Original Article

Palliative Care in the Intensive Care Unit: Are Residents Well Trained to Provide Optimal Care to Critically ill Patients?

American Journal of Hospice & Palliative Medicine® 2015, Vol. 32(7) 758-762 ª The Author(s) 2014 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/1049909114536979 ajhpm.sagepub.com

Ghassan Kamel, MD1, Miguel Paniagua, MD2, and Aditya Uppalapati, MD3

Abstract Palliative care (PC) and end-of-life (EOL) care are gaining importance in the management of critically ill patients in the ICU. Residents form a significant work force in the ICU and most often are the only group that provides round the clock coverage. Methods: We conducted a cross sectional study where residents were surveyed to assess their knowledge, skills and perceived barriers towards palliative care in the ICU. Results: The most common barrier identified by our residents was discrepancies in goals of care between the medical team and patients/families (18.7%). A palliative care consult was most commonly obtained when the patient was terminally ill (22.9%). Discussion: Teaching should focus on overcoming the identified barriers especially communication with patients and their families. More studies are needed to identify the best method to teach Palliative care in the ICU. Keywords palliative care, end of life, critical care, ICU, education, death

Introduction Intensive care unit (ICU) patients have complex issues and high burden of acute illness. The mortality rates range from 5% to 40% in ICUs across the United States.1 More than 20% of deaths in the United States occur in or directly after discharge from the ICU.2 These critically ill patients and their families often need help with decision making in the face of life-threatening illness. Palliative care (PC) clinical services can improve communication between health care teams and patients’ families. Involving PC has been shown to decrease ICU length of stay3 and lower health care costs.4 Palliative care is becoming an integral part of the ICU patient care and a key quality measure for health care in general.5 The Institute of Medicine identified improvement in PC as a national health priority. However, there have been many barriers to successful implementation of PC in the ICU.6 Some of the identified barriers are lack of knowledge, skill and training, logistics, cultural differences, fear of conflict, and inability to acknowledge PC-requiring situations.6,7 Palliative care delivery must be individually integrated into specific care settings with attention to the culture of the organization. Resident trainees form a significant workforce in the ICU. They are most often the only group of physicians who provide round the clock coverage in the ICU. To provide effective care, the resident should possess adequate knowledge, skills, and attitudes to deliver PC in the ICU.

Education and training in PC is one of the key identified barriers in delivering PC in the ICU.8 Palliative care also accounts for about 3% of the content of American Board of Internal Medicine (ABIM) certification examination for internal medicine.9 Our study objectives were to identify resident’s knowledge and their perceived barriers of PC-end-of-life (EOL) care utilization in the ICU in our tertiary hospital.

Methods Design and Sample The study is a cross-sectional survey conducted at St Louis University Hospital, the main training site for the St Louis University School of Medicine. This study was conducted 1

Department of Internal Medicine, St Louis University School of Medicine, St Louis, MO, USA 2 Division of General Internal Medicine, Section of Hospital Medicine, St Louis University School of Medicine, St Louis, MO, USA 3 Division of Pulmonary, Critical Care and Sleep Medicine, St Louis University School of Medicine, St Louis, MO, USA Corresponding Author: Aditya Uppalapati, MD, Division of Pulmonary, Critical care and Sleep medicine, St Louis University School of Medicine, 7S-FDT, 1402S Grand Avenue, St Louis, MO 63104, USA. Email: [email protected]

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Table 1. Common Forms of PC Training Reported by Respondents. Type of training

n

%

Didactic lectures in residency Didactic lectures in medical school Elective in residency Elective in medical school Required medical school course Required residency rotation Required medical school rotation

20 14 3 3 2 0 0

45 32 7 7 5 0 0

Abbreviation: PC, palliative care.

between March 2013 and July 2013. Electronic surveys were sent via e-mail to residents from the department of internal medicine. Residents from postgraduate year 1, 2, and 3 were surveyed. All survey recipients rotate at the St Louis University ICUs during their training. The study was approved by the Institutional Review Board of the St Louis University. The study team consisted of a third-year medicine resident, the medical ICU director, and the internal medicine residency program director an ABIM-certified Hospice & Palliative Medicine specialist.

