The Distinct Role of Palliative Care in the Surgical Intensive Care Unit

Recognize Pain and Distress

It takes an abundance of time and high level communication skills to carefully identify, assess, and manage the symptoms of complex ICU patients with acute and chronic organ failure. Ventilated patients in the SICU have difficulty expressing their symptoms given their loss of voice, in concert with preexisting cognitive changes and ongoing sedation. In particular, pain, dyspnea, anxiety, restlessness, agitation, delirium, sleep disturbances, thirst/dry mouth, generalized weakness, and a sense of abandonment occur frequently in this patient group.^{15 -21} Recently, clinical practice guidelines were published for the management of adult ICU patients with pain, agitation, or delirium. ²² A palliative care team can focus on these symptoms, with the goal of improving the lived experience of the patient, with additional beneficial effects for the family and providers. A palliative care philosophy can strengthen patient symptom management in the SICU, regardless of the patient’s ultimate prognosis.

Establish Patient’s Wishes, Beliefs, and Values and Their Impact on Decision Making

Understanding patient preferences is a cornerstone in providing patient-centered care. These preferences are a blend of the patient’s expressed wishes, beliefs, and values. ²³ It is important that the patient’s most recent applicable expressed wishes are incorporated into decision-making discussions. These wishes may be written or verbal. ²³

Patient values can be considered from a treatment-specific or goal-oriented perspective. ²³ These concepts overlap and may compete within decision making. For example, a patient may wish to have a peaceful death in a hospice devoid of interventions, yet when an untimely sudden event such as myocardial infarction occurs, they may express the wish to have acute interventions in an attempt to recover and subsequently participate in a highly valued family event. Given the uncertainty and complexity of each patient’s unique circumstances, it may take more than one meeting to understand an individual’s wishes, beliefs, and values. Culture significantly affects the patient’s/family’s attitudes and behaviors, and providers must demonstrate cultural competence to acknowledge and respect family values and dynamics. ²³

Four clinical principles that are integral to ethical decision making are patient preferences (from the patient’s most recently expressed wishes, beliefs, and values), clinical factors (create a team-based treatment plan), cultural humility (respect individuals and cultures and understand diversity), and creating a moral community (follow commitments to health care). ²³ The benefits of this principled approach include enhanced patient satisfaction by improving patient-centered care, the potential to reduce harm, and assistance in conflict resolution. ²³ In addition, addressing ethical issues comprehensively improves employee morale and productivity while reducing the risk of litigation and conserving institutional resources. Participation of a clinical ethicist who is well versed in these principles may help with the integration of these principles in the SICU. ²³

Develop Flexible Communication Strategies

Communication skills are central to palliative principles of practice. Communication affects quality of care, length of stay, and patient and family satisfaction. ¹² End-of-life decisions and communication gaps create primary sources of conflict in ICUs. ²⁴ Good communication likely reduces conflict by clarifying prognoses, patient preferences, family grief reactions, and communication gaps between all persons involved in the care plan. ¹²

Physicians play a key role in communicating during a patient/SDM decision-making meeting. During these meetings, if the physician depends on one communication style, it may only be effective in some situations but not in others. Therefore, it is important for physicians to develop various approaches to communicating with a variety of patient/SDMs and situations that are encountered in clinical practice. An intensive communication strategy for critically ill patients resulted in a significant increase in physician-led meetings and the early introduction of palliative care and reduced the ICU length of stay in the target group without increasing their likelihood of mortality. ²⁵

There are four described methods physicians use during end-of-life decision-making family meetings: informative, facilitative, collaborative, and directive. ²⁶ Developing the skill to shift between these communication styles as required to support the patient’s/surrogate’s needs is a valuable, advanced physician communication skill. In the facilitative role, providers give medical information, elicit patient values, clarify the role of surrogate decision making, enforce the importance of patient values in decisions, and summarize statements making a link between values and “hypothetical” recommendations. ²⁶ These conversations permit the patient/surrogate the opportunity to contemplate and then participate in developing a treatment plan. Facilitative-type discussions may permit patients and families to gently link medical knowledge to their situation, thus aiding the transition from acute to end of life care. On other occasions, this style may be preferred when the physician or surgeon identifies potential interventions for a patient with considerable prognostic uncertainty. Alternatively, the collaborative role involves providing medical information, eliciting the patient’s values, and making a clear recommendation. ²⁶ This method of participating in family meetings is helpful when the physician feels confident of the best treatment option and when the patient/surrogate asks the physician to provide a recommendation. Uncommonly, the patient/surrogate may want to be the sole decision maker without the advice of the physician. In these situations, the physician participates using an informative role, giving medical information while not engaging in deliberations or making recommendations. ²⁶ The final described communication style is the directive role, in which the provider independently makes a treatment decision, requests acceptance of the plan, offers minimal medical information, and limits deliberation. Facilitative and collaborative roles are most often used. Physicians should be flexible in their approach and meet patients’ and surrogates’ needs during the decision making process. ²⁶

