5 Triggers for Palliative Care in the ICU

Right now, I notice that some patients get palliative care too late in their stay at the hospital and sometimes pass away a day later after the consult was put in. We can do better than that to ensure patients are living the way they want to!!

I came across an article in a critical care newsletter called Estimates of the Need for Palliative Care Consultation across United States Intensive Care Units Using a Trigger-based Model. It said 1 in 7 patients need palliative care and that there are 5 triggers that indicate the patient has a poor prognosis and the healthcare team should put in a consult. It will give the patient and the family members more support and help guide them through difficult decisions. Here are the 5 triggers:

  1. ICU admission after hospital length of stay of at least 10 days
  2. failure of three or more organ systems
  3. stage IV malignancy
  4. status after cardiac arrest
  5. intracerebral hemorrhage requiring mechanical ventilation

 

If you have a serious illness, should you get palliative care?

caregivers

Yes. Palliative care provides an additional level of support while still providing curative treatment. Hospice care, on the other hand, also provides support but focuses on pain management and a good quality end-of-life care. Coming from NYU, I’m aware of the NICHE program (Nurses Improving Care for Healthsystem Elders). One thing it does is provide caregiver resources especially useful while you or your loved one is at the hospital. Here is their guide for helping you determine if you need palliative care.

1. Do you have one or more serious illnesses?

Such as: • Cancer • Congestive heart failure (CHF) • Kidney failure • Liver failure • Neurological diseases (e.g., ALS, Parkinson’s) • Dementia • Chronic obstructive pulmonary disease (COPD), emphysema, lung disease

Yes___ No___

2. Do you have symptoms that make it difficult to be as active as you would like to be, or impact your quality of life?

These symptoms might include: • Pain or discomfort • Shortness of breath • Fatigue • Anxiety • Depression • Lack of appetite • Nausea • Constipation

Yes___ No___

3. Have you, or someone close to you, experienced the following:

• Difficult side effects from treatment • Eating problems due to a serious illness • Frequent emergency room visits • Three or more admissions to the hospital within 12 months, and with the same symptoms

Yes___ No___

4. Do you, or someone close to you, need help with:

• Knowing what to expect • Knowing what programs and resources are available • Making medical decisions about treatment choices/options • Matching your goals and values to your medical care • Understanding the pros and cons (benefits/burdens) of treatments (e.g., dialysis, additional cancer treatments, surgery, etc.)

Yes___ No___

5. Do you, or someone close to you, need help with:

• Coping with the stress of a serious illness • Emotional support • Spiritual or religious support • Talking with your family about your illness and what is important to you

Yes___ No___

If you answered yes to more than one of the questions, palliative care is something you or your loved one may need. If you feel you may benefit from palliative care, please talk to your healthcare provider today.


Update from April 24, 2014
To spread awareness about COPD and raise money for the COPD Foundation, you can write your story and Healthline will donate $10. The top 5 stories will receive a $75 American Express card.

First Code – CPR or hospice care for terminal illness?

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This 90 something year old man was repeating, “I want to die” a couple days before. With stage 4 cancer (meaning, it spread from the source location), he should’ve been DNR (Do Not Resuscitate). But since he started to lose his mind (he couldn’t answer the 3 questions: name, location, and time), his family members began to make decisions for him (as a Heath Care Proxy). His family was in such denial that it was time for him to pass away. They believed he didn’t need morphine to ease his pain and should remain in full code in case his heart rhythm converted to v fib or v tach (at this point, you do CPR).

Throughout the night, he kept moaning. But his family would only allow him to take Tylenol. Which honestly isn’t enough if you have overgrown cells invading essential organs. And these organs allow you to breathe and circulate blood throughout your body.

After I had given out my morning meds and taken out a foley, I saw a nurse run. The next thing I heard was “999 on 1 West”. I saw 2 nurses with the crash cart wheel past me heading to a room in the next district over. When I saw them wheel the cart into that room, I knew it was him. The nurse there was already doing CPR compressions and someone else got the ambu bag ready. Though it felt like 5 minutes, about 30 seconds later, 2 critical care PAs, 3 critical care nurses, 2 MDs, respiratory therapist, nurse educator, patient care assistants, and all the nurses on the unit were there. The PAs took over the compressions. The pads were slapped on.

The EKG monitor was still on, so I watched it go in and out of v fib and v tach. Nurses made the call out to the attending and the family to tell them to come in immediately. My nurse manager told me to go the next unit over to get the Line Cart. I learned fast that’s the cart with the equipment to do a central line. Inserting a central line would allow them to bolus (or “quickly give”) fluid directly to his heart to increase blood pressure. Without a properly beating heart, the body won’t have circulating blood.

When I came back, I saw that he was also bleeding out from his rectum and abdomen. Cracked ribs and his tap sites from before may be the cause. Regardless, I primed the normal saline line to attach it to blood that we would give to him.

More epinephrine was needed. More flushes. The nurse educator asked if I knew any of the nurses in the room so she can document everything that’s happening in the room. I gave some names and then let the nurse who was taking care of him take over.

After the defibrillator delivered the shock, I heard that sound. That sound was an asystole sound. A solid beeeeeeeeeep. I looked at the EKG monitor and saw a solid line. He was gone. He got his wish.

This happened in 17 minutes.

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If only he had been DNR and was comforted, he would’ve died more peacefully. He wouldn’t have bled, have cracked ribs, have something tied to keep his tongue down in case of intubation. He died suffering from pain and misery. It could’ve been in peace in his sleep.

Family members may feel guilty if they decide to make their loved ones a DNR. They may feel that they aren’t doing the right thing and that they should do everything possible to save them. But in terminal cases, the focus should switch from treatment to comfort. This increases the quality of someone’s end-of-life care.

In my mind, when I die, I would want to die in my sleep. Peacefully. No pain. Just as living is a part of life, death is too. And we should pass with dignity.