Survey Development and Content Survey questions were derived based on our literature review on PC and EOL care in ICUs focusing on resident’s experience and training. Survey consisted of 9 questions (see Appendix A). House staff were invited to participate in the study via e-mail. E-mails were sent twice, separated by a 1week interval. Access to the survey questions required a username and password. Anonymous responses were collected. Survey answers were automatically converted into a data sheet using Microsoft Excel. Descriptive statistics were performed

Results Seventy-eight residents from the department of internal medicine were surveyed. A total of 30 responses were collected, yielding a 38.46% response rate. Of these responses, 5 (16.6%) were from first-year residents, 11 (36.7%) responses were from second-year residents, and 14 (46.7%) responses were from third-year residents. Of the 30 respondents, only 23 (77.0%) reported to have ever received any training in PC. Didactic lectures were identified as the most common form of PC training, either in medical school or during the course of residency. Only 7% of the respondents reported taking an elective rotation in PC (Table 1). Of the 30 respondents, 28 (93.3%) strongly agreed that knowledge of and skills in delivering PC are important in the care of critically ill patients. Of the 30 respondents, 20 (66.7%) felt comfortable providing PC-EOL care in the ICU and consider themselves appropriately trained in that area. In all, 6 (20.0%) residents did not feel appropriately trained to provide PC in the ICU, whereas 4 (13.3%) were not

Table 2. Commonly Identified Barriers Toward Optimal PC-EOL in the ICU. Barrier

n

%

Discrepancies in treatment goals between medical team and families Lack of advance directives from patients at the time of admission Lack of a protocol for managing palliative care patients Lack of effective communication with families Uncertainties in prognosis Cultural barriers Discomfort in talking about palliative care or death Lack of comfort in using and titrating opiates Lack of pain assessment and monitoring tools Fear of litigation (lawsuit) Inadequate availability of palliative care consults service

24 18.7 17 13.3 15 11.7 15 11.7 13 10.1 11 8.6 10 7.8 8 6.2 6 4.7 6 4.7 3 2.3

Abbreviations: ICU, intensive care unit; PC-EOL, palliative care end of life.

Table 3. Common Scenarios When Palliative Care Team is Involved. Timing of palliative care consult

n

%

When the patient is considered terminally ill When the patient’s condition is deteriorating rapidly When no other treatment options are available When the patient is dying When the patient’s code status is changed to do not resuscitate or do not intubate Around the time of admission

22 21 20 17 15

22.9 21.8 20.8 17.7 15.6

2

2

sure whether they were ready. Among the first-year residents, 3 (60.0%) reported feeling confident in providing PC in the ICU; and 9 (75.0%) of the second-year residents and 10 (76.9%) of the third year residents reported feeling appropriately trained to deliver PC-EOL in the ICU. Only 10 (33.3%) of the respondents were aware of previously identified barriers toward providing optimal PC-EOL in the ICU, whereas 14 (46.6%) of the respondents were not sure whether such barriers were previously reported in the literature. The most common barriers identified by our residents were discrepancies in goals of care between the medical team and patients/families (18.7%) followed by lack of advanced directives at the time of admission (13.3%), lack of effective communication with families (11.7%), and lack of a specific protocol for PC-EOL (11.7%). Table 2 lists all the barriers identified by our respondents. The most common scenarios reported by the residents where the PC team was involved in the care of the patient are (1) when the patient is considered terminally ill (22.9%), (2) when the patient’s condition is deteriorating rapidly (21.8%), (3) when no other treatment options are available (20.8%), and (4) when the patient is dying (17.7%). Only 1 respondent reported involving the PC team when family members had questions regarding hospice at home versus at a facility (Table 3).

