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Palliative/End of Life Care in the ICU

Society Statements & Guidelines:

Truog RD, Campbell ML, Curtis JR, et al. Recommendations for end-of-life care in the intensive care unit: a consensus statement by the American College of Critical Care Medicine. Crit Care Med 2008; 36:953-63. Provides an overview of ethical issues as well as a compassionate approach to practical aspects of end-of-life care.
PMID: 18431285

Lanken PN, Terry PB, DeLisser HM, et al. An official American Thoracic Society clinical policy statement: palliative care for patients with respiratory diseases and critical illnesses. Am J Respir Crit Care Med 2008;177:912-27. Overlap with above ACCM statement but offers additional worthwhile discussion of hospice eligibility and on timing and settings for palliative care.
PMID: 18390964

Bosslet, GT, Pope T, Rubenfeld GD, et al. An official ATS/AACN/ACCP/ESICM/SCCM policy statement: Responding to requests for potentially inappropriate treatments in intensive care units. Am J Respir Crit Care Med 2015; 191:1318-1330. This consensus statement differentiates between the terms, “futile”, and, “potentially inappropriate”, reserving the former for when “surrogates request interventions that simply cannot accomplish their intended physiologic goal.” They also recommend implementing proactive strategies to prevent conflict at the institutional level, while engaging the public to implement change at the health policy and legislative level.
PMID: 25978438

End of Life Discussions with Patients and Families:

Clinical Trials:

White DB, Angus DC, Shields AM et al. A randomized trial of a family-support intervention in intensive care units. N Engl J Med. 2018; 378:2365-2375. Cluster-randomized trial involving the surrogates of 1,400 patients with a high risk of death compared a nurse-led multicomponent family-support intervention to usual care. The intervention did not significantly affect the surrogates' burden of psychological symptoms, but did improve surrogates' ratings of the quality of communication and patient- and family-centeredness of care. Of note, the length of ICU stay was 0.7 days shorter in the intervention group (p = .045) but 6-month mortality did not differ, suggesting the intervention did not lead to premature transition to comfort care.
PMID: 29791247
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Carson S, Cox C, Wallenstein S, et al. Effect of palliative care–led meetings for families of patients with chronic critical illness: a randomized clinical trial. JAMA. 2016; 316:51-62. This trial of usual care (ICU-led family meetings + brochure) vs Palliative Care-led conferences + brochure for patients with chronic critical illness and their families found no difference in family anxiety or depression. The Palliative Care intervention group may have increased risk of PTSD. The authors conclude that routine palliative care consult is not indicated, but remains important for select cases.
PMID: 27380343
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Detsky ME, Harhay MO, Bayard DF, et al. Discriminative accuracy of physician and nurse predictions for survival and functional outcomes 6 months after an ICU admission. JAMA. 2017; 317: 2187-2195. Prospective cohort study of 303 critically ill patients in which the discriminative accuracy of intensive care unit physicians and nurses in predicting 6-month patient mortality and morbidity was examined. As might be expected, when providers had low confidence in their decision, prognostic accuracy was poor. However, when confidence was high (particularly if both nurses and intensivists agreed), the prognostic accuracy was quite good.  These findings can be useful for framing goals of care discussions.
PMID: 28528347
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Practical Guidance:

Scheunemann LP, Arnold RM, White DB. The facilitated values history: helping surrogates make authentic decisions for incapacitated patients with advanced illness. Am J Respir Crit Care Med. 2012;186:480-6 This article offers a practical framework for how best to assist surrogate decision-makers with the challenge of determining, and applying, patients’ values to medical decision-making in this population.
PMID: 22822020

Billings JA, Block SD. The end-of-life family meeting in intensive care part III: A guide for structured discussions. J Palliat Med 2011; 14:1058-64. Offers an explicit step-by-step blueprint for approaching family conferences while recognizing the need for flexibility depending on family and patient circumstances. Provides sample language useful for navigating difficult aspects of decision-making.
PMID: 21910613
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