Conduct Family Meetings and Establish Goals of Care

It is important to focus on and clarify the goals of care to improve care in critically ill patients. ²⁷ Decision making conversations can be considered in stages prior to, during, and after the meeting. ²⁸ Prior to the meeting, it is necessary to decide who should be present,^29-31 understand fully the patient’s medical issues and investigations or treatments that they may benefit from, ³² determine the potential health care options to offer, review the patient’s social situation and advance care planning documents, and decide the goals of the meeting and the most suitable location for it to occur, During the meeting, after introductions are completed, the physician leader should determine the patient’s/SDM’s understanding and expectations,^29,30,33 review the medical summary that was prepared prior to the meeting, support the participants if they have an emotional response, and provide information.^29,34 Subsequently, the key therapeutic options should be highlighted, after which the patient’s/SDM’s expressed wishes^23,29 and goals of care are definitively clarified. The next step is to “translate the goals into a care plan.” ²⁸ This is a very significant time in the meeting and the need to actualize the care plan is worth stating openly. If consensus cannot be achieved with respect to a new care plan, then more information or time to comprehend the situation may be required to determine the best care plan. ³⁵ Episodically, there are fixed discrepancies in opinions concerning the next steps in the care plan, and conflict resolution strategies are necessary.^23,28 In this eventuality, the meeting leader should ensure that there is a follow-up plan and reassure the patient/SDM that care will continue regardless of the goals of care and care plan deliberations. After the meeting, the agreed upon goals of care and care plans should be clearly documented in the patient’s chart.

Provide Family Support During the Dying Process

Sudden critical illness is stressful for family members, and it is associated with heightened psychosocial needs and mental and physical illness. ¹² Family members and lay team members are central to decision making and carry the living memory of the event over the long term. Therefore, many institutions are striving to more fully address family needs via lengthened visiting hours and by permitting spiritual care and death rituals prior to and after death.

There is a significant long-term impact on both the patient and family after prolonged critical illness. Family members’ lives are changed because of caregiving, leaving work, delaying education, delaying family members’ care needs, and loss of life savings. ³⁶ Therefore, both patients and families should be supported during and after hospital stay. ³⁶

Family members’ reactions to life-limiting, life-altering events are profound. Caring for the family in the SICU affects their long-term outcomes and their interactions with providers. ³⁷ Grief begins prior to death and influences family actions and decision-making abilities in the ICU. Family members express grief through multiple emotions (despair, anxiety, guilt, anger, hostility, and loneliness), behaviors (agitation, fatigue, and crying), cognitive perceptions (helplessness, hopelessness, and self-blame), and physical changes (sleep loss, exhaustion, and increase in disease). Interactions with staff, conversations, and the methods of breaking news affect grief reactions and are important for providers to consider as quality improvement initiatives are developed.

Establish Reasonable Goals for Life Support and Resuscitation

Resuscitation preferences, advance care plans, prognosis, functional ability, and expected quality of life post–SICU stay are integral components in decision making. There are independent predictors of a do not resuscitate (DNR) status, such as increasing age, comorbidities, and organ failure prior to injury. ³⁸ Patients living with chronic illness or a terminal diagnosis, for example cancer, are more likely to have a DNR status. ³⁹ In contrast, the severity of illness as identified by APACHE scores did not correlate with a DNR order in a recent study in the SICU. ³⁹

Palliative care practitioners recognize that DNR discussions can be more challenging than obtaining consent for intraoperative procedures. ⁴⁰ DNR consent may be reversed because of an unforeseeable event or iatrogenic concern as a result of the physician’s sense of responsibility, potential litigation, and a belief that the advance directive did not apply in a particular circumstance. ⁴¹ Nonetheless, conversations considering withdrawal of life support ⁴² permit an open discussion recognizing that the patient has a grave and possibly terminal prognosis. This discussion should be followed by a balance of ordinary and medical language while explaining the situation and then an agreement on end-of-life care plans. If there are discrepancies in goals of care between physicians and families, one should explore what the family and providers hope to achieve, such as extending life, restoring health, relieving pain, and avoiding unnecessary suffering. At times, formal conflict resolution methods are required.

Example guidelines for withdrawal of life support policies/protocols are posted on the IPAL-ICU Web site under http://www.capc.org/ipal/ipal-icu/improvement-and-clinical-tools.

