Clareen Wiencek, PhD, RN, ACHPN, ACNP Immediate Past President American Association of Critical-Care Nurses Clareen.Wiencek@aacn.org Palliative Care and Critical Care: A New Decade The purpose of this session is to enable the participant to understand how palliative care is now an expected component of high quality critical care and to gain knowledge about team based provision of primary and specialist primary care so they can use this knowledge in the care of patients who are seriously ill. By the end of the session(s) the attendees will be able to: 1. Describe milestones behind the convergence of palliative care and critical care. 2. Discuss the current state and evidence supporting palliative care in the critical care setting. 3. Examine how the interdisciplinary team can incorporate primary and specialist palliative care in the practice setting. Outline I. Past milestones and progress a. Public sector i. IOM Dying in America 2015; 1997 Approaching death: Improving care at end of life. ii. CMS January 2016 ACP billing codes iii. Impact of regulatory oversight, external forces iv. CAPC stats % of hospitals with PC programs ; Halpern NEJM Nov 2015 b. Professional societies i. AACN s efforts: HWE, voice initiatives, PFCC, mission work ii. CCSC position statements iii. Most recent: ATS and ACCM Shared Decision Making; Joint ATS/AACN/ACCP/ESICM/SCCM policy statement on inappropriate treatments c. Private sector - Media, cultural events i. Being Mortal ii. Physician assisted death laws iii. Brittany Maynard, 29; diagnosed with brain tumor, moved with her mother and husband of one year from CA to Oregon; Palliative Care and Critical Care: A New Decade Page 1 of 6
aid in dying law allowed terminally ill patients to end their life. Started Brittany Maynard Fund to lobby for such laws. Died Nov 1, 2014 open letter that otherwise would be dominated by fear, uncertainty, and pain. iv. Presidential campaign 2016 ACA II. Current momentum and state of the relationship a. Primary palliative care: Primary palliative nursing includes the management of pain and symptoms, combined with discussion of treatments, disease progression, and imminent death. (Dahlin, 2015). Specific primary palliative nursing skills and competencies mean that the nurse: Understands the natural trajectory of illnesses and conditions with the associated critical decision making points. Recognizes and treats common conditions, including care of the dying patient, by using basic principles of pain and symptom management and evidence-based practice. Discusses advance care planning, goals of care, issues of advanced disease, and provides culturally appropriate psychosocial support for patients and their families. Understands palliative and hospice care services, eligibility, and how to access these services in one s setting and community. Attends to population-specific concerns across the continuum of care and life, such as pediatric oncology palliative care, geriatric oncology palliative care. Understands community resources. (Dahlin 2015) b. Secondary or specialist primary care c. State of the evidence i. JAMA January 2016 issue ii. Bekelman, et al. Comparison of site of death in 7 developed countries iii. ATS and ACCM Shared Decision Making iv. Multi-society statement responding to requests for inappropriate treatments d. Share stories of success i. NTI ii. MUSC iii. ELNEC CCF, others Palliative Care and Critical Care: A New Decade Page 2 of 6
III. IV. Future directions a. Each nurse provides primary palliative care: It Matters b. NAM roundtable private sector ;ANA Professional Issues Panel c. Academia: C.A.R.E.S.; graduate level d. Research: NINR, PCORI e. Practice: David and Goliath; Barriers to practice insights; CSI Team based models References A controlled study to improve care for seriously ill hospitalized patients. The Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT). The SUPPORT principle investigators Understanding costs and cost effectiveness in critical care: Report from the second American Thoracic Society workshop on outcomes research. JAMA 1995; 274:1591-1598. Angus, D.C., Truog, R.D.. Toward better ICU use at end of life. JAMA 2016;315:255-256. Bosslet, G., Pope, T., Rubenfeld, G., et al. An official ATS/AACN/ACCP/ESICM/SCCM policy statement: Responding to requests for potentially inappropriate treatments in Intensive Care Units. Am J Respir Crit Care Med 2015;191:1318-1330. Angus, D.C., Barnato, A.E., Linde-Zwirble, W.T., et al. Robert Wood Johnson Foundation ICU End-of-Life Peer Group: Use of intensive care at the end of life in the United States: An epidemiologic study. Crit Care Med 2004; 32:638-643. Aslakson, R., Curtis, J.R., Nelson, J. The changing role of palliative care in the ICU. Crit Care Med 2014;42:2418-2428. Aslakson, R., Cheng, J., Vollenweider, D., et al. Evidence-based palliative care in the intensive care unit: A systematic review of interventions. J Palliat Med 2014;17:219-235. Bekelman, J.E., Halpern, S., Blankart, C.R., et al. Comparison of site of death, health care utilization, and hospital expenditures for patients dying with cancer in 7 developed countries. JAMA 2016; 315(3):272-283. Berlinger, N., Jennings, B., Wolf, S. The Hastings Center Guidelines for Decisions on Life-Sustaining Treatment and Care Near the End-of-Life: Revised and Expanded second edition. New York, NY: Oxford University Press; 2013. Palliative Care and Critical Care: A New Decade Page 3 of 6
