Palliative care in the trauma intensive care unit

What is palliative care in the intensive care unit?

Palliative care in the ICU integrates and applies the principles of shared decision making and relief of suffering to critical care practice. The family and the patient are the unit of care; this requires an interdisciplinary approach with team members from not only trauma surgery and critical care nursing, but also pain management, social work, psychosocial support, and pastoral care. Depending on the injury and trajectory of illness, some domains may predominate. For example, palliative care may primarily focus on the family and their support, as in traumatic brain injury with rapid progression to brain death. Here minimal attention to patient comfort is required, and care is refocused on family crisis and grief, death rituals, and spiritual issues. Conversely, in the patient with sepsis and respiratory failure, palliative care will focus on pain and symptom management and shared decision making around goals of care and life support, often in parallel with ongoing aggressive critical care.

The unique nature of traumatic injury suggests four main domains of palliative care that are essential in the management of critically ill patients in the trauma ICU: communication and shared decision making, withholding and withdrawal of life support, bereavement and family support, and pain and symptom management. These four components of palliative care are essential for good-quality care for trauma patients in the ICU. Evidence suggests that implementation of these components in a pathway or bundle improves many aspects of care. Integration of these four areas of assessment and management into standard critical care in a timed sequence ensures their application when appropriate. Assessment of patient, family, and prognosis is the first step, followed by appropriate family support, communication, and family meetings. From these steps, goals of care should be developed. This should be completed within 72 hours of admission ( Table 1 ).

When to start palliative care in the intensive care unit

Although fatality from injury is correlated with Injury Severity Score and increasing age, prognosis on admission to the ICU is not always clear for every patient. The majority of trauma deaths in the ICU occur in the first 48 hours secondary to traumatic brain injury or traumatic hemorrhage, and another significant proportion (20%–30%) will linger in the ICU only to die weeks later from sepsis and multiple-organ failure. In the first group, catastrophic injuries have a rapid trajectory toward death, usually with prognostic certainty; here palliative care should be started early in the ICU course, shortly after admission. In this context, bereavement support and communication with the family while attending to patient care are crucial. This early support sets the stage for later decision making, minimizes conflict, and has a salutary effect on family grief, bereavement, and even organ donation rates. For patients who have a protracted course and uncertain prognosis, waiting for death to be imminent before instituting palliative care means that many patients will receive end-of-life care late, have untreated suffering and symptoms, or remain on life support long after it is futile. Thus, palliative care in some form should start early in this group as well, regardless of ultimate outcome.

All trauma patients are admitted to the ICU with the hope and expectation for lifesaving care, not only on the part of their families, but for physicians and nurses as well. The transition in goals of care to palliative can seem daunting in the face of these hopes. This transition is best initiated on admission with a simple palliative care assessment. The Trauma Quality Improvement Program Best Practice Guidelines recommends that all trauma patients be assessed for palliative care needs within 24 hours of admission to the hospital. This assessment should include identification of any advance care directives and a prognostic assessment based on injuries taking into account age, preexisting comorbidities, and preinjury functional status. At this time, patients should be provided pain and symptom management and family support as needed. Any patient that is identified as having major life threatening or disabling traumatic injuries should have a goals of care conversation within 72 hours ( Table 2 ). Patients should continue to be reassessed throughout their hospitalization for any additional needs.

To aid in identification of patients who would benefit from palliative care, physicians may utilize the “surprise” question. A physician answering “no” to the question “Would I be surprised if this patient died?” should trigger evaluation of palliative care needs and a goals of care conversation. In addition, objective triggers can be used to help identify patients with unmet palliative care needs. Potential triggers include severe TBI, multisystem organ failure, positive frailty assessment, extended ICU LOS or prolonged intubation.