Education About Palliative Care in the Intensive Care Unit: Rediscovering Opportunity

Abstract

U nderlying palliative care is a philosophy that aligns patients' health care with what they deem most important. For patients in the final stages of life, this often includes the desire to avoid burdensome and high-intensity care. In the intensive care unit (ICU), where we see the highest acuity of illness, often there are many competing priorities. The principles of palliative care are vital in refocusing our attention on what matters most to the patient and his or her family. Because of the value of these principles, there is increasing interest in finding ways to improve education in palliative care and to integrate palliative care education into the ICU. To achieve this goal, 3 models for incorporating palliative care in the ICU have been proposed: the integrative model (education in primary palliative care skills for ICU clinicians); the consultative model (access to palliative care specialists); and the mixed model that uses both of these approaches simultaneously. 1,2 It is increasingly clear that a mixed model, in which the education and deployment of palliative care specialists is combined with the education of all clinicians in basic principles of palliative care, is the optimal approach to address the diverse range of palliative care needs in the ICU. 2 Effective integration of palliative care into the ICU setting has important implications for graduate medical education. The ICU is 1 of the settings in our health care system where residents and fellows have the most contact with critically ill or dying patients. Despite this intimate exposure, there is little formal training about how best to care for these patients and their families. Effective communication, a key role of the ICU clinician, is 1 of the 6 core competencies from the Accreditation Council for Graduate Medical Education. More specialties are incorporating Milestones into the Next Accreditation System that include palliative care principles, such as delivering difficult news, conducting family conferences, and using shared decision making tailored to a patient's values. 3 In this issue of the Journal of Graduate Medical Education, Saft and colleagues 4 set out to determine if 3 factors related to palliative care-(1) the perceived quality of critical care fellowship training in palliative care, (2) the number of point-of-care support tools for palliative care, and (3) the availability of an inpatient palliative care consultation service-were associated with ICU utilization in the final 6 months of life. The authors ground this study in ''provider behavioral theory,'' which suggests that the best way to effect positive change in patient care is to rely less on the variable nature of individual clinicians and instead improve support for the entire patient-provider-system unit. 5 They hypothesized that these 3 initiatives, each supporting a different aspect of care delivery, would decrease ICU utilization. Their observational study encompassed 71 training programs in 89 hospitals, using surveys from program directors (with an approximately 50% response rate) and data from the Dartmouth Atlas. 6 It found that for every additional bedside tool an institution had implemented in the ICU, there was an associated 0.31-day decrease in ICU length of stay at the end of life. Additionally, for every 1-point increase in self-rated quality of palliative care education, there was a 0.57-day decrease in length of stay. The study did not find any association between the presence of a palliative care consultation service and ICU utilization at the end of life. One of the most notable findings by Saft and colleagues 4 was the high proportion (more than 80%) of hospitals that had a palliative care consultation service. Because there were so few hospitals without a palliative care consultation service, this study was not powered to examine the effect of having access to specialty palliative care. Furthermore, the authors had no information about the degree to which the palliative care specialists were integrated into the ICU. In our experience, there is enormous variability in how palliative care specialists are incorporated into the ICU. This ranges from hospitals where the palliative care service first began in a critical care setting to hospitals where the intensivists and the palliative care specialists collaborate very little or not at all. It would be interesting to examine whether the degree of incorporation of palliative care specialists into the ICU is a predictor of quality of palliative care in the ICU.