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Discussion Our study identified didactic lectures as the main teaching method for PC and EOL in medical school and residency. Didactics do not completely prepare house staff to confidently and effectively deliver PC to critically ill patients and their families, as skills to deliver such care are not acquired during a lecture. One-third of our house staff did not feel appropriately trained or were not sure whether they can deliver optimal PC-EOL care in the ICU. In addition to didactic teaching, other methods have to be identified to train house staff and overcome the identified barriers. In a previous study, death rounds had a positive impact on the ability of the residents to cope with death in the ICU.10 Experiential, case-based, patient-centered curricula may help with resident confidence in withdrawal of life-sustaining treatment decisions. However, it may be optimal to focus teaching on providing residents with the appropriate skills to deliver optimal PC care to patients and families in the ICU. Simulation-based training could better approximate the necessary skills for such nuanced interactions in the ICU setting. Simulation-based teaching has been studied by Curtis but failed to show transference of the acquired skills to real patient care.11 More studies are needed to assess optimal methods for teaching PC-EOL care skills in the ICU setting and incorporating these methods into daily practice. Discrepancies in treatment goals between medical team and families, lack of effective communication with patient families, lack of a clear protocol for PC-EOL care, and lack of advanced directives at the time of admission were some of the common barriers to PC-EOL care in the ICU identified by our residents. These barriers are consistent with the ones previously reported in the literature.2,8,12 To some extent, discrepancies in goals of care between the medical team and families identified by our study can be attributed to lack of a good communication with families. Due to the absence of qualitative responses, it is difficult to ascertain the challenges in communication. Suboptimal communication with families can be attributed to many factors including busy schedule in the ICU, lack of resident’s comfort when discussing such issues, or lack of appropriate supervision from ICU attendings or fellows. Levin et al have shown that effective communication with patient families reduces psychological stress, improves quality of death, and shortens ICU length of stay.13 Multidisciplinary family meetings were shown to improve communication with families regarding EOL decisions,14 and satisfaction of families was found to be directly related to the duration of family speech during such meetings.15 The Value, Acknowledge, Listen, Understand, Elicit (VALUE) mnemonic when used by physicians in family meetings was shown to reduce anxiety, depression, and Post Traumatic Stress Disorder (PTSD) symptoms among family members.15,16 Thus, it is imperative to improve the resident’s communication with patients and families in the ICU setting. The PC-EOL plays a vital role in addressing the goals of care by working in partnership with patients, medical specialists, and family members. We suggest involving the PC team as early as possible

during the ICU stay (rather than when the patient is actively dying) to help identify those goals and achieve a shorter ICU stay without affecting mortality and families’ satisfaction.3 We have noticed a lack of knowledge and awareness among our residents with regard to the role of PC in the ICU (see Table 3). Residents reported obtaining a PC consult when the medical team was faced with a dying patient or an EOL situation. Rarely was a PC consult obtained around the time of admission. This reflects inability of the residents to identify situations where a PC consult would be helpful early on during the hospitalization. One-third of our residents either did not feel appropriately trained or were not sure whether they are appropriately trained to deliver PC-EOL care in the ICU. Proactive involvement of a PC team has been shown to decrease length of ICU stay, minimize use of unnecessary resources, and lower cost of care.17 Knowledge and attitude toward PC in the ICU might play a vital role in those situations, but we cannot ignore the fact that residents are largely influenced by the attending physician’s views regarding PC. Assessing the attending physician’s attitudes toward PC in the ICU can be helpful to identify their impact on the resident’s views toward PC-EOL care. Our study had some limitations that are important. First, our sample size was small and was conducted at 1 medical center only. A larger group of residents and a multicenter survey will have a better representation of the knowledge, skills, and perceived barriers to PC utilization. Second, responses lacked qualitative explanation, which is important to allow subjective explanation of responses. Third, we lacked representative responses from specialties other than internal medicine. Insight from other specialties is important to better assess resident education in PC across the physician continuum. In summary, we believe our residents are inadequately trained to deliver optimal PC and EOL care in the ICU. In order to do so, they should possess adequate knowledge and skills in PC in the ICU setting. More studies are needed to identify the best method to teach PC knowledge and skills specific to the ICU setting.

