Quality of palliative care training, bedside tools reduce end-of-life ICU use
Executive Summary
The quality of palliative care training in critical care medicine programs and the use of bedside tools were independently associated with reduced intensive care unit (ICU) use at the end of life. Bioethicists can play a role in decreasing ICU use by working with program directors to:
• Implement evidence-based bedside tools such as protocols for comfort measures or for withdrawal of life-sustaining treatment.
• Improve palliative care education.
• Help clinicians to explain risks and benefits of critical care interventions.
Definition of "unnecessary" is subjective
The quality of palliative care training in critical care medicine programs and the use of bedside tools were independently associated with reduced intensive care unit (ICU) use in the last six months of life for patients with chronic illness, according to a 2014 study.1
"We hear a great deal about the use of ICU at the end of life. Looking at the policy literature, there seemed to be a disconnect between the research and what happens in the ICU," says Howard Saft, MD, MSHS, the study’s lead author and assistant professor in the Division of Pulmonary, Critical Care and Sleep Medicine at David Geffen School of Medicine at University of California, Los Angeles.
Critical care program directors at 89 hospitals evaluated the quality of palliative care education in critical care fellowships, the number of bedside tools, and the presence or absence of an inpatient palliative care consultation service. For each additional level of education quality, there was a 0.57 day decrease in ICU days. For each evidence-based bedside tool, there was a 0.31 day decrease in ICU days.
"We attempted to bridge the modifiable characteristics that impact clinical practice with the same level of data — in our case, the Dartmouth Atlas — that often stimulates the national conversation on the subject," says Saft.
The chosen characteristics — education, bedside tools, and palliative care consultation — begin to help answer the question of how training program and practice environments should be designed, he adds.
"The degree of impact of the quality of education and bedside tools used by the trainees had a higher impact than we expected," reports Saft.
Although the study didn’t look at which training approaches were most effective, Saft says the findings suggest that bioethicists can play a role in decreasing ICU use by working more closely with critical care program directors. Tools such as comfort measure protocols, ordering protocols, or withdrawal of life support protocols, used in daily practice, "streamline the process and promote physician communication with the patient and family for shared decision making whenever it is needed," says Saft.
Critical care medicine program directors typically have many responsibilities and training priorities, and often lack time and resources to focus on this issue. "An ethicist can contribute to this area by talking with the critical care program directors and seeing how the ethicist can help the program directors with education or integrating some of these tools," says Saft.
Approaches to decreasing ICU use
The definition of "unnecessary" ICU use is very subjective, says Mitchell M. Levy, MD, FCCM, FCCP, medical director of the Medical Intensive Care Unit at Rhode Island Hospital and professor of medicine and division chief of pulmonary and critical care medicine at The Warren Alpert Medical School of Brown University in Providence, RI.
"The literature has long reported a discordance between the perception of the medical staff — physicians, nurses, respiratory therapists, and social workers — and the family," he notes.
Patients and families sometimes have unrealistic expectations for the potential benefits of critical care. "In Europe, families and patients place more trust in physicians, and it’s the physician who makes the decision," says Levy. "In the United States, patient autonomy is a primary principle of ethics, and, therefore, it’s the family or the patient who makes the decisions."
While most patients would not want therapies if there was no chance of benefit, says Levy, the meaning of "no benefit" is subjective. "It’s a challenge to explain the risk and benefits of different interventions in critical care, or for that matter, the value of critical care altogether," he says. "That’s why the shared decision-making model has become so important."
Levy says the answer lies in better communication between clinicians, patients, and their loved ones, so that a partnered decision-making process can be utilized. This gives both sides a deeper understanding of the patient’s wishes and the likely outcome, so they can work together to come to the best conclusion for the patient.
"Families have to be willing to let clinicians help make the decision. And clinicians have to be willing to help," he says. "I think it’s fair and good for clinicians to say, Here’s what I recommend. Here’s what I would do.’"
There is a need to publicize data on critical care outcomes, so that the public has a better understanding of how likely it is to survive an infection, a heart attack, kidney failure, or combinations of those, argues Levy. "I think we still have the view of medicine that we see on TV, where someone is snatched out of the jaws of death by a miracle worker in the critical care unit," he says. "Outcomes can vary. Not everything has a happy ending."
Proactive ethics consults can facilitate communication, says Levy, "but it is also important for bioethicists to teach clinicians how to recognize the ethical principles operating in a given situation. That can guide decision-making and resolution."
- Saft HL, Richman PS, Berman AR, et al. Impact of critical care medicine training programs’ palliative care education and bedside tools on ICU use at the end of life. Grad Med Educ. 2014; 6(1):44-49.
- Mitchell M. Levy, MD, FCCM, FCCP, Medical Director, Medical Intensive Care Unit, Rhode Island Hospital, Providence. Phone: (401) 444-5518. E-mail: [email protected].
- Howard Saft, MD, MSHS, Assistant Professor, Division of Pulmonary, Critical Care and Sleep Medicine, David Geffen School of Medicine at University of California — Los Angeles. Phone: (310) 478-3711. E-mail: [email protected].
