Palliative care in the icu Katie Forbes Northeastern University Palliative care in the icu

What is Palliative Care? Palliative care is specialized medical care that focuses on providing patients with relief from pain, symptoms, and stress due to a serious illness Goal: improve quality of life for both the patient and the family Palliative care dose NOT mean end-of-life Can be provided at any stage of a life-threatening illness Purpose: to provide support for the patient and family

Steps/Interventions of Palliative Care Researchers have identified three specific steps/interventions that can be implemented to help improve/decrease palliative care in the ICU. Early Identification Early communication Proper Administration

Step 1: Early Identification GSF Prognostic Indicator Guide Purpose: Developed to help identify palliative care patients early in order to allow healthcare professionals to provide better quality, well-organized care to patients during a serious/life-threatening illness Presents a series of questions that physician's can follow to determine if the patient is a candidate for palliative or hospice care

Step 1: Early Identification GSF Prognostic Indicator Guide Criteria Triggers: The surprise question: “Would you be surprised if the patient where to die within the next year?” General Indicators of Decline: Deterioration Advanced disease Decreased response to treatment Choice for no further disease modifying treatment Clinical Indicators: Cancer Organ failure Elderly/fragility/dementia

Step 1: Early Identification GSF Prognostic Indicator Guide Begin GSF Process: Identify: After the patient is identified as having a life-threatening illness the healthcare professional should determine if palliative care or hospice care is appropriate Assess: Next, the healthcare professional should speak with the patient and their family members, assessing their wants and needs Plan: Finally, begin discussing the appropriate plan of care

Step 2: Early Communication Through early communication with patients and their family members unnecessary/detrimental life-saving treatments, such as CPR and intubation, can be avoided Discussion Topics: Patient status and diagnosis Plan of care options (i.e. palliative care vs. hospice care) Advance Directives, DNR status, living wills, etc. The death and dying process

Step 3: Proper Administration Palliative Care in the ICU FACT: “20% of deaths in the US occur in the ICU… with 90% of deaths… happening after the decision to limit treatment” (Cox, 2012). Example: Patient A was admitted into the ICU s/p Cardiac Arrest Hypothermia protocol was implemented 48 hrs. after completion of hypothermia protocol patient A was diagnosed as brain dead How should the healthcare provided respond?

Step 3: Proper Administration Palliative Care in the ICU Implementation of the GSF Process Identify: Does the patient meet the GSF Prognostic Indictor Guide Criteria? YES – patient is brain dead (clinical indicator) and can not survive without mechanical ventilation (surprise question) Assess: Discuss with family members about patient diagnosis, patient wishes, patient/family wants/needs Plan: discuss potential plan of care options (i.e. withdrawal of life-sustaining treatment and implementation of palliative care)

Step 3: Proper Administration Palliative Care in the ICU Once the family states they would like to withdrawal care then, Step 3 can officially begin Withdrawing Care: 2 physicians must sign stating the patient has a life-threating and irreversible illness Family members agree to withdrawal of care Discontinue all life-sustaining treatments and begin palliative care Palliative Care Objectives: Keep patient comfortable and free of pain through the use of medications opioids (Morphine) = pain relief benzodiazepines (Lorazepam) = sedation Provide family support

Step 3: Proper Administration Palliative Care in the ICU Medication Administration Use a combination of Morphine and Ativan to keep the patient free of pain and distress Morphine 1-2 mg q1hr PRN pain Ativan 1 mg q1hr PRN anxiety S/S of pain or distress Tachypnea Labored breathing Tachycardia Use of accessory muscles Grimacing Restlessness Diaphoresis

Step 3: Proper Administration Palliative Care in the ICU After death occurs, the ICU nurse should… Provide support to the family as needed Show compassion and understanding Be respectful of any rituals preformed Answer any questions/concerns about next step in process (i.e. funeral home, organ donation, etc.)

Reference Cox, S., Handy, J., & Blay, A. (2012, October). Palliative Care in the ICU. Journal of the Intensive Care Society, 13(4), 320-326. Retrieved July 26, 2016, from http://inc.sagepub.com/content/13/4/320.full.pdf html Facts About Morphine and other Opiods. (2016). Retrieved August 3, 2016, from www.palliativecare.org.au The Dying Process. (2016). Retrieved August 3, 2016, from www.palliativecare.org.au Thomas, K. (2011). Early Identification & Prognostic Indicator Guide. The Gold Standards Framework Centre In End of Life Care, 1(4), 1-5. Retrieved August 1, 2016, from https://www.cancercare.on.ca/common/pages/UserFile.aspx?fileId=344053 PROCEDURE FOR WITHDRAWAL OF LIFE SUPPORT IN THE MICU/MCP. (2001). The Johns Hopkins Hospital Medical Nursing Service Standards of Care Manual. Retrieved August 3, 2016. Prognostic Indicator Guidance. (2008, September 8). Royal College of General Practitioners. Retrieved August 8, 2016, from http:// www.gpscbc.ca/sites/default/files/ 11_EOL_PSP_GSF_Prognostic_Indicator_0.pdf Ventilator Withdrawal Guidelines. (n.d.). Merging Cultures, 1-6. Retrieved August 3, 2016. What is Palliative Care? (2016). Retrieved August 2, 2016, from https:// getpalliativecare.org/whatis/ Reflective Note: The purpose of this powerpoint is to provide information about palliative care to ICU personal, specifically ICU registered nurses (RNs). I choose this topic because as an ICU nurse I provide palliative care on a regular basis, however I have never specifically been provided palliative care training. As a result, I have learned how to properly provide palliative care to my patients and their family members through personal research and the experience of my coworkers. When I asked my educator, if she had any information on how to properly provide palliative care in the ICU, her answer was “No”. Thus, I believed creating a powerpoint presentation that could be used for educational purpose to help teach ICU RNs about palliative care would be useful. I created this presentation hoping if would be used in either a classroom setting, as part of orientation for new incoming ICU RNs, or printed and provided as handouts to the existing staff. As a result, I designed this presentation in way in which the reader would be able to read through the slides without any extra commentary. The powerpoint is meant to educate ICU nurses on the steps taken in an attempt to keep patient's out of the ICU, as well as what to do if the nurse was to receive a patient who required the implementation of the steps/interventions of palliative care. I believe this presentation could be chosen to be part of my professional portfolio because it shows diversity in my writing style. However, this project was a little bit more difficult than I believe it would be at first. Even though the topic was one that I am familiar with, being able to explain and provide adequate information in a clear and concise manner was more difficult than I originally thought it would be.