When to think about palliation Hannah Wunsch, MD MSc Department of Critical Care Medicine, Sunnybrook Health Sciences Centre Associate Professor of Anesthesiology, University of Toronto Visiting Assistant Professor, Department of Anesthesiology, Columbia University
Conflicts/Funding No conflicts of interest Current funding from: National Institute on Aging Canadian Institutes of Health Research
Does the public think about palliative care?
Palliative care Palliative care is an approach that improves the quality of life of patients and their families facing the problem associated with lifethreatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual. -World Health Organization
Early Palliative care services are helpful not only when a person is approaching death but also during the earlier stages of an illness. Palliative care may be combined with other treatments aimed at reducing or curing the illness, such as chemotherapy. -Canadian Hospice Palliative Care Association
Always
However Limited resources Limited time Some critical illness is self-limiting Resistance from other practitioners Need to be strategic
Crit Care Med 2010
Triggers for palliative care Circumvents resistance from any individuals Surgeons Oncologists Families Ensures palliative care is addressed Appropriate individuals don t get missed
What does a trigger mean? Integrated model ICU team focuses on rounds on palliative issues such as symptom management ICU team explicitly discusses preferences for care (Palliative care physician as part of ICU team) Consultative model Evaluation and separate interaction by palliative care team
Clinical Triggers for Palliative Care Consultation Primary Triggers 1 Alternative Triggers 2 (Surgical ICU) ICU admission following hospital stay 10 days Age > 80 with two or more life-threatening comorbidities Futility considered/declared by medical team Death expected during same SICU stay Alternative Triggers 3,4 (Campbell) Global cerebral ischemia Multi-system organ failure 3 systems Diagnosis of active stage IV malignancy (metastatic disease) SICU stay > 1 month Advanced-stage dementia Status post cardiac arrest Diagnosis with median survival < 6 months Diagnosis of intracerebral hemorrhage requiring mechanical ventilation > 3 SICU admissions during same hospitalization Multi-organ system failure > 3 systems 1 Norton SA, Hogan LA, Holloway RG, Temkin-Greener H, Buckley MJ, Quill TE: Proactive palliative care in the medical intensive care unit: effects on length of stay for selected high-risk patients. Crit Care Med 2007; 35: 1530-5 2 Bradley C, Weaver J, Brasel K: Addressing access to palliative care services in the surgical intensive care unit. Surgery; 147: 871-7 3 Campbell ML, Guzman JA. Impact of a proactive approach to improve end-of-life care in a medical icu. Chest 2003;123:266-271. 4 Campbell ML, Guzman JA. A proactive approach to improve end-of-life care in a medical intensive care unit for patients with terminal dementia. Crit Care Med 2004;32:1839-1843.
Project IMPACT 385,770 admissions to 179 ICUs 53,124 (13.8%) admissions met one or more primary triggers for PC consultation Upper limit of 19.7% when using all triggers
ICUs (N) * Patients (N) * Admissions Meeting Triggers % (SD) P value All ICUs 179 385,770 13.8 (4.8) Type of ICU * Medical 36 58,545 13.3 (4.1) Ref Surgical 16 31,305 13.9 (5.9) 0.77 Mixed 95 236,428 13.6 (4.7) 0.77 Medical- Surgical Trauma/Burn 28 53,854 14.7 (5.5) 0.41 Type of Hospital * Government 7 14,485 13.4 (3.3) 0.70 Community 12 15,890 12.8 (3.5) Ref for-profit Community 119 261,714 13.1 (4.7) 0.78 non-profit Academic 41 93,680 15.8 (5.0) 0.06 Hospital Location * Urban 100 225,799 13.8 (4.8) 0.97 Suburban 60 103,130 13.8 (4.9) 0.98 Rural 18 56,066 13.7 (5.1) Ref
Are these good triggers? Combined hospital mortality and discharge to hospice or a palliative care unit: 39.7% for patients meeting triggers 11.1% for patients not meeting triggers Lack of appropriate measures of success of palliative care interventions
Burden after ICU discharge 30.1% 57.6% Wunsch et al JAMA 2010
Big concern with closed model of intensive care
Conclusions Palliative care Palliative care
Thank you! hannah.wunsch@sunnybrook.ca