Impact of a Proactive Approach to Improve End-of-Life Care in a Medical ICU

1. Impact of a Proactive Approach to Improve End-of-Life Care in a Medical ICU Intern ???

2. Purpose To improve ICU care at the end of life To define the goals of care in advance of ICU admission

3. Current Problem (1) Pre-ICU communications about preferences for CPR and prolonged mechanical ventilation are uncommon Clinicians may not abide by those pre-stated preferences

4. Current Problem (2) No clear clinical predictors for the outcome or having a DNR order have yet been identified. Age Abnormal mental status Malignancy Cardiac arrest

5. Study objectives To assess the impact of a proactive case finding approach to end-of-life care for critically ill patients. Critically ill patients in this study: experiencing global cerebral ischemia (GCI) after CPR multiple organ system failure (MOSF)

6. GCI population (1) Patients with any of the following physical findings 24 h after cardiac arrest were included in the study: Coma Absent pupillary and/or corneal reflexes Posturing or absent response to deep painful stimuli Tonic-clonic seizures or myoclonic jerks attributed to cerebral ischemia

7. GCI population (2) Patients were excluded if < 18 years old, Receiving barbiturates or neuromuscular blocking agents Having clinical criteria for brain death.

8. MOSF population Patients were included in the study when they had three or more organ systems simultaneously in failure for 3 days. MOSF was defined according to the classic criteria of Knaus et al.

9. Setting Patients admitted to Medical ICU of the Detroit Receiving Hospital, Wayne State University, Detroit

10. Design Comparative study of The historical control subjects (retrospective cohort, through a retrospective chart review, during the period of July 1, 1998, to June 30, 1999) The proactive case finding approach subjects (prospective cohort, during the period of July 1, 1999, to June 30, 2000)

11. Criteria for prospective cohort Early involvement in the process of communicating to the family Assistance in identifying patient�s advance directives or preferences for end-of life care Assistance with discussion of the prognosis and treatment options with patients or their surrogates Implementation of palliative care strategies when goals changed to "comfort measures only"(CMO) Provision of consultation and education to the primary team regarding palliative care strategies

12. Proactive Interventions for GCI (1) On the day of MICU admission: Patients were identified for study inclusion. Families or surrogates were informed of the probability of a poor prognosis based on the duration of CPR and the physical findings. On the second MICU day: A family meeting was convened. Changes in the patient�s medical condition were communicated. Understanding of the previous discussion was ascertained and clarified as needed.

13. Proactive Interventions for GCI (2) On the third MICU day: The poor prognosis was confirmed with the MICU team based on physical findings and EEG report before that daily family meeting. Based on prognosis, a change of treatment goals to a focus on comfort-oriented care was recommended, and ventilator withdrawal was discussed as an option. On subsequent MICU days: Meetings were held if the family was still undecided or unwilling to accept the recommended treatment goals.

14. Proactive Interventions for GCI (3) When treatment goals were changed to CMO: The palliative care service remained involved to facilitate implementation of palliative care interventions. To facilitate withdrawal of support if indicated. To move the patient from the ICU if death was not imminent.

15. Proactive Interventions for MOSF Once patients were identified and included in the study: The palliative care service facilitate the family or surrogate to understand of disease severity and anticipated outcome. Subsequent daily family meetings were held to confirm the poor prognosis and recommend a change in treatment goals to CMO. If goals changed to CMO The palliative care service remained involved in the patient�s terminal care.

20. Results (1) Comfort measures only (CMO) chosen as the DNR goal in proactive cohort were twice more frequently than that in retrospective cohort. The proactive palliative care intervention decreased the time between identification of the poor prognosis and having a DNR order in MOSF. The retrospective cohort vs the proactive cohort For MOSF (4.7 � 2.4 days vs 1.5 � 0.6 days)

21. Results (2) The proactive case finding approach decreased hospital length of stay The retrospective cohort vs the proactive cohort For MOSF (20.6 � 4.1 days vs 15.1 � 2.5 days) For GCI (8.6 � 1.6 days vs 4.7 � 0.6 days)

22. Results (3) The proactive palliative care intervention decreased the time between identification of the poor prognosis and the establishment of comfort care goals The retrospective cohort vs the proactive cohort For MOSF (7.3 � 2.9 days vs 2.2 � 0.8 days) For GCI (6.3 � 1.2 days vs 3.5 � 0.4 days)

23. Results (4) The proactive palliative care intervention decreased the time between MOSF and death The retrospective cohort vs the proactive cohort For MOSF (5.8 � 2.1 days vs 2.1 � 0.7 days)

24. Conclusions Proactive interventions from a palliative care consultant within this subset of patients Decreased the use of non-beneficial resources and the cost of care Most important of all, shift goals of care to comfort much earlier in the dying process

25. Challenges in end-of-life care in the ICU Statement of the 5th International Consensus Conference in Critical Care: Brussels, Belgium, April 2003 Intensive Care Med (2004) Apr 30:770�784

26. Q1. Is there a problem with end-of-life care in the ICU? variability in practice inadequate predictive models for death elusive knowledge of patient preferences poor communication between staff and surrogates insufficient or absent training of health-care providers the use of imprecise and insensitive terminology incomplete documentation in the medical records

27. Q2. What is the �epidemiology� of death in the ICU? what is common to all studies is that they deal with a population that shares the medical consensus that further aggressive care is unlikely to be beneficial. Current data suggest that 20% of all patients dying in the USA, die in an ICU, and there is an increasing recognition of the need to change from a curative to a comfort philosophy of care in a certain subset of patients.

29. Q3. How does one explain the differences between and within countries and cultures regarding end-of-life care? Legal framework and national or professional societal guidelines Religious and cultural influences Staff intensivists vs attending physicians Differences in the organization of intensive care services Insurance

30. Q4. Who decides to limit life-sustaining treatments in the ICU? The patient or surrogate The health-care team: Clinicians, Nurses, Others A Canadian survey of families showed that 15% wanted the physician alone to decide 24% wanted the physician to decide after considering their opinion 39% wanted to share responsibility for the decision 22% wished to decide after physician input 1% wanted to make the decision alone

31. Q5. What is the optimal care for patients dying in the ICU? Provides relief from pain and other distressing symptoms Intends neither to hasten nor to postpone death Affirms life and regards dying as a normal process Integrates the psychological and spiritual aspects of patient care Offers a support system to help patients live as actively as possible until death Offers a support system to help the family cope during the patient s illness and in their bereavement.

32. Recommendation (1) Respect for patient autonomy The intention to honor decisions to decline unwanted treatments should be conveyed to the family and caregiver team. �Shared� approach to end-of-life Decision-making involving the caregiver team and patient surrogates. Process of negotiation Nurses must be involved in the process. In the event of conflict The ICU team may agree to continue support for a predetermined time. If the conflict persists, however, an ethics consultation may be helpful.

33. Recommendation (2) Final decision maker Ultimately, it is the attending physician�s responsibility to decide on the reasonableness of the planned action. Against euthanasia The jury subscribes to the moral and legal principles that prohibit administering treatments specifically designed to hasten death. A pain free death The patient must be given sufficient analgesia to alleviate pain and distress; if such analgesia hastens death, this �double effect� should not detract from the primary aim to ensure comfort.