Palliative Care in the Intensive Care Unit

Palliative and end-of-life care have been inherent and immutable components of critical care delivery since the inception of the specialty and critical care units. Developed in the mid-20th century to optimize nursing care and medical outcomes for the most ill of patients, critical care units housed the sickest patients who not only had high mortality but also significant morbidity, including high prevalence of physical and psychological symptoms (Crit Care Med 2021;49:1626-37). Provision of high-quality and effective palliative care for critically ill patients and their families is considered a core competency of intensive care unit (ICU) practice and is widely incorporated into critical care guidelines and reviews.

The domains of palliative care are extensive and include everything from physical symptomatology to social aspects of care to the legal, practical, and ethical processes essential for advancing care planning and goals-related communication. In the ICU, palliative care is often more clearly delineated. Elements of palliative care that critically ill patients and their loved ones cite as most important include: 1) timely, clear, and compassionate communication, 2) decision-making centered around patients’ values and goals, 3) patient care that maintains comfort, dignity and personhood, 4) family-centered care with open communication among the care team and access to patients, and 5) bereavement care for families of patients who died or are dying (Figure) (Crit Care Med 2010;38:1765-72). These elements of care can be provided by a spectrum of clinicians, ranging from critical care team members (primary palliative care) to specialist consultants (specialty palliative care) to some combination of both.

Specialty palliative care typically involves delivery by a multidisciplinary, interprofessional team. The physicians are usually subspecialist-trained through a year-long hospice and palliative medicine fellowship. In this care model, the palliative care team may lead, and/or supplement, preexisting ICU team discussions surrounding patient values, goals, and wishes to facilitate alignment of proposed interventions with patient priorities. The palliative care team may provide recommendations for symptom management and end-of-life care, and may also take a more integrated approach, such as rounding with or otherwise “behind-the-scenes-supporting” the palliative care that is delivered by the ICU team. While there is widespread consensus among intensivists that palliative care integration is an essential component of critical illness care, optimal triggers and strategies for doing so are more controversial (Crit Care Med 2017;45:e372-8). Significant work has been devoted to identifying and delineating triggers for specialist palliative care consultation in the ICU; estimates of the prevalence of palliative care needs among ICU patients meeting these triggers range from one in five to one in seven admissions, depending upon the criteria used (Crit Care Med 2010;38:1765-72; Am J Respir Crit Care Med 2014;189:428-36). Specialist palliative care interventions have been associated with reductions in ICU length of stay and are not associated with increased mortality rates; however, at many institutions, limited specialist staffing reduces the availability of specialist palliative care (J Intensive Care 2022;10:20).

By contrast, primary palliative care, also called the “integrative model,” refers to symptom management, psychosocial support, prognostication, and serious illness communication delivered by the critical care team (Crit Care Med 2010;38:808-18). Primary palliative care may complement or in some cases replace specialist palliative care, particularly when provided by an ICU clinician trained and skilled in palliative care provision. There are limited data on how critical care specialists operationalize primary palliative care in the ICU, and less still is known about how primary palliative care may impact patient and clinician outcomes.

Palliative care skills training is also being increasingly incorporated into critical care fellowships, with many now integrating communication skills training and palliative care electives into their curricula. However, many anesthesiologist-intensivists may still receive limited exposure to serious illness communication. Thankfully, there are numerous resources for anesthesiologists and anesthesiologist-intensivists interested in acquiring communication skills to do so. Freestanding programs such as the Serious Illness Care Project (ariadnelabs.org/serious-illness-care/), VitalTalk (vitaltalk.org), and the Academy of Communication in Healthcare (achonline.org) provide opportunities for anesthesiologists and intensivists interested in buttressing their communication skills to pursue additional training and to learn and test new skills in a safe and supportive environment. Palliative care subspecialist teams at your own institution are also a local resource, particularly as many consider a core part of their mission to be to support and, if desired, provide guidance to clinicians providing primary palliative care.

While the value of palliative care in critical illness may be universal, all culture is local. Our experience is that there are varying palliative care patient needs and resources across different hospitals and even across different ICUs at the same hospital. It is important to familiarize yourself with the specialist and primary palliative care resources at your institution. Integrating them when possible and appropriate is the first step in providing the high-quality, person-centered, and compassionate palliative care that is so often needed and deserved by all critically ill patients and their family members.