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Staying Time in The Intensive Care Unit (ICU) May be Reduced by Consultations

The aim of palliative care is to provide the best possible quality of life both for people approaching the end of life and for their families and carers. It is a holistic approach to care and support, and takes into account emotional, psychological and spiritual needs as well as physical needs. Pain control is central to the concept of palliative care. Freedom from pain allows people to come to terms with their approaching death and enables them to make arrangements for the future of others who depend on them, as well as to live as fully as possible for as long as possible.Palliative care is a relatively modern branch of clinical medicine that deals with pain and symptom relief and emotional support in patients with terminal diseases including cancer and heart failure.

WHO defines palliative care as an approach that:

- Affirms life and regards death as a normal process.
- Does not hasten or postpone death.
- Provides relief from pain and other symptoms.
- Offers a support system to help patients live as actively as possible right up to their death.
- Integrates psychological and spiritual care.
- Provides a wider support to help the family cope during the patient’s illness and their own bereavement after death.
- Palliative care and intensive care are not mutually exclusive and may be synergistic; recognize unmet palliative needs of ICU patients and families; and identify strategies to improve the quality of palliative care for patients with critical illness and their families

Palliative care is a philosophy of care that evolved from the hospice philosophy to meet the gaps in care for seriously ill and dying patients. The aims of pediatric palliative care should best intersect with the aims of curing and healing, and this approach should be instituted when diagnosis, intervention, and treatment are not limited to a disease process, but rather become instrumental for improving the quality of life, maintaining the dignity, and ameliorating the suffering of seriously ill or dying children in ways that are appropriate to their upbringing, culture, and community.

It usually takes place in an intensive care unit (ICU) or trauma center. Problems that might need critical care treatment include complications from surgery, accidents, infections and severe breathing problems.

Monitors, intravenous (IV) tubes, feeding tubes, catheters, ventilators and other equipment are common in critical care units. These can sustain life but can also increase the risk of infection.

With the introduction of a new ICU-based palliative care program at Lehigh Valley Hospital (Allentown, PA), it became clear that a key component of high-quality care for patients included care and concern for their families and visitors. Because families of critically ill and dying patients often spend a great deal of nonvisiting time in the ICU waiting room, it was necessary to take an in-depth look at the waiting room to see what improvements could provide more comfort and enable staff to better meet the needs of patients’ families ;study shown.

Palliative care can be provided at home or in a hospital or hospice facility. The person who has cancer and his or her family members will have to decide which option is right for them. Before making this choice, it's a good idea to find out as much as possible about each care setting. It can also be helpful to talk with a doctor about the good and bad points of each option. It may be possible to receive care at home for a while and then move into a hospital or hospice facility as the cancer progresses.

People, families and medical caregivers want improvements for those who die in hospital intensive care. In an era of increasing trust in use of home hospice many people say that they would prefer to die at home, or in a homelike setting. But a considerable number of patients with chronic, life-threatening illnesses enter hospital for acute care near the end of life and die in an intensive care unit (ICU).

Intensive Care Units (ICUs) provide sophisticated, state-of-the-art care to seriously ill patients. Patients are living longer with serious, complex illness, which for many means multiple ICU admissions over the course of their illness. Unfortunately, there are many barriers to providing effective palliative care in this setting. According to a study presented at the 2003 American Thoracic Society International Conference, lead researcher Judith Nelson, M.D., J.D. noted.

Palliative care treatment does not preclude aggressive treatment and addresses the physical, intellectual, emotional, social and spiritual needs of the patient and their loved ones. The goal of palliative care is comfort, which all patients may benefit from.

A three-years study, called the Palliative Care Project, challenges the current model of medical care in which terminally ill patients must choose between continued medical treatment from conventional health care providers and the supportive benefits of hospice care. Patients in a new program may be enrolled in hospice at the beginning of their treatment, allowing them the benefits of both hospice care and cutting-edge medical therapy.

Is it worth it? Many people with advanced cancer want to try every possible treatment, for fear they'll let down their loved ones if they don't. But sometimes, getting ineffective treatments only takes you away from your family and loved ones for longer periods of time.In truth, your doctor might find your prognosis difficult to estimate, and you might be afraid to admit feelings of depression or anxiety. For this reason, it's important that you and your doctor have adequate time to ask each other questions and not be afraid to ask or answer difficult questions about your future.

The majority of deaths occur in the hospital setting, and of these deaths, 20% are in an intensive care unit (ICU). Care provided on the ICU shifts from curative to palliative when a patient's death appears to be imminent. Nursing care decisions made at the end of life are critical to the experience of the patient, and leave a lasting impression on the patient's family and the nurses involved in providing care. One of the main concerns of family members during this time is the comfort of their loved one.

For seriously ill patients, early proactive palliative care reduced the length of stay in the intensive care unit by more than seven days but did not have an effect on death rates.

That's the conclusion of a study by University of Rochester Medical Center researchers that's published in the issue of the journal Critical Care Medicine.

"One goal of a palliative care consultation is to provide assistance and support to patients and their families while they make health care decisions," lead author Sally Norton, assistant professor at the university's School of Nursing, said in a prepared statement.

"Palliative care consultations are designed to help patients and their families to more fully understand their medical condition, the benefits and burdens of treatments, and likely outcomes to help them make the most informed decisions about the treatments as possible," Norton said.

"By earlier identification of patients whose medical treatments are no longer in line with their personal goals, we can better alleviate their pain, manage symptoms, and get them into an environment they prefer, thereby improving their overall quality of life," she added.

For this study, Norton and her colleagues examined the impact of palliative care interventions on 191 seriously ill patients with a high risk of dying who were admitted to the medical intensive care unit (MICU) at Strong Memorial Hospital in Rochester between March 2004 and March 2005.

Within 72 hours of admission, the patients were screened by physician and nursing palliative care leaders. One group of patients received a palliative care consultation only after a MICU physician referral, which was standard practice at the time. Another group of patients received a proactive palliative care consultation shortly after they were admitted to the hospital.

Patients who received the proactive consultation spent much less time in the MICU but did not have shorter overall hospital stays or lower death rates than patients who received the standard palliative care consultation.

Palliative Care Consultation offers active, comprehensive support for managing patients with life-threatening or life-limiting conditions. Palliative care can be appropriate at all stages of illness, not just the terminal phase, and can be provided at the same time as active or life-prolonging treatments. We can help with many aspects of care including:

Symptom management
Communication challenges
Complex decision-making
Advance care planning
Transitions throughout the course of an illness

Know that your doctor has your best interests in mind, and listen to your doctor's reasoning. Ask questions. Be honest about how the thought of ending your treatment makes you feel. Just because your doctor suggests no longer treating your cancer, your doctor will always continue to treat you, to assure comfort and relieve symptoms to the best of his or her ability.

Due to the uncertainty of prognosis in acute illness, we hypothesized that the best way to bring quality care at the end of life was to apply the principles of palliative care to all patients, regardless of their likelihood of survival. This means providing pain and symptom management, bereavement/family support and good communication to all critically injured patients and their families.