Palliative care in intensive care units: why, where, what, who, when, how

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Abstract

Palliative care is patient and family-centered care that optimizes quality of life by anticipating, preventing, and treating suffering when “curative” therapies are futile. In the Intensive Care Unit (ICU), critically ill patients receive life-sustaining therapies with the goal of restoring or maintaining organ function. Palliative Care in the ICU is a widely discussed topic and it is increasingly applied in clinics. It encompasses symptoms control and end-of-life management, communication with relatives and setting goals of care ensuring dignity in death and decision-making power. However, effective application of Palliative Care in ICU presupposes specific knowledge and training which anesthesiologists and critical care physicians may lack. Moreover, logistic issues such protocols for patients’ selection, application models and triggers for consultation of external experts are still matter of debate.

The aim of this review is to provide the anesthesiologists and intensivists an overview of the aims, current evidence and practical advices about the application of palliative care in ICU.

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Most cited references 56

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Long-term cognitive impairment after critical illness.

P.P. Pandharipande, T.D. Girard, J.C. Jackson … (2013)

Survivors of critical illness often have a prolonged and disabling form of cognitive impairment that remains inadequately characterized. We enrolled adults with respiratory failure or shock in the medical or surgical intensive care unit (ICU), evaluated them for in-hospital delirium, and assessed global cognition and executive function 3 and 12 months after discharge with the use of the Repeatable Battery for the Assessment of Neuropsychological Status (population age-adjusted mean [±SD] score, 100±15, with lower values indicating worse global cognition) and the Trail Making Test, Part B (population age-, sex-, and education-adjusted mean score, 50±10, with lower scores indicating worse executive function). Associations of the duration of delirium and the use of sedative or analgesic agents with the outcomes were assessed with the use of linear regression, with adjustment for potential confounders. Of the 821 patients enrolled, 6% had cognitive impairment at baseline, and delirium developed in 74% during the hospital stay. At 3 months, 40% of the patients had global cognition scores that were 1.5 SD below the population means (similar to scores for patients with moderate traumatic brain injury), and 26% had scores 2 SD below the population means (similar to scores for patients with mild Alzheimer's disease). Deficits occurred in both older and younger patients and persisted, with 34% and 24% of all patients with assessments at 12 months that were similar to scores for patients with moderate traumatic brain injury and scores for patients with mild Alzheimer's disease, respectively. A longer duration of delirium was independently associated with worse global cognition at 3 and 12 months (P=0.001 and P=0.04, respectively) and worse executive function at 3 and 12 months (P=0.004 and P=0.007, respectively). Use of sedative or analgesic medications was not consistently associated with cognitive impairment at 3 and 12 months. Patients in medical and surgical ICUs are at high risk for long-term cognitive impairment. A longer duration of delirium in the hospital was associated with worse global cognition and executive function scores at 3 and 12 months. (Funded by the National Institutes of Health and others; BRAIN-ICU ClinicalTrials.gov number, NCT00392795.).

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To provide clinicians with evidence-based strategies to optimize the support of the family of critically ill patients in the ICU.

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Assessment of the worldwide burden of critical illness: the intensive care over nations (ICON) audit.

Yasser Sakr, Massimo Antonelli, Peter Pickkers … (2014)

Global epidemiological data regarding outcomes for patients in intensive care units (ICUs) are scarce, but are important in understanding the worldwide burden of critical illness. We, therefore, did an international audit of ICU patients worldwide and assessed variations between hospitals and countries in terms of ICU mortality. 730 participating centres in 84 countries prospectively collected data on all adult (>16 years) patients admitted to their ICU between May 8 and May 18, 2012, except those admitted for fewer than 24 h for routine postoperative monitoring. Participation was voluntary. Data were collected daily for a maximum of 28 days in the ICU and patients were followed up for outcome data until death or hospital discharge. In-hospital death was analysed using multilevel logistic regression with three levels: patient, hospital, and country. 10,069 patients were included from ICUs in Europe (5445 patients; 54·1%), Asia (1928; 19·2%), the Americas (1723; 17·1%), Oceania (439; 4·4%), the Middle East (393; 3·9%), and Africa (141; 1·4%). Overall, 2973 patients (29·5%) had sepsis on admission or during the ICU stay. ICU mortality rates were 16·2% (95% CI 15·5-16·9) across the whole population and 25·8% (24·2-27·4) in patients with sepsis. Hospital mortality rates were 22·4% (21·6-23·2) in the whole population and 35·3% (33·5-37·1) in patients with sepsis. Using a multilevel analysis, the unconditional model suggested significant between-country variations (var=0·19, p=0·002) and between-hospital variations (var=0·43, p<0·0001) in the individual risk of in-hospital death. There was a stepwise increase in the adjusted risk of in-hospital death according to decrease in global national income. This large database highlights that sepsis remains a major health problem worldwide, associated with high mortality rates in all countries. Our findings also show a significant association between the risk of death and the global national income and suggest that ICU organisation has an important effect on risk of death. None. Copyright © 2014 Elsevier Ltd. All rights reserved.

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Author and article information

Contributors

Sebastiano Mercadante: terapiadeldolore@lamaddalenanet.it

Cesare Gregoretti: c.gregoretti@gmail.com

Andrea Cortegiani:

ORCID: http://orcid.org/0000-0003-1416-9993

+390916552730 , cortegiania@gmail.com

Journal

Journal ID (nlm-ta): BMC Anesthesiol

Journal ID (iso-abbrev): BMC Anesthesiol

Title: BMC Anesthesiology

Publisher: BioMed Central (London )

ISSN (Electronic): 1471-2253

Publication date (Electronic): 16 August 2018

Publication date PMC-release: 16 August 2018

Publication date Collection: 2018

Volume: 18

Electronic Location Identifier: 106

Affiliations

[1 ]ISNI 0000 0004 1762 5517, GRID grid.10776.37, Anesthesia and Intensive Care Unit and Pain Relief and Supportive-Palliative Care Unit, La Maddalena Cancer Center, ; Via san Lorenzo 312, 90145 Palermo, Italy

[2 ]ISNI 0000 0004 1762 5517, GRID grid.10776.37, Department of Biopathology and Medical Biotechnologies (DIBIMED). Section of Anestesia, Analgesia, Intensive Care and Emergency. Policlinico Paolo Giaccone, , University of Palermo, ; Via del vespro 129, 90127 Palermo, Italy

Author information

Andrea Cortegiani http://orcid.org/0000-0003-1416-9993

Article

Publisher ID: 574

DOI: 10.1186/s12871-018-0574-9

PMC ID: 6094470

PubMed ID: 30111299

SO-VID: b30dd314-7dd8-4f60-9373-691fc31906fd

License:

Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

History

Date received : 10 February 2018

Date accepted : 3 August 2018

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ScienceOpen disciplines: Anesthesiology & Pain management

Keywords: palliative care,intensive care unit,icu,patient-centered care,end-of-life care

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ScienceOpen disciplines: Anesthesiology & Pain management

Keywords: palliative care, intensive care unit, icu, patient-centered care, end-of-life care

Palliative care in intensive care units: why, where, what, who, when, how

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Most cited references 56

Long-term cognitive impairment after critical illness.

Guidelines for Family-Centered Care in the Neonatal, Pediatric, and Adult ICU.

Assessment of the worldwide burden of critical illness: the intensive care over nations (ICON) audit.

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