3.3 (15.7) Palliative medicine in the ICU

Question 1

List four reasons that PC is important in the ICU

Answer 1

SYMPTOMS:
suffer pain and discomfort
highly dependent

FUNCTION/SUPPORTS:
patients are fragile
family often required to be involved in the decision process

FUTURE PLANNING:
high mortality (50%)
immediate prognosis uncertain
required to undergo unpleasant, invasive procedures

Question 2

List three factors that make delivery of PC difficult in ICU

Answer 2

• profession culture - culture directed towards saving lives
• uncertainty of decision making
• time course - acute (hours to days)
• environment - loud, shared spaces, pts on multiple monitors/devices
• patient communication - usually unable/limited
• scarce and expensive resource - pressure to move transfer pt

FS: patient/family, doctor, culture, illness, environment

Question 3

What are four of the seven standards that comprise PC competencies in ICU?

Answer 3

1. Patient care and maintain comfort, dignity and personhood
2. Interdisciplinary support of families during critical illness and bereavement
3. emotional and organizational support for ICU clinicians
4. Timely, clear compassionate communication
5. clinical decision making processes led by pt goals, values, preferences
6. identification of and respect for patients advanced medical directors and decision makers
7. development of contingency plans for withdrawal of supportive interventions

Question 4

List two factors that contribute to dissatisfaction with communication to families in ICU

Answer 4

inadequate dedicated time
inconsistent info
provision of info by multiple different providers

Question 5

List 3 practices that improve communication in the ICU

Answer 5

• early and frequent interaction with key care personal
• initial meeting to inform pts status, measures taken to stabilize condition and level of risk and liklihood recovery
• subsequent meetings when change in status
• meeting multidisciplinary (nurse and SW, MD)
• staff corrobate info before meeting to avoid presenting conflicting info

FS: early, regular, consistent, multidisciplinary

Question 6

Should choice to donate organ be offered to someone dying in ICU? Why?

Answer 6

yes based on idea this could be consistent with patient’s prior wishes/values

Question 7

List four common symptoms in ICU. List two issues that make symptom assessment difficult in ICU

Answer 7

pain
agitation
dyspnea
delirium

issues that make assessment difficult - sedation, delirium, paralysis

Question 8

List four signs a patient in ICU is having pain

Answer 8

facial tension - grimacing, frowning, wincing
physical movement, immobility, increased muscle tone
tearing and diaphoresis

FS: similar to FLACC assessment in non verbal kids

Question 9

What is a validated tool for assessing if a ventilated patient is having pain

Answer 9

behavioural pain score

Question 10

Name two non-benzo sedatives used in ICU. What are two benefits of using non-benzodiazepine agents to manage agitation

Answer 10

propofol and dexmeditomidine associated with:
- improved patient outcomes including shortened duration of mechanical ventilation and admission to ICU
-lower incidence of delirium and long term cognitive dysfunction

Question 11

List four behavioural indicators of dyspnea in ICU

Answer 11

tachypnea
tachycardia
fearful facial expression

accessory muscle use
paradoxical breathing (diaphragmatic)
nasal flaring

Question 12

List two consequences of delirium in ICU. What is the best method to determine if delirium is present in ICU

Answer 12

increased ventilator dependency
increased ICU LOS
higher short and long term mortality

Confusion assessment method - ICU assessment tool (CAM-ICU)

Question 13

List 3 non-pharmacological strategies for managing delirium in ICU

Answer 13

removing restraints
promoting sleep
reducing noise and lights
providing calming family or staff member

Question 14

What should be done with neuromuscular blocking agents when there is impending plan to stop mechanical ventilation? Why?

Answer 14

they should be discontinued as they may mask distress and confound physical examination of stress
-if cannot wait for reversal of neuromuscular agent, do deep sedation before ventilation withdrawal

Question 15

List 3 models for providing PC in ICU. Describe each

Answer 15

(1) consultative model - dedicated teams of pc clinicians called in by ICU team for patients they feel would benefit from PC

(2) integrative model - integration of PC principles and education into daily care of all ICU patients

(3) mixed model - both

Question 16

When should ET tube be left in during discontinuation of mechanical ventilation?

Answer 16

complex decision - if it is anticipated that there may be secretions and airway collapse it is reasonable to leave in

Question 17

List three benefits of PC provision in ICU

Answer 17

significant reduction in ICU stay

increased DNR orders

increased transition to goals focussed on comfort

reduction of non beneficial resource utilization

Question 18

List 5 steps to improving PC in an established ICU

Answer 18

convene an interdisciplinary planning/implementation group

conduct needs assessment

define problem

evaluate resources for EOL care for ICU patients

develop an action plan

FS:
Plan, do, study, act