#38 Palliative Care in Critical Illness: Intentional & Compassionate Palliation with Dr. Anand Iyer, MD

Written By Nick Mark

On this week's episode of Critical Care Time, Cyrus & Nick are honored to be joined by palliative care expert, Dr. Anand Iyer. Together they explore the intricacies of palliation in the ICU, exploring the challenge and nuances of addressing this critical element of care amongst the sickest patients in the hospital. How do you begin these discussions? How do you ensure your patients and families feel heard? How do you help them realize palliation is part of the care process and not that you are giving up on a loved one? What terms should we avoid using? We cover all of this and more with Dr. Iyer so make sure to give this episode a listen and leave us some feedback! 


What is palliative care?

  • Palliative comes from the Latin Palliare which means to cloak; an act providing comfort and dignity.

  • Palliative care is associated with a number of benefits, including improved symptom burden, quality of life, and patient satisfaction

  • In the ICU, we pigeonhole this specialty to goals of care conversation and “palliative extubations” at the very end of life. However palliative care has much more potential. These roles include:

    • Symptom assessment/management (e.g. pain, dyspnea, anxiety, etc.)

    • Communication between patient and stakeholders

      • Serious illness conversations about a person’s values and wishes for end of life  

    • Helping to coordinate care with the ICU team

      • Inter-professional care teams

    • Terminal extubations

    • Discharge planning and coordination (e.g. hospice)

    • Caregiver engagement and bereavement


Primary vs Secondary Primary Care

  • True palliation is incredibly complex and difficult. It requires a system in your ICU to assess symptoms comprehensively and know how to manage them, as well as engaging in difficult but essential serious illness conversations about a person’s values and wishes for end of life and who they are as people. As with many aspects of critical care, this takes a village.

  • Primary palliative care refers to the basic skills and competencies required of all physicians and other health care professionals. Secondary palliative care refers to the specialist clinicians and organizations that provide consultation and specialty care.

    • Palliative care is much more than goals of care conversations. There will never be enough specialist palliative care clinicians to meet the need.

    • Secondary palliative care can be very useful in complex or difficult circumstances.


“The delivery and integration of primary and specialty palliative care should focus on the function (principles of integration) rather than the form (specific models of care like triggers or co-rounding). Given the diversity of cultures of different ICUs, we can be certain that the best form for how patients’ and families’ palliative care needs are met and how primary and specialty palliative care are integrated will vary from ICU to ICU, but the functions of providing high-quality palliative care to critically ill patients and their families are universal”


Specific Communication techniques

Headline statement

  • A clinical headline is a 1-3 sentence summary of the medical issues and what they mean for a patient. The “headline” is typically communicated to the patient and family in the context of a family meeting.

    • The first part typically summarizes the medical condition (“Your dad was admitted with a very serious infection. Despite everything we have done, his lungs, kidneys, and other organs are getting worse.”).  

    • The last part summarizes what the medical data means for the patient (“I am worried that he is dying.”) and to anticipate what information the patient and family really want to know, such as “Will he be on lifelong dialysis? “Will he be able to go home?” “Will he be able to feed himself?”

  • A good headline statement frames the situation, and provides important context for the conversation.

NURSE

  • NURSE is a structured approach to help you respond to strong emotions and articulate empathy.

  • It consists of 5 stages:

Acronym Example
N Name/acknowledge "I'm wondering if you are feeling ____?"
U Understand "I can see how you would feel ____."
R Respect "I understand that you want _____."
S Support "You are not alone."
"You don't have to go through this/make decisions all by yourself."
E Explore "how do you feel like this will effect you?"


SPIKES

  • SPIKES is a structured approach used to break bad news to patients or loved ones.

  • It consists of 6 steps:

Acronym Examples
S Setup - obtain the relevant knowledge (survival, prognosis, likely symptom progression, etc)
- invite the appropriate people (family, specialists, etc)
- physically setup the room (chairs, tissues, etc)
- provide introductions

P Perception - measure the temperature of the room
e.g. "what have you been told about ____?"

I Invitation - Provide an invitation to the discussion.
e.g. "are you ready to hear the news?"
Determine the altitude for the conversation
e.g. "are you the kind of person who likes details or do you just want the big picture?"

K Knowledge - Provide a warning shot
e.g. "I'm afraid the news isn't good"
- Break the bad news
- Pause for reaction
E Empathy respond to emotions (see NURSE rubric)

S Summary/Support - Summarize the conversation.
- Repeat steps as necesary.


Jumpstart tool

  • A short tool designed to facilitate goals of care conversations, described in JAMA 2023.

  • It consists of one question to initiate a short conversation about goals of care followed by a choice of one of three questions designed to elicit information about patient understanding, acceptable status, or values.

How to get better a providing palliative care



Misconceptions about palliative care

  • Some common misconceptions about palliative care in critical care settings:

    1. End of life care only - palliative provides far more than this

    2. Palliative is synonymous with Hospice - not necessarily

    3. Palliative is synonymous with Narcotics/opioids/benzos - again not necessarily

    4. “Going palliative”

    5. He’s the DNR guy - palliative provides far more than a change in code status

    6. Withdrawal of care - say “withdrawal of life support” we never stop caring


Support for ICU Clinicians

5 Key Take-Aways

  1. Palliation is appropriate at any stage of serious illness.

    • Go back to your home ICUs and evaluate your symptom assessment tools/triggers. Do you have them? Are they adequate and comprehensive? What does your ICU do with the score? 

  2. Train up:

    • Find serious illness conversation training opportunities large and small and then practice, practice, practice. Then teach. 

    • Go to a place like CAPC.org where you can find asynchronous training in primary PC for the ICU and clinic.

  3. Work with your home palliative care teams to evaluate different models of team-based integration and thresholds for consultation.

  4. Integrate PC education to pulm-crit fellowship conferences and develop simulation modules around terminal extubation

  5. Don’t forget about the family/caregivers/co-survivors.

Additional Resources:

Nick Mark
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