with the patient`s needs and symptom burden in an even more unfiltered and profound way. That is why they may identify other trigger factors such as different symptoms burden but also a lack of honest communication, inconsistent decisions and the burden on relatives. With additional support of specialised palliative care teams, communication about realistic therapy goals with patients and relatives can then be improved.
Collaboration between intensive care and palliative care already works quite well in some places. During the pandemic, intensive care teams were extensively confronted with patients and clinical settings that had rarely occurred to this extent before. Awake patients on Extra Corporeal Membrane Oxygenation (ECMO) with extremely poor prognosis for ECMO weaning may serve as a striking example. These patients and their loved ones suffered from symptoms on all four levels (physical, psychological, social and spiritual). Visits were restricted for relatives and friends but nevertheless patients were often awake and in high need of communication. Consequently, substantial moral distress arose among members of intensive care teams, and in some cases, this also contributed to the involvement of palliative care teams. At University Hospital Düsseldorf, to address high levels of moral distress, we offered multi-professional communication seminars to our colleagues in intensive care wards. With the help of these seminars, confidence was built and thus helped relieve emotional pressure and distress.
In addition, solutions were sought and found for particularly stressful situations, for example, patients suffering from loneliness due to visiting restrictions. In this context, digitally driven communication via tablets, even during the process of dying, was established and is now a well-known tool to support patients and their relatives who are not able to visit the ICU. These examples show the benefits of cooperation between intensive care and palliative care, getting to know each other and working out common patient goals. To facilitate this collaboration, both the benefits and implementation could be topics of discussion early in medical training and education, perhaps even in shared teaching programs. On a daily routine basis, this collaboration can be enhanced through regular interactions. It seems crucial to maintain this common effort in the future for the good of patients, relatives and healthcare professionals alike.
Links and resources
- Hua et al. Estimates of the Need for Palliative Care Consultation across United States Intensive Care Units Using a Trigger-based Model, American Journal of Respiratory and Critical Care Medicine.
- Adler et al. Will your patient benefit from palliative care? A multicenter exploratory survey about the acceptance of trigger factors for palliative care consultations among ICU physicians. Intensive Care Medicine.
- PallPan eLearning: Palliative care in times of a pandemic – communication between employees and relatives. Palliativversorgung in Pandemiezeiten – Die Kommunikation zwischen Mitarbeitenden und Angehörigen.
- PallPan eLearning: Guidance on ‘Acting correctly in the care of the seriously ill and dying in times of a pandemic‘
- Schwartz et al. Psychische Belastung des Intensivpersonals Kommunikationsseminare helfen (Psychological stress on Intensive care staff: Communication seminars help.) Deutsches Ärzteblatt.
About the authors
Priv. Doz. Dr. med. Martin Neukirchen is Head of the Department of Palliative Care, University Hospital Duesseldorf, Heinrich-Heine University, Germany. His research interests include co-operation between intensive and palliative care. Orchid: 0000-0002-2287-7896.
Manuela Schallenburger, MSc is a palliative care nurse, research assistant and Lead Co-ordinator of palliative care teaching for medical students at the Department of Palliative Care, University Hospital Duesseldorf, Heinrich-Heine University. Her research interests include trigger factors in intensive care from a nurses‘ perspective, interprofessional teamwork, learning and education. Orcid: 0000-0002-3364-6137.
Dr. med. Jacqueline Schwartz is Co-Head of the Department of Palliative Care, University Hospital Düsseldorf, Heinrich-Heine University, Germany. Her research interests include trigger factors for palliative care in oncology and intensive care. Orcid: 0000-0002-0945-1292.
Dr. med. Yan-Nicolas Batzler is an urologist and palliative care physician at the Department of Palliative Care, University Hospital Duesseldorf, Heinrich-Heine University. His research interests are the voluntary stopping of eating and drinking and ethics in palliative medicine. Orcid: 0000-0002-4436-6448.
Dr. med. Stefan Meier, D.E.A.A. is a Consultant at the Department of Anesthesia and Critical Care, University Hospital Düsseldorf, Heinrich-Heine University, Germany. His research interests are integration of palliative care in intensive care, and the appropriateness of intensive care. Orcid: 0000-0001-5924-0357.
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