Background     The Intensive Care Unit (ICU) is the setting for high-intensity health care designed to resolve life-threatening illnesses and extend life.  However, risks of mortality and severe morbidity remain high and virtually all ICU patients have palliative care needs.  Integration of palliative care services into ICU care is increasingly seen as a method to improve clinical care (1,10).  This Fast Fact reviews the role of palliative care consultations in the ICU along with options for more generalist palliative care services provided by ICU clinicians.

What occurs in an ICU Palliative Care Consultation

• Assess/treat distressing physical, psychological, and spiritual symptoms/problems.

• Communicate information about prognosis and treatment options to patient/family in concert with ICU, primary care and subspecialty colleagues.
• Establish/clarify goals of care that are realistic and appropriate in relation to the patient’s condition, values and preferences, and help match treatments to these goals.
• Formulate a transition care plan that accounts for prognosis, goals of care and patient/family needs.
• Provide support for the families.
• Support the ICU medical team in making clinically, ethically, and emotionally challenging decisions.

Research Data on Benefits of Palliative Care ICU Consultation

• Early identification of a dying trajectory leading to decreased time to institution of patient- and family-centered, comfort-focused treatment goals (2-3).

• Movement of appropriate patients to lower intensity care sites (ward, palliative care unit, home hospice) (5-6).
• Reduction in ICU length of stay for adult patients (2-4, 7).
• Reduction in the cost of care, without an increase in mortality, due to early establishment of realistic treatment goals leading to reduction in use of high-cost ICU resources/interventions (2-4, 7-8).
• Support for staff in challenging and emotionally draining/morally distressing patient/family care situations.
• Palliative Care consultation for hospitalized patients can reduce the need for ICU admission through establishment of treatment goals that preclude future ICU admission (7-8).
• Continuity of care when the patient transitions from the ICU to ward or palliative care unit as the Palliative Care team follows the patient.

ICU/Palliative Care Collaboration   A range of options exist for integrating palliative care services into the ICU.  At one extreme, ICU staff consult a palliative care specialist team for problems the ICU staff deems appropriate for consultative advice on an ad hoc basis.  At the other extreme, the ICU embeds systems in place to provide ICU-led generalist palliative care services to all ICU patients, utilizing palliative care specialists for complex problems.  Embedding systems that ensure the needs of all patients are met includes screening all patients on admission and daily for unmet palliative care needs, early identification of a surrogate, timely symptom management, and routinely-scheduled family meetings to discuss goals of care (1,9,10). Quality outcomes related to patient and family experience and to health care utilization should be tracked within the framework of available resources (1,11).

When to use Specialist Palliative Care Services    Consultations can either be initiated on a case-by-case basis by ICU or other primary clinicians, or triggered proactively using a system to identify patients at high-risk for unmet needs (2-4). Key indications for consultation include:

• Difficult-to-control physical symptoms despite usual treatment approaches.
• Patients/surrogates wish to explore non-ICU supportive care options such as hospice services.
• Staff have questions about the appropriateness of life-sustaining therapies in the setting of advanced complex illnesses.
• There are complex family dynamics impacting decisions about use of life-sustaining treatments.
• There are disagreements among staff or between staff and patients/surrogates about prognosis and/or use of life-sustaining treatments.
• Patients are being readmitted to the ICU more frequently within a given time frame.

Summary     Specialist palliative care consultations, together with integration of palliative care principles into the care of all ICU patients, can improve the patient/family experience, reduce length of stay and improve ICU throughput without increasing mortality, and lower health care costs.

Additional resources:     Fast Facts # 122-123.

References

1.   Nelson JE, Mulkerin CM, Adams LL, Pronovost PJ. Improving comfort and communication in the ICU: a practical new tool for palliative care performance measurement and feedback. Qual Saf Health Care. 2006; 15(4):264-271.

2.   Campbell ML, Guzman JA. Impact of a proactive approach to improve end-of-life care in a medical ICU. Chest. 2003; 123(1):266-271.

3.   Campbell ML, Guzman JA. A proactive approach to improve end-of-life care in a medical intensive care unit for patients with terminal dementia. Crit Care Med. 2004; 32(9):1839-1843.

4.   Norton SA, Hogan LA, Holloway RG, Temkin-Greener H, Buckley MJ, Quill TE. Proactive palliative care in the medical intensive care unit: effects on length of stay for selected high-risk patients. Crit Care Med. 2007; 35(6):1530-1535.

5.   Carlson RW, Devich L, Frank RR. Development of a comprehensive supportive care team for the hopelessly ill on a university medical service. JAMA. 1988; 259(3):378-383.

6.   Smith TJ, Coyne P, Cassel B, Penberthy L, Hopson A, Hager MA. A high-volume specialist palliative care unit and team may reduce in-hospital end-of-life care costs. J Palliat Med. 2003; 6(5):699-705.

7.   Morrison RS, Dietrich J, Ladwig S, et al. Palliative care consultation teams cut hospital costs for Medicaid beneficiaries. Health Aff (Millwood). 2011; 30(3):454-463.

8.   Penrod JD, Deb P, Luhrs C, et al. Cost and utilization outcomes of patients receiving hospital-based palliative care consultation. J Palliat Med. 2006; 9(4):855-860.

9.   Weissman DE, Meier DE. Identifying patients in need of palliative care assessment in the hospital setting: consensus recommendations. J Palliat Med. 2011; 14(1):1-7.

10. Nelson JE, Bassett R, Boss RD, et al. 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). Crit Care Med. 2010; 38(9):1765-1772.

11. Nelson JE, Brasel KJ, Campbell ML, et al. Evaluation of ICU Palliative Care Quality: A technical assistance monograph from the IPAL-ICU Project.

Authors’ Affiliations: College of Nursing, Wayne State University, Detroit, MI (MLC); Medical College of Wisconsin, Milwaukee, WI (DEW); Mount Sinai School of Medicine, New York, NY (JEN).

Version History: Originally published April 2012; Copy-re-edited August 2015