Appendix A 1- What is your level of training? a. PGY I b. PGY II c. PGY III d. PGY IV e. Other: 2- When taking care of critically ill patients, when do you most commonly involve the palliative care team in the ICU? (choose all that apply): a. Around the time of admission b. When the patient is considered terminally ill

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c. When the patient’s condition is deteriorating rapidly d. When the patient’s code status is changed to do-not-resuscitate or do-not-intubate e. When no other treatment options are available f. When the patient is dying g. Other: 3- Based on your knowledge and clinical experience, palliative care is defined as (choose all that apply): a. Treatment aimed at improving the patient’s quality of life b. Treatment that takes into account the patient and family c. Care of a patient during ‘‘the act of dying’’ d. Withdrawal of life-sustaining treatments e. Absence of curative treatments f. Control of pain and anxiety g. Other: 4- During the course of your training, have you received any training in palliative care medicine? a. Yes b. No 5- If yes, specify the type of training you have received (choose all that apply): a. Didactic lecture(s) in medical school b. Clinical elective in medical school c. Required medical school rotation d. Required medical school course e. Elective in residency f. Required residency rotation g. Didactic lecture(s) in residency h. Other: 6- Knowledge of, and skills in delivering palliative care are important in the care of ICU patients (choose one): a. Strongly agree b. Agree c. Neutral d. Disagree e. Strongly disagree 7- I feel appropriately trained to deliver palliative care and end of life care in the ICU setting (choose one): a. b. c. d. e.

Strongly agree Agree Neutral Disagree Strongly disagree

8- Barriers to delivering optimal palliative care and end of life care in the ICU have been previously identified (choose one): a. Strongly agree b. Agree c. Neutral d. Disagree

e. Strongly disagree 9- In your opinion, what are the common barriers towards optimal palliative care and end of life care in the ICU? (Choose all that apply): a. Lack of pain assessment and monitoring tools b. Uncertainties in prognosis c. Discrepancies in treatment goals between medical team and families d. Lack of comfort in using and titrating opiates e. Cultural barriers f. Lack of effective communication with families g. Inadequate availability of palliative care consult service h. Lack of a protocol for managing palliative care patient i. Lack of advances directives for patients at the time of admission j. Discomfort in talking about palliative care or death k. Fear of litigation (lawsuit) l. Other: Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.

References 1. Danis M, Federman D, Fins JJ, et al. Incorporating palliative care into critical care education: principles, challenges, and opportunities. Crit Care Med. 1999;27(9):2005-2013. 2. Aslakson RA, Wyskiel R, Thornton I, et al. Nurse-perceived barriers to effective communication regarding prognosis and optimal end-of-life care for surgical ICU patients: a qualitative exploration. J Palliat Med. 2012;15(8):910-915. 3. Aslakson R1, Cheng J, Vollenweider D, Galusca D, Smith TJ, Pronovost PJ. Evidence-based palliative care in the intensive care unit: a systematic review of interventions. J Palliat Med. 2014; 17(2):219-235. 4. Morrison RS1, Penrod JD, Cassel JB, et al. Cost savings associated with US hospital palliative care consultation programs. Arch Intern Med. 2008;168(16):1783-1790. 5. AHRQ. http://www.ahrq.gov/research/findings/nhqrdr/nhqr11/ nhqr11.pdf. Accessed January 2014. 6. Nelson JE. Identifying and overcoming the barriers to highquality palliative care in the intensive care unit. Crit Care Med. 2006;34(11 suppl):S324-S331. 7. Dalgaard KM, Bergenholtz H, Nielsen ME, Timm H. Early integration of palliative care in hospitals: a systematic review on methods, barriers, and outcome [published online March 13, 2013.]. Palliat Support Care. 2014:1-19. 8. Friedenberg AS, Levy MM, Ross S, Evans LE. Barriers to endof-life care in the intensive care unit: perceptions vary by level

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Palliative Care in the Intensive Care Unit: Are Residents Well Trained to Provide Optimal Care to Critically ill Patients?

Palliative care (PC) and end-of-life (EOL) care are gaining importance in the management of critically ill patients in the ICU. Residents form a signi...
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