CORRESPONDENCE References 1. Jozwiak M, Teboul JL, Anguel N, Persichini R, Silva S, Chemla D, Richard C, Monnet X. Beneficial hemodynamic effects of prone positioning in patients with acute respiratory distress syndrome. Am J Respir Crit Care Med 2013;188:1428–1433. 2. Magder S. Is all on the level? Hemodynamics during supine versus prone ventilation [editorial]. Am J Respir Crit Care Med 2013;188: 1390–1391.
Copyright © 2014 by the American Thoracic Society
Palliative Care: A Core Competency for Intensive Care Unit Doctors To the Editor: Using a set of screening criteria that suggest very poor prognosis in critically ill patients, Hua and colleagues report that up to 20% of intensive care unit (ICU) admissions meet triggers for palliative care consultation (1). At the same time, an accompanying editorial by Ford (2) estimates a shortage of between 6,000 and 18,000 palliative care physicians (with only z180 trained annually) for all these consultations. Rather than expect thousands of newly trained palliative care doctors to meet this need, the reality is that ICU physicians will and should provide this care. Conversations about end-of-life care goals and options are key interventions that all intensivists should become experts in, as important as understanding our patients’ physiology and offering procedural expertise. Care of many ICU patients is often fragmented, and there might not be a more appropriate person to have these discussions. Thus, this study should push those of us in critical care to define the key components of palliative care and learn how to better implement them. Quill and Abernethy recently proposed a model of generalist versus specialist palliative care (3). They argue that a patient’s primary physician can perform basic elements of palliative care and that consultation should be reserved for more complex cases—similar to how ICU physicians practice regarding most other specialties. For example, if an ICU patient has an arrhythmia, the intensivist orders an ECG for diagnosis, selects appropriate first-line medications, and stabilizes the patient, only calling a cardiology consultation for difficult cases (e.g., electrophysiologist) or advanced therapy (e.g., pacemaker). Palliative care should not be inherently different. How will we provide this care? Valid concerns exist about the degree of training required to have these conversations, the different approaches to conducting these discussions, and whether this increased emphasis on conversations surrounding serious illness might be unrealistic, given the other responsibilities of intensivists. In response, we propose the use of a “checklist approach,” which has been effective in communication in other arenas. From its initial roles in aviation and nuclear power, the checklist approach has been validated across high-stress settings from safer surgery to limiting catheter-associated infections in the ICU (4, 5). This methodology led to the development of a structured communication guide that distills the key elements of a discussion of end-of-life care goals. This guide aims to help non–palliative care physicians efficiently explore their
Correspondence
patients’ understanding of illness, values, and trade-offs (6). It is currently being tested in the outpatient oncology setting at our institution, and an adapted version is being piloted for surrogates of the critically ill. Demonstrating that such a conversation can be teachable and time effective could have a major impact on end-of-life care. Of course, palliative care consultation will remain essential for complex cases, but from our perspective, we cannot afford to defer the basics of palliative care to consultants. With this study’s results in mind, we need to study integrative models of palliative care in the ICU with the same rigor that we have applied to ventilator management in acute respiratory distress syndrome and sedation regimens, for example. Palliative care competencies add value to our care of patients and have been shown to improve quality of life and even to decrease mortality (7). In addition to more training of palliative care physicians, we need to educate ourselves and develop new methods to integrate these competencies into the care of our patients today. n Author disclosures are available with the text of this letter at www.atsjournals.org Daniela J. Lamas, M.D. Robert L. Owens, M.D. Brigham and Women’s Hospital Boston, Massachusetts Rachelle E. Bernacki, M.D. Susan D. Block, M.D. Brigham and Women’s Hospital Boston, Massachusetts and Dana Farber Cancer Institute Boston, Massachusetts
References 1. Hua MS, Li G, Blinderman CD, Wunsch H. Estimates of the need for palliative care consultation across United States intensive care units using a trigger-based model. Am J Respir Crit Care Med 2014;189: 428–436. 2. Ford DW. Palliative care consultation needs in United States intensive care units: another workforce shortage? Am J Respir Crit Care Med 2014;189:383–384. 3. Quill TE, Abernethy AP. Generalist plus specialist palliative care— creating a more sustainable model. N Engl J Med 2013;368: 1173–1175. 4. Haynes AB, Weiser TG, Berry WR, Lipsitz SR, Breizat AH, Dellinger EP, Herbosa T, Joseph S, Kibatala PL, Lapitan MC, et al.; Safe Surgery Saves Lives Study Group. A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med 2009;360: 491–499. 5. Guerin K, Wagner J, Rains K, Bessesen M. Reduction in central line-associated bloodstream infections by implementation of a postinsertion care bundle. Am J Infect Control 2010;38: 430–433. 6. Bernacki RE, Block SD. Serious illness communications checklist. Virtual Mentor 2013;15:1045–1049. 7. Temel JS, Greer JA, Muzikansky A, Gallagher ER, Admane S, Jackson VA, Dahlin CM, Blinderman CD, Jacobsen J, Pirl WF, et al. Early palliative care for patients with metastatic non-small-cell lung cancer. N Engl J Med 2010;363:733–742.