Seek Educational Opportunities to Improve End-of-Life Management Skills

Advanced education is necessary to appreciate, learn, and then provide the principles of palliative care practice. Surgeons have opportunities to learn palliative principles of care. An online resource titled Surgical Palliative Care: A Resident’s Guide ⁴³ is endorsed by the American College of Surgeons. It covers fundamental palliative principles, including the following: pain and symptom management (dyspnea, delirium, depression, nausea, and constipation), managing specific patient circumstances (malignant bowel obstruction, artificial hydration, and nutrition), palliative surgery, pediatric palliative care, communication skills (breaking bad news, code status discussions, cultural aspects of care), and referral to specialist palliative care and hospice. ⁴³

Another clear opportunity in the United States is the potential to train leaders in the field of surgical palliative medicine through subspecialty certification in hospice and palliative medicine for surgeons. There are 2 routes of entry: a practice pathway and a training pathway. ⁴⁴ For those interested in learning more details the overview can be found online at http://www.absurgery.org/default.jsp?certhpm. An additional resource for advancing education and the integration of palliative medicine in critical care is available via the Centre to Advance Palliative Care. ⁴⁵

Appreciate How Traditional Palliative and Surgical Cultures May Influence Integration of Palliative Care in the SICU

Integrating palliative care into a SICU has unique challenges. ⁴⁶ Mosenthal et al ⁴⁶ published a recent article on this issue in Critical Care Medicine, supported by the National Institutes of Health. ⁴⁶ Table 1 highlights some surgical routines of providing care that may have an impact on the integration of common palliative principles.^{41,46 -48}

OPEN IN VIEWER

Table 1.

Concepts and Descriptions From Existing Models of Surgical Intensive Care and Their Impact on Managing Dying and Death as a Phase of Life.

Care Concepts	Description	Impact
Culturea-c	Created by the development of the Critical Care team, and its policies, procedures, responsibilities, attitudes, and team dynamics, a and national values c Surgical culture focuses on individual care providers, for example, with public reports of surgeons’ unexpected successes and failures b Emotion such as guilt, regret, frustration, anger, and shame drive prolonged care b	This varies with the individuals and the care environment even when the same disciplines are involveda,c Minimizes the importance of team contributions and responsibilities b Patient and surgeon experience similar emotions b
Expectations	Patients and surgical teams are very optimistic for recovery even with serious life-threatening illnessa-d Surgeons are warriors b	Heroic optimism decreases opportunities for conversations regarding realistic expectations and outcomesa,b,d Mixed messages are given to family between medical and surgical providers a Reduces conversations regarding all health care options, including palliative end-of-life care for dying patients b
Common organizational structuresa,c	Surgeons’ round and communicate independently a Open, semiclosed, and closed SICUs shift practice patterns c	• Not conducive to collaborative interdisciplinary-based patient carea,c
Rescue mission, surgeons have a “covenant,” “buy-in” type relationship with patientsa-d	Surgeon has a strong obligation to provide surgery and protect the patient from unwanted outcomes, even if anticipated or unrelated to the surgerya,b Surgeon’s sense of accountability for patient outcomes, cannot admit defeata-d Surgeons account negative outcomes to technical or judgment error rather than patient disease b Covenant fulfilled if the patient has good outcomes b	Surgeon has shared hopes, risks, respect, and desire for miracles with patient and family b Surgeon may refuse to operate if patient does not accept aggressive postoperative care d Patient is expected to reciprocate by committing to recovery even if quality-of-life outcomes may be compromised after an uncertain, protracted course of carea,d Leads to aggressive acute care longer than the patient/family may choosea,d May contribute to conflict between surgeon and other providers d May reduce opportunities to redirect a care plan from rescue to palliative end-of-life care when patients are dying b
Circumstances around death a	SICU death is less common than medical ICU, yet part of routine care a >35% of deaths occur after 7 days in the SICU a Advanced age associated with increase in death post-ICU and early after hospital discharge a	Most deaths occur with prognostic uncertainty, after long fluctuating hospital course Death may be after a rapid decline with more predictable outcome
If patient is dying and if death occursa,b,d	Surgeons accept responsibility for death privately and publicly, whereas other medical specialties believe that the patient failed the treatment or the treatment failed the patient d Mortality statistics publicly reported with personal and institutional consequences a	Surgeon may experience grief and shame This perpetuates the current model of care Reduces the likelihood of integration of palliative philosophies of care Resistance to changing goals of care to end-of-life care is greater the longer the surgeon has known the patient preoperatively (transplant patient vs trauma) and if surgery is elective

