Program Encourages Palliative Care Techniques in the ICU

Critical care and palliative care may seem like opposing concepts, but experts in both fields say bringing palliative care techniques into the intensive care unit can decrease costs and improve patient satisfaction.

A new project launched in partnership with the Center to Advance Palliative Care aims to jump-start the integration of palliative care techniques into ICU programs by providing a slew of online tools and resources.

The IPAL-ICU Project (www.capc.org/ipal-icu

The first step for anyone considering introducing palliative care into the ICU is to make the case to the multidisciplinary critical care team and to hospital leaders, said Dr. Judith E. Nelson, the project director for the IPAL-ICU Project and a professor of medicine at Mount Sinai School of Medicine in New York City. But it's not a difficult case to make, she said.

“There is absolutely no downside here,” Dr. Nelson said. “There is enhanced care and satisfaction for everyone involved, and efficiencies for the institution and the health care system as a whole. It's really a win across the system, and there aren't that many places or strategies in health care that we can say that about.”

Research shows that the use of palliative care consultation programs has resulted in cost savings throughout hospitals, including reductions in ICU costs (Arch. Intern. Med. 2008;168:1783-90). Those savings aren't achieved by increasing mortality, Dr. Nelson said. Instead, the better communication fostered by using palliative care strategies results in a reduced use of nonbeneficial ICU treatments and even a decreased length of stay. “It cuts back on delay and improves communication,” Dr. Nelson said.

The biggest barrier is convincing people to let go of the old model of sequential care, Dr. Nelson said. In that model, a patient receives aggressive care in the ICU and, when that is exhausted, moves to palliative care in a hospice setting.

There's a fear that the introduction of palliative care early on means that the intensive care will somehow be diminished, she noted. “That's not necessary, and it's not optimal,” Dr. Nelson explained. When done right, palliative care should support an aggressive care plan by making sure it is tailored to the patient's needs and desires. Palliative care can also help identify untreated pain and other symptoms.

Over the last decade, palliative care programs in general have spread across the country and increasingly been embraced by physicians. Dr. Nelson said she hopes that palliative care in the ICU setting will have similar success.

The concept of palliative care in the ICU is already catching on, noted Dr. J. Randall Curtis, professor of medicine at the University of Washington and head of the section of pulmonary and critical care medicine at Harborview Medical Center in Seattle. Just a few years ago, many people thought the very idea was crazy, he said—but he doesn't hear that anymore.

“I think people are still struggling with how to do it well, but I think there's a common acceptance that this is an important part of critical care,” said Dr. Curtis, who is a member of the IPAL-ICU advisory board.

Still, ICUs can be a difficult place to integrate palliative care, he cautioned.

For starters, critical care units are busy places. Physicians and nurses working there need to balance considerations such as providing supportive palliative care against the need to focus on reducing central line infections and using ventilators appropriately. In addition, palliative care isn't the primary goal in the ICU—so the clinicians there need training on how to provide both types of care.

Another potential pitfall can be a “clash of cultures” between the ICU team and palliative care consultants, Dr. Curtis said. Palliative care specialists need to learn about the culture of the ICU, or they risk coming in with the attitude that the critical care team is being overly aggressive in their approach to some patients. That can happen if they don't understand the outcomes of conditions commonly treated in the ICU.

Palliative and critical care teams need to operate on the same page, agreed Dr. Daniel E. Ray, director of the palliative medicine fellowship program at the Lehigh Valley Health Network in Allentown, Pa., and a member of the advisory board for the IPAL-ICU Project. Otherwise, it opens up the possibility that patients and families could receive conflicting recommendations from providers.

The IPAL-ICU Project resources should go a long way to helping institutions get started on the concept. However, he cautioned that the resources should be customized to the unique culture of each hospital, and that leaders need to work on getting buy-in from everyone on the team to ensure that the templates are actually used.

Critical care and palliative care may seem like opposing concepts, but experts in both fields say bringing palliative care techniques into the intensive care unit can decrease costs and improve patient satisfaction.

A new project launched in partnership with the Center to Advance Palliative Care aims to jump-start the integration of palliative care techniques into ICU programs by providing a slew of online tools and resources.

The IPAL-ICU Project (www.capc.org/ipal-icu

The first step for anyone considering introducing palliative care into the ICU is to make the case to the multidisciplinary critical care team and to hospital leaders, said Dr. Judith E. Nelson, the project director for the IPAL-ICU Project and a professor of medicine at Mount Sinai School of Medicine in New York City. But it's not a difficult case to make, she said.

“There is absolutely no downside here,” Dr. Nelson said. “There is enhanced care and satisfaction for everyone involved, and efficiencies for the institution and the health care system as a whole. It's really a win across the system, and there aren't that many places or strategies in health care that we can say that about.”

Research shows that the use of palliative care consultation programs has resulted in cost savings throughout hospitals, including reductions in ICU costs (Arch. Intern. Med. 2008;168:1783-90). Those savings aren't achieved by increasing mortality, Dr. Nelson said. Instead, the better communication fostered by using palliative care strategies results in a reduced use of nonbeneficial ICU treatments and even a decreased length of stay. “It cuts back on delay and improves communication,” Dr. Nelson said.

The biggest barrier is convincing people to let go of the old model of sequential care, Dr. Nelson said. In that model, a patient receives aggressive care in the ICU and, when that is exhausted, moves to palliative care in a hospice setting.

There's a fear that the introduction of palliative care early on means that the intensive care will somehow be diminished, she noted. “That's not necessary, and it's not optimal,” Dr. Nelson explained. When done right, palliative care should support an aggressive care plan by making sure it is tailored to the patient's needs and desires. Palliative care can also help identify untreated pain and other symptoms.