Copyright © 2014 by the American Thoracic Society
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Copyright © 2014 by the American Thoracic Society
Palliative Care: A Core Competency for Intensive Care Unit Doctors To the Editor: Using a set of screening criteria that suggest very poor prognosis in critically ill patients, Hua and colleagues report that up to 20% of intensive care unit (ICU) admissions meet triggers for palliative care consultation (1). At the same time, an accompanying editorial by Ford (2) estimates a shortage of between 6,000 and 18,000 palliative care physicians (with only z180 trained annually) for all these consultations. Rather than expect thousands of newly trained palliative care doctors to meet this need, the reality is that ICU physicians will and should provide this care. Conversations about end-of-life care goals and options are key interventions that all intensivists should become experts in, as important as understanding our patients’ physiology and offering procedural expertise. Care of many ICU patients is often fragmented, and there might not be a more appropriate person to have these discussions. Thus, this study should push those of us in critical care to define the key components of palliative care and learn how to better implement them. Quill and Abernethy recently proposed a model of generalist versus specialist palliative care (3). They argue that a patient’s primary physician can perform basic elements of palliative care and that consultation should be reserved for more complex cases—similar to how ICU physicians practice regarding most other specialties. For example, if an ICU patient has an arrhythmia, the intensivist orders an ECG for diagnosis, selects appropriate first-line medications, and stabilizes the patient, only calling a cardiology consultation for difficult cases (e.g., electrophysiologist) or advanced therapy (e.g., pacemaker). Palliative care should not be inherently different. How will we provide this care? Valid concerns exist about the degree of training required to have these conversations, the different approaches to conducting these discussions, and whether this increased emphasis on conversations surrounding serious illness might be unrealistic, given the other responsibilities of intensivists. In response, we propose the use of a “checklist approach,” which has been effective in communication in other arenas. From its initial roles in aviation and nuclear power, the checklist approach has been validated across high-stress settings from safer surgery to limiting catheter-associated infections in the ICU (4, 5). This methodology led to the development of a structured communication guide that distills the key elements of a discussion of end-of-life care goals. This guide aims to help non–palliative care physicians efficiently explore their
Correspondence
patients’ understanding of illness, values, and trade-offs (6). It is currently being tested in the outpatient oncology setting at our institution, and an adapted version is being piloted for surrogates of the critically ill. Demonstrating that such a conversation can be teachable and time effective could have a major impact on end-of-life care. Of course, palliative care consultation will remain essential for complex cases, but from our perspective, we cannot afford to defer the basics of palliative care to consultants. With this study’s results in mind, we need to study integrative models of palliative care in the ICU with the same rigor that we have applied to ventilator management in acute respiratory distress syndrome and sedation regimens, for example. Palliative care competencies add value to our care of patients and have been shown to improve quality of life and even to decrease mortality (7). In addition to more training of palliative care physicians, we need to educate ourselves and develop new methods to integrate these competencies into the care of our patients today. n Author disclosures are available with the text of this letter at www.atsjournals.org Daniela J. Lamas, M.D. Robert L. Owens, M.D. Brigham and Women’s Hospital Boston, Massachusetts Rachelle E. Bernacki, M.D. Susan D. Block, M.D. Brigham and Women’s Hospital Boston, Massachusetts and Dana Farber Cancer Institute Boston, Massachusetts
References 1. Hua MS, Li G, Blinderman CD, Wunsch H. Estimates of the need for palliative care consultation across United States intensive care units using a trigger-based model. Am J Respir Crit Care Med 2014;189: 428–436. 2. Ford DW. Palliative care consultation needs in United States intensive care units: another workforce shortage? Am J Respir Crit Care Med 2014;189:383–384. 3. Quill TE, Abernethy AP. Generalist plus specialist palliative care— creating a more sustainable model. N Engl J Med 2013;368: 1173–1175. 4. Haynes AB, Weiser TG, Berry WR, Lipsitz SR, Breizat AH, Dellinger EP, Herbosa T, Joseph S, Kibatala PL, Lapitan MC, et al.; Safe Surgery Saves Lives Study Group. A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med 2009;360: 491–499. 5. Guerin K, Wagner J, Rains K, Bessesen M. Reduction in central line-associated bloodstream infections by implementation of a postinsertion care bundle. Am J Infect Control 2010;38: 430–433. 6. Bernacki RE, Block SD. Serious illness communications checklist. Virtual Mentor 2013;15:1045–1049. 7. Temel JS, Greer JA, Muzikansky A, Gallagher ER, Admane S, Jackson VA, Dahlin CM, Blinderman CD, Jacobsen J, Pirl WF, et al. Early palliative care for patients with metastatic non-small-cell lung cancer. N Engl J Med 2010;363:733–742.
Copyright © 2014 by the American Thoracic Society
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