a

Mosenthal et al. ⁴⁶

b

Buchman et al. ⁴¹

c

Cassell et al. ⁴⁸

d

Schwarze et al. ⁴⁷

As an understandable consequence to the concepts outlined in Table 1, many surgeons prefer to retain ownership of the patient, thus controlling principal decision making regarding goals of care and care planning. ⁴⁶ Preoperatively, surgeons may develop a contractual patient relationship for the acceptance of postoperative life support called surgical buy-in. ⁴⁷ End-of-life decisions and communication issues among caregivers themselves or caregivers and families are the primary sources of conflict in the ICU. ⁴⁸ Surgeons may experience significant distress if new information, for example, an advance directive requesting limitation to acute postoperative care, is presented postoperatively. ⁴⁷ They may feel personal responsibility and emotional distress for poor outcomes, especially for elective procedures when success is expected. ⁴⁷ If the patient requests unacceptable postoperative limitations, the surgeon may refuse to operate, negotiate for more time, or refuse to consent to withdrawal of life support despite patient/family requests to do so. ⁴⁷

The Society of Thoracic Surgery has created a national US database that provides detailed risk-prediction models for various cardiac surgical procedures. ⁴⁹ The purpose of this database includes the benchmarking of performance measures, the provision of feedback on patient care guidelines, and quality improvement. In addition, several states (eg, New York) publish surgeon-specific and institutional-specific mortality rates after cardiac surgery. ⁵⁰ Unfortunately “shame and blame” public reporting may have a negative impact on the acceptance of dying as a phase of life and on the integration of palliative principles into SICUs. A recent cross-sectional survey has identified components of surgical practice that create conflict and challenges, including deciding goals of care, emphasis on physician profiling, communicating poor outcomes, managing personal discomfort with poor outcomes, and managing the patient’s fears and clinical needs regarding complications. ⁵¹

The traditional palliative care culture also demonstrates potential limitations to the integration of palliative care practice in SICUs. The foundational assumptions of the surgical and palliative cultures are illustrated in Table 2. These surgical and palliative care foundational perspectives may complicate the intentions of both the surgical and palliative services and add to the complexity of the situation. A local collaborative multidisciplinary team should consider each service’s unique perspectives as it creates a shared model of care for SICU patients/families.

OPEN IN VIEWER

Table 2.

Differences in EOL Care Between the Surgical ICU and Traditional Palliative Care.

	Surgical ICU EOL	Traditional Palliative Care
Trajectory of illness	Unexpected sudden change in health state, from previously healthy or chronic illness state:. for example, trauma with resulting neuorological events Prognostic uncertainty a	• Chronic gradual, more predictable decline, for example, cancer a
Presentation	• Complicated by trauma/postoperative events/iatrogenic concerns/chronic critical illness a ; older patients with prolonged stay often require custodial care on discharge b	Intrinsic illness progression where dying is acceptable a Palliative care delivery models for organ failure, frailty, and sudden death are not as common c
Decision making	• Patient often unable to communicate, increased burden on family already in emotional distress a	• Increased opportunity for patient to participate in conversation, wishes often known a
Bereavement and psychosocial needs	• Peak early in course of illness, complicates discussions a	• Longer course of illness to address these issues a
Death	• Seen as failure, and palliative care interpreted as giving up a	• Natural phase of life a
Outcomes	• Mortality, morbidity, length of stay, identify blame a	• A good peaceful death, quality of life a

Abbreviations: EOL, end of life; ICU, intensive care unit.

a

Mosenthal and Murphy. ⁵²

b

Mosenthal et al. ⁴⁶

c

Murray et al. ⁵³

Helping Resolve Team Conflicts

In our personal experience in the SICU there can be a “creative tension” between the surgical team who performs high-risk operations and the multidisciplinary critical care team who play a major role in postoperative care. We are not unique because surgeons reporting conflict with ICU physicians and nurses is common when determining goals of care for patients with poor postsurgical outcomes. ⁵¹ As noted above, most surgeons seek “buy-in” from high-risk surgical patients before they agree to perform complex procedures. ⁴⁷ If such patients develop serious postoperative complications, it is not uncommon for surgeons to insist on continuing life-sustaining interventions in the ICU, which may not be in line with the patient’s and the family’s preferences. ⁴⁷ In such instances, the critical care team may be “caught in the cross-fire between patient preferences and the surgical rescue effort,” without having had the opportunity to have witnessed or participated in the preoperative “buy-in” negotiations. ⁴⁷ Improving practice relationships through building trust, respectful interactions, and accepting diversity has been shown to improve quality of care delivery. ⁵⁴ Our experience is similar to that described in the literature,^{10-12,14-16,46,52} which highlights the fact that palliative care physicians have the training and mindset to assist surgical and critical care teams in resolving these conflicts. As a result of palliative collaboration with all team members, the critically ill patient, and the patient’s family, the team is more likely to achieve congruence with respect to the goals of care and resuscitation preferences.