Over the last decade, palliative care programs in general have spread across the country and increasingly been embraced by physicians. Dr. Nelson said she hopes that palliative care in the ICU setting will have similar success.

The concept of palliative care in the ICU is already catching on, noted Dr. J. Randall Curtis, professor of medicine at the University of Washington and head of the section of pulmonary and critical care medicine at Harborview Medical Center in Seattle. Just a few years ago, many people thought the very idea was crazy, he said—but he doesn't hear that anymore.

“I think people are still struggling with how to do it well, but I think there's a common acceptance that this is an important part of critical care,” said Dr. Curtis, who is a member of the IPAL-ICU advisory board.

Still, ICUs can be a difficult place to integrate palliative care, he cautioned.

For starters, critical care units are busy places. Physicians and nurses working there need to balance considerations such as providing supportive palliative care against the need to focus on reducing central line infections and using ventilators appropriately. In addition, palliative care isn't the primary goal in the ICU—so the clinicians there need training on how to provide both types of care.

Another potential pitfall can be a “clash of cultures” between the ICU team and palliative care consultants, Dr. Curtis said. Palliative care specialists need to learn about the culture of the ICU, or they risk coming in with the attitude that the critical care team is being overly aggressive in their approach to some patients. That can happen if they don't understand the outcomes of conditions commonly treated in the ICU.

Palliative and critical care teams need to operate on the same page, agreed Dr. Daniel E. Ray, director of the palliative medicine fellowship program at the Lehigh Valley Health Network in Allentown, Pa., and a member of the advisory board for the IPAL-ICU Project. Otherwise, it opens up the possibility that patients and families could receive conflicting recommendations from providers.

The IPAL-ICU Project resources should go a long way to helping institutions get started on the concept. However, he cautioned that the resources should be customized to the unique culture of each hospital, and that leaders need to work on getting buy-in from everyone on the team to ensure that the templates are actually used.

Critical care and palliative care may seem like opposing concepts, but experts in both fields say bringing palliative care techniques into the intensive care unit can decrease costs and improve patient satisfaction.

A new project launched in partnership with the Center to Advance Palliative Care aims to jump-start the integration of palliative care techniques into ICU programs by providing a slew of online tools and resources.

The IPAL-ICU Project (www.capc.org/ipal-icu

The first step for anyone considering introducing palliative care into the ICU is to make the case to the multidisciplinary critical care team and to hospital leaders, said Dr. Judith E. Nelson, the project director for the IPAL-ICU Project and a professor of medicine at Mount Sinai School of Medicine in New York City. But it's not a difficult case to make, she said.

“There is absolutely no downside here,” Dr. Nelson said. “There is enhanced care and satisfaction for everyone involved, and efficiencies for the institution and the health care system as a whole. It's really a win across the system, and there aren't that many places or strategies in health care that we can say that about.”

Research shows that the use of palliative care consultation programs has resulted in cost savings throughout hospitals, including reductions in ICU costs (Arch. Intern. Med. 2008;168:1783-90). Those savings aren't achieved by increasing mortality, Dr. Nelson said. Instead, the better communication fostered by using palliative care strategies results in a reduced use of nonbeneficial ICU treatments and even a decreased length of stay. “It cuts back on delay and improves communication,” Dr. Nelson said.

The biggest barrier is convincing people to let go of the old model of sequential care, Dr. Nelson said. In that model, a patient receives aggressive care in the ICU and, when that is exhausted, moves to palliative care in a hospice setting.

There's a fear that the introduction of palliative care early on means that the intensive care will somehow be diminished, she noted. “That's not necessary, and it's not optimal,” Dr. Nelson explained. When done right, palliative care should support an aggressive care plan by making sure it is tailored to the patient's needs and desires. Palliative care can also help identify untreated pain and other symptoms.

Over the last decade, palliative care programs in general have spread across the country and increasingly been embraced by physicians. Dr. Nelson said she hopes that palliative care in the ICU setting will have similar success.

The concept of palliative care in the ICU is already catching on, noted Dr. J. Randall Curtis, professor of medicine at the University of Washington and head of the section of pulmonary and critical care medicine at Harborview Medical Center in Seattle. Just a few years ago, many people thought the very idea was crazy, he said—but he doesn't hear that anymore.

“I think people are still struggling with how to do it well, but I think there's a common acceptance that this is an important part of critical care,” said Dr. Curtis, who is a member of the IPAL-ICU advisory board.

Still, ICUs can be a difficult place to integrate palliative care, he cautioned.

For starters, critical care units are busy places. Physicians and nurses working there need to balance considerations such as providing supportive palliative care against the need to focus on reducing central line infections and using ventilators appropriately. In addition, palliative care isn't the primary goal in the ICU—so the clinicians there need training on how to provide both types of care.

Another potential pitfall can be a “clash of cultures” between the ICU team and palliative care consultants, Dr. Curtis said. Palliative care specialists need to learn about the culture of the ICU, or they risk coming in with the attitude that the critical care team is being overly aggressive in their approach to some patients. That can happen if they don't understand the outcomes of conditions commonly treated in the ICU.

Palliative and critical care teams need to operate on the same page, agreed Dr. Daniel E. Ray, director of the palliative medicine fellowship program at the Lehigh Valley Health Network in Allentown, Pa., and a member of the advisory board for the IPAL-ICU Project. Otherwise, it opens up the possibility that patients and families could receive conflicting recommendations from providers.

The IPAL-ICU Project resources should go a long way to helping institutions get started on the concept. However, he cautioned that the resources should be customized to the unique culture of each hospital, and that leaders need to work on getting buy-in from everyone on the team to ensure that the templates are actually used.