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

2. 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

3. 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

4. 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

5. 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

6. 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

7. 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

8. 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?

9. 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)

10. 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

11. 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

12. 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.)

13. Reference
Cox, S., Handy, J., & Blay, A. (2012, October). Palliative Care in the ICU. Journal of the Intensive Care Society, 13(4), Retrieved July 26, 2016, from html
Facts About Morphine and other Opiods. (2016). Retrieved August 3, 2016, from
The Dying Process. (2016). Retrieved August 3, 2016, from
Thomas, K. (2011). Early Identification & Prognostic Indicator Guide. The Gold Standards Framework Centre In End of Life Care, 1(4), Retrieved August 1, 2016, from
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 _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 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.