By Theresa Lombardo, DNP, APRN, AGACNP-BC
Lead Advanced Practice Provider, MICU and Inpatient Lung Transplant, Division of Pulmonary and Critical Care, Northwestern Memorial Hospital, Chicago
SYNOPSIS: Patients with severe COVID-19 acute respiratory distress syndrome that require extracorporeal membrane oxygenation support can benefit from implementing palliative care communication early in their treatment course.
SOURCE: Siddiqui S, Lutz G, Tabatabai A, et al. Early guided palliative care communication for patients with COVID-19 receiving ECMO. Am J Crit Care 2023;32:166-174.
This single-center study involved COVID-19 patients, aged 18 years or older, who required extracorporeal membrane oxygenation (ECMO) support at a large urban academic facility between March and October 2020. An ECMO acknowledgment meeting involving a palliative care clinician was held with family members within 48 to 72 hours of ECMO cannulation to evaluate the family members’ emotional state and understanding of risks, benefits, and limitations of ECMO therapy. Interdisciplinary clinicians involved in the initial meetings underwent a two-hour simulation workshop to learn a tailored script developed by the palliative care team with the goal of promoting clear and consistent communication between families and the medical care team. The palliative care team remained available to support the clinical team and family during the patient’s hospitalization and subsequent care meetings. A descriptive content analysis of the electronic medical record was performed to determine the characteristics and outcomes of COVID-19 patients undergoing ECMO therapy and examine family members’ experiences while the patient was receiving ECMO therapy.
A total of 43 patients were involved in the study with an initial ECMO acknowledgment meeting documented for 26 of 43 patients (60%). Nineteen of the 26 patients (73%) had a meeting within three days of cannulation, and seven patients (27%) had a meeting that occurred later than three days. The median age of the patients was 44 years (range 37-53 years), the majority were male (81%), and a majority were Hispanic/Latino (63%). Twenty-four of the 43 patients (56%) survived to discharge, with an average length of stay of 44.9 days. There was no significant difference found in intensive care unit (ICU) length of stay (43.9 days vs. 36 days) in those patients who had documented palliative care involvement vs. those who did not.
Overall, the study team found that early involvement of palliative care and regularly scheduled meetings improved communication between members of the clinical team and families by providing consistent messaging, building trust and maintaining realistic expectations, allowing for open dialogue regarding the plan of care, and providing extra support for family members when needed. There were seven family comment themes that emerged when reviewing palliative care notes: hope, reliance on faith and spirituality, multiple family members with COVID-19, families with young children coping with a new normal, visitation restrictions, gratitude for clinicians and care, and end-of-life discussions.
COMMENTARY
The COVID-19 pandemic forced a unique set of stressors onto families, given the restrictions on visiting, unknown disease progression, and unknown outcomes. This is compounded by the complexity of ECMO therapy and risks associated with the therapy. This study showed a benefit of having early and ongoing palliative care involvement with COVID-19 patients receiving ECMO therapy. The main benefits seen were in streamlining communication, improving family participation in medical decision-making for patients, and helping families understand the benefits and limitations of ECMO therapy. Steps to improve family engagement and involvement have been shown to improve patient and family satisfaction with decision-making and quality of care as well as improve overall outcomes when included as a part of bundled care.1,2
The seven family comment themes documented when analyzing palliative care notes provide a unique insight into the thoughts of families who had a member critically ill from COVID-19. These thoughts and feelings often are felt by families of patients who are critically ill from a variety of causes and can be useful in understanding the reasons behind the medical decision-making of patients and their families.
There was no difference in length of stay or mortality between those patients who had early palliative care involvement and those who did not; however, it is important to note that this may be due to the nature of the COVID-19 pandemic. It is unclear if the uncertainty of outcomes at that time caused families to defer withdrawal of life-sustaining ECMO support in hopes of patient improvement. More research into the impact of early palliative care involvement on length of stay of ECMO patients is needed.
REFERENCES
- Kleinpell R, Zimmerman J, Vermoch KL, et al. Promoting family engagement in the ICU: Experience from a national collaborative of 63 ICUs. Crit Care Med 2019;47:1692-1698.
- Pun BT, Balas MC, Barnes-Daly MA, et al. Caring for critically ill patients with the ABCDEF bundle: Results of the ICU liberation collaborative in over 15,000 adults. Crit Care Med 2019;47:3-14.
