Question 24

Regarding the provision of palliative care to ICU patients, outline the advantages and disadvantages of using:
a) A traditional Intensive care consultant - based approach (integrative palliative care).
(50% marks)
b) Palliative care specialty involvement in the ICU by specific consultation (consultative palliative care). (50% marks)

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College answer

Generally answered well by outlining the limitations of an ICM physician, especially time pressure, care of other critically ill patients and transition of care to the ward. There were multiple references to ICM physicians considering palliation as failure of ICU therapy or having "guilt" which impacts provision of palliative care. Virtually all candidates discussed specific clinical aspects, whereas other aspects such as resources, staffing, and model comparisons, were not addressed.

Discussion

This answer would work better as a table. The use of the terms "integrative" and "consultative" is not unique but suggests that specific (largely North American) resources were used by the examiners to create this question.

Advantages	Disadvantages
"Integrative" intensivist-led palliative care
Family will already have rapport with the intensivist Uniquely ICU-related aspects of ICU patient end-of-life symptoms would be better managed by ICU staff (eg. post-extubation stridor) ICU staff may derive satisfaction from being able to provide "a good death" Some may consider end-of-life care as an integral part of good ICU care Skill mix of ICU staff and palliative medicine staff is sufficiently overlapping (especially in terms of communication skills)	Impact on ICU clinician may be significant (psychological and emotional burden) ICU environment is a poor environment for restful endo of life care and patient/family privacy Rapport may be interrupted by constantly rotating ICU staff Busy intensivists may not have the necessary time or attention to dedicate to monitoring for symptoms and attending to family questions
"Consultative" palliative medicine referral
Specialist care with focused attention to symptoms (and perhaps better able to recognise subtle signs of distress) Skill mix of nursing and medical staff is optimised for end of life care Transition to ward-based palliative care is smoother, with less information loss during handover Resources are optimally distributed (cost of a palliative medicine bed is much lower than that of an ICU bed) The palliative medicine team should not have many other priorities other than symptom control, i.e. not distracted by other demands	Intensive care staff may experience dissatisfaction with the loss of agency over the management decisions Interruption of rapport which has been developed between ICU staff and the family The perception of "failure" can develop in the intensive care team, as the result of the perceived inability to meet the palliative care needs of the dying patient The perception of abandonment by the family can develop as the result of the intensivist disenaging and handing over care No evidence for benefit in a closed model. All the evidence for benefit comes from studies based on "open model" ICUs

References

Hill, Stephanie A., et al. "Palliative medicine in the intensive care unit: needs, delivery, quality." BMJ Supportive & Palliative Care 12.1 (2022): 38-41.

Einav, Sharon, Nathan I. Cherny, and J. Randall Curtis. "Palliative medicine in the intensive care unit." Oxford Textbook of Palliative Medicine (2021): 121.

Kościuczuk, Urszula, et al. "Aspects of palliative medicine in intensive care units: A narrative review." Palliative Medicine in Practice (2022).

Stamper, Tara Orgon, Renee Kerr, and Daniela Sporter. "The Evolution of Palliative Medicine in Intensive Care." Critical Care Nursing Quarterly 45.4 (2022): 332-338.

Tomko, Caitlin, et al. "The Practical Implementation of an Embedded Palliative Care Team in a Medical Intensive Care Unit (QI435)." Journal of Pain and Symptom Management 63.5 (2022): 904.

Bhan, Swati, et al. "Palliative Care in Intensive Care Unit." Onco-critical Care: An Evidence-based Approach. Singapore: Springer Nature Singapore, 2022. 515-524.

Ito, Kaori, et al. "Primary palliative care recommendations for critical care clinicians." Journal of Intensive Care 10.1 (2022): 20.

Effendy, Christantie, et al. "Barriers and facilitators in the provision of palliative care in adult intensive care units: a scoping review." Acute and Critical Care 37.4 (2022): 516-526.

Martins, Belmira DCPCC, Reinaldo A. Oliveira, and Antonio JM Cataneo. "Palliative care for terminally ill patients in the intensive care unit: Systematic review and metaanalysis." Palliative & Supportive Care 15.3 (2017): 376-383.

Carson, Shannon S., et al. "Effect of palliative care–led meetings for families of patients with chronic critical illness: a randomized clinical trial." Jama 316.1 (2016): 51-62.

Strand, Jacob J., and J. Andrew Billings. "Integrating palliative care in the intensive care unit." The journal of supportive oncology 10.5 (2012): 180-187.

Trankle, Steven A. "Is a good death possible in Australian critical and acute settings?: physician experiences with end-of-life care." BMC palliative care 13.1 (2014): 1-14.

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