Cassell, J., Buchman, T.G., Streat, S., et al. Surgeons, intensivists, and the covenant of care: Administrative models and values affecting care at the end-of-life- Updated. Crit Care Med 2003; 31:1551-1557. Clarke, E.B., Curtis, J.R., Luce, J.M., et al. Robert Wood Johnson Foundation Critical Care End-of-Life Peer Workgroup Members: Quality indicators for end-of-life care in the intensive care unit. Crit Care Med 2003;31:2255-2262. Choosing Wisely Campaign: Critical Care Societies Collaborative. Critical Care-Five Things Physicians and Patients Should Question. Available at: http://www.choosingwisely.org/wp-content/uploads/2014/01/sccm- 5things-List-012014.pdf Curtis, J.R., Treece, P.D., Nielsen, E.L., et al. Integrating palliative and critical care: Evaluation of a quality improvement intervention. Am J Respir Crit Care Med 2008;178-269-275. Curtis, J.R., Nielsen, E.L., Treece, P.D., et al. Effect of a quality improvement intervention on end-of-life care in the intensive care unit: a randomized trial. Am J Respir Crit Care Med 2011;183:348-355. Gawande, A. Being Mortal. New York, NY: Metropolitan Books, 2014. Gawande, A. Quantity and quality of life: Duties of care in life-limiting illness. JAMA 2016;315(3):267-269. Halpern, S. Toward evidence-based end-of-life care. N Engl J Med 2015;373:2001-2003. Improving palliative care in the ICU (IPAL-ICU): Evaluation of ICU Palliative Care Quality. Available at: http://ipal.capc.org. Institute of Medicine. Dying in America: Improving quality and honoring individual preferences near the end of life. Washington, DC: The National Academies Press; 2015. Kelley, A., Morrison, R.S. Palliative care for the seriously ill. N Engl J Med 2015; 373:747-755. Khandelwal, N., Curtis, J.R. Economic implications of end-of-life care in the ICU. Current Op Crit Care 2014;20:656-661. Khandelwal, N., Kross, E.K., Engelberg, R., et al. Estimating the effect of palliative care interventions and advance care planning on ICU utilization: A systematic review. Crit Care Med 2015; 43:1102-1111. Palliative Care and Critical Care: A New Decade Page 4 of 6
Kon, A.A., Davidson, J.E., Morrison, W., Dannis, M., White, D.B. Shared decision making in ICUs: An American College of Critical Care Medicine and American Thoracic Society Policy Statement. Crit Care Med 2016;44:188-201. Morrison, S., Penrod, Cassel, J.B., et al. Cost savings associated with US hospital palliative care consultation programs. Archives of Internal Medicine 2008; 168: 1783-1790. Mosenthal, A.C., Weissman, D.E., Curtis, J.R., et al. Integrating palliative care in the surgical and trauma intensive care unit: A report from the Improving Palliative Care in the Intensive Care Unit (IPAL-ICU) Project Advisory Board and the Center to Advance Palliative Care. Crit Care Med 2012; 40:1199-1206. National Consensus Project for Quality Palliative Care. Clinical Practice Guidelines for Quality Palliative Care. 3 rd ed. Pittsburgh, PA: National Consensus Project for Quality Palliative Care, 2013. Nelson, J.E., Cortez, T.B., Curtis, J.R., et al. Integrating palliative care in the ICU: The nurse in a leading role. J Hospice Palliat Nurs 2011; 13:89-94. Nelson, J., Bassett, R., Boss, R.D., et al. Improve Palliative Care in the Intensive Care Unit Project: Models for structuring a clinical initiative to enhance palliative care in the ICU: A report from the IPAL-ICU Project. Crit Care Med 2010; 38:1765-1772. Nelson, J., Puntillo, K., Pronovost, P.J., et al. In their own words: patients and families define high-quality palliative care in the intensive care unit. Crit Care Med 2010; 38:808-818. Perrin, K.O., Kazanowski, M. Overcoming barriers to palliative care consultation. Crit Care Nurse 2015; 35:44-51. Promoting excellence in palliative and end-of-life care. Available at: http://www.aacn.org/wd/practice/content/palliative-and-end-of-lifecare.content?menu=practice Quill, T.E., Holloway, R. Time limited trials near the end-of-life. JAMA 2011; 306:1483-1484. Rothman, D. Where we die. NEJM 2014; 370:2457-2460. Scheunemann, L.P., McDevitt, M., Carson, S.S., et al. Randomized controlled trials of interventions to improve communication in intensive care: A systematic review. Chest 2011; 139:543-554. Palliative Care and Critical Care: A New Decade Page 5 of 6
Temel, J., Greer, J., Muzikansky, M., et al. Early palliative care for patients with metastatic non-small-cell lung cancer. NEJM 2010; 363:733-742. Teno, J.M., Gozalo, P.L., Bynum, J.P., et al. Change in end-of-life care for Medicare beneficiaries : site of death, place of care, and heath care transitions in 2000,2005, and 2009. JAMA 2013; 309: 470-477. Wiencek, C. Palliative care in the Intensive Care Unit setting. In: Dahlin, C., Coyne, P., Ferrell, B., eds. Advanced Practice Palliative Nursing. New York, NY: Oxford University Press; 2016:65-73. Wolf, S.M., Berlinger, N., Jennings, B.. Forty years of work on end-of-life care from patient s rights to systemic reform. NEJM 2015;372:678-682. Palliative Care and Critical Care: A New Decade Page 6 of 6