ICU

Question 1

List trajectories of death (as per ICU CBM)

Answer 1

• Terminal illness (Eg. Cancer)
  
  • short period evident decline
  • clear terminal phase
  • most amenable to traditional palliative care
  • may avoid ICU admission
• Chronic illness (organ failure)
  
  • intermittent serious episodes with some recovery
  • overall decline
  • sudden, seemingly unexpected death
  • commonly accept ICU care
• Frailty
  
  • prolonged dwindling
  • more likely to accept ICU
• Sudden event
  
  • previously healthy
  • trauma, MI, ex.
  • Very commonly accept ICU

Question 2

Why should palliative care be integrated into ICU?

Answer 2

• Death in ICU common
• ICU providers require knowledge and skills
• improves care delivery and ACP

Question 3

List ways of integrating palliative care into ICU

Answer 3

• ICU palliative care education
• local champions
• ICU / Pall care protocols
• ICU QI data

Question 4

Steps to develop palliative care in ICU

Answer 4

• Interdisciplinary planning team with key stakeholders
• Needs assessment
• Define the problem
  
  • high utilization of ICU by patients who don’t benefit from it
  • patient distress /dissatisfaction
  • delayed / inconsistent use of evidence based pall care
• Evaluate resources for palliative care for ICU staff
• Develop an action plan with goals, targets, PDSA cycles

Question 5

What is the role of the PC team in the ICU?

Answer 5

• Symptom assessment and management
• leading patient/ family and interprofessional communication
• Aligning treatment goals with care plan
• transitioning from acute care to pall care
• Emotional and social support

Question 6

List 2 models of palliative care in the ICU

Answer 6

• Integrative model
  
  • ICU staff trained in PC
  • PC essential part of ICU care
  • consultant PC not needed
  • PC available for all patients all the time
  • requires maintenance of skills, education, commitment
• Consultative model
  
  • separate PC team
  • provision of care depends on referrals
• Ideal would be a blend of both models depending on funding and feasibility

Question 7

How do ICU physicians decide to refer to PC?

Answer 7

• Routine assessment triggers:
  
  • Surprise question
  • functional assessment decline
  • weight loss
  • LTC patients
  • no previous ACP
  • weak social supports
  • family request
  • elderly, cog impairment
  • home 02 use
  • out of hospital cardiac arrest
  • incurable cancer
  • difficult to control sx
  • trach / G tube
  • admission > 7 days
  • recurrent ICU
  • unclear GOC
  • poor outcome likely
• Informal means to identify
• PC team at daily rounds in ICU

Question 8

List features/ domains of high quality PC in ICU?

Answer 8

• Communication
  
  • clear, timely, compassionate
• Patient focused decision making
  
  • goals, values, preferences
• Maintaining the patient
  
  • dignity, comfort, privacy, personhood
• Caring for the family
  
  • access to patient
  • interprofessional support
  • bereavement support

Question 9

ICU communication : Use of Silence

Answer 9

• Invitational silence
  
  • interested silence enables sharing by families
• Compassionate silence
  
  • creates empathy

Question 10

Symptoms in ICU : Pain

Answer 10

• Causes
  
  • treatment, procedures
  • underlying illness
• Management
  
  • choose necessary interventions
  • pain assessment for non verbal patients Critical Care Pain Observational Tool
  • opioids

Question 11

Dyspnea in ICU : causes and management

Answer 11

• Causes:
  
  • resistance to ventilation
  • resp muscle weakness
  • infections
  • ARDS
  • Asthma
  • Cardiac disease
• Presentation
  
  • anxiety, diaphoresis, agitation, fighting the ventilator
• Management
  
  • review vent settings
  • opioids
  • disease specific treatments

Question 12

Anxiety in ICU : Causes and managment

Answer 12

• Causes
  
  • communication limitation, discomfort, procedures, prognosis
  • dyspnea, pain
  • medication withdrawal or effects
• Management
  
  • treat underlying cause
  • psychological support
  • medications prn

Question 13

Agitation in the ICU : Causes and managment

Answer 13

• RASS score
• treat causes
• alcohol withdrawal / Delirium tremens

Question 14

Delirium in the ICU : Causes and treatments

Answer 14

• Causes
  
  • DIMS
  • multifactorial
• Importance
  
  • increased length of ventilation
  • LOS
  • mortality
  • reduction in functional status and cognition
• Management
  
  • CAM -ICU
  • underlying causes
  • neuroleptics and monitor for AE

Question 15

Sleep disturbances in ICU : Causes and management

Answer 15

• Causes
  
  • illness, environment, symptoms uncontrolled, mechanical ventilation, medications
• Management
  
  • little evidence for options

Question 16

Thirst, Dry mouth in ICU : causes and management

Answer 16

• Causes
  
  • hypovolemia
  • increased osmolarity
  • mouth breathing
  • infection
  • meds (anticholingeric, opioids, steroids, diuretics)
  • n/vx
  • fever
  • anemia
• Management
  
  • mouth care
  • ice chips
  • articifial saliva, substitutes

Question 17

Critical Illness Polyneuropathy and Myopathy : Causes and management

Answer 17

• Causes
  
  • sepsis
  • sirs
  • multi organ dysfunction
• Management
  
  • treat underlying illness
  • PT and rehab
  • resolves in weeks- months, sometimes residual

Question 18

Critical Illness Polyneuropathy vs Myopathy

Answer 18

• Polyneuropathy
  
  • decreased sensation, hypoactive reflexes
  • quadriparesis, resp muscle weakness
  • spares facial nerves
  • decreased sensation
  • axonal neuropathy and denervation on biopsy
• Myopathy
  
  • normal sensation, reflexes preserved
  • quadriparesis, resp muscle weakness, reflexes normal
  • facial muscle weakness
  • normal sensation
  • myosin filament loss / necrosis on biopsy

Question 19

Approach to communication with ventilated patients

Answer 19

1. Can the patient respond?
   
   1. eye contact, one step commands
   2. nodding, hand squeezing, eye blinking etc
2. Letter and picture boards
3. Mouth words slowly
4. Writing
5. List of common concerns to point to
6. Speaking valves with trachs
7. SLP consult for help

Question 20

Sedation and Analgesic needs unique to ICU

Answer 20

• use of protocols and targets for sedation
• mechanical ventilation – balance between medication for comfort and being awake to communicate
• needs frequent reevaluation to align with goals of care

Question 21

Communication in ICu between patient/SDM and ICU interprofessional teams

Answer 21

• patient decision aids
• quality of care improvement
• printed material for patient/ family
• palliative and ethics consults
• Structured ICU team communication with patient/family

Question 22

EOL ethical issues in ICU

Answer 22

• collaborative discussion
• values, preferences, goals of patient
• patient to help in decision making when possible
• palliative consults
• ethics, consent and capacity board consults prn

Question 23

List ways that Palliative Care delivery is different in the ICU

Answer 23

• Professional Culture
  
  • interventional, life support
• Uncertainty of outcomes
• Abrupt time course
  
  • difficult for families to adjust to prognosis and make decisions
• Environment
  
  • noise, patient appearance, lack of privacy
• Inability of patients to communicate
  
  • sedation, procedures, medical procedures
• Scarce and expensive resources (allocation)

Question 24

Conflicts in ICU

Answer 24

• withholding/withdrawing care
• shared goals of caring for patient
• acknowledge emotions
• time may be required for family to adjust and observe deterioration
• repeated discussions may be necessary
• social workers
• Trial of therapy may be helpful

Question 25

Discontinuing mechanical ventilation / palliative extubation

Answer 25

• Discontinue paralytics
• Pre emptive sedation
• Discontinue ventilation
  
  • decrease Fi02 (to room air or wean) and PPV over 10-30 min
  • if distressed, add medication and increase slightly
• Decide whether to extubate or not
  
  • patient and family dependent
• Stay present with family
• Turn off monitors