Integrating Palliative Care Into the PICU

Abstract

Objective This review highlights the benefits that patients, families and clinicians can expect to realize when palliative care service is intentionally incorporated into the PICU, focusing on pain and symptom management, enhancing quality of life, communication and decision-making, length of stay and sites of care, and grief and bereavement. Data Sources MEDLINE Data Synthesis and Conclusions The American Academy of Pediatrics suggests that palliative care should begin at the time of a potentially life-limiting diagnosis and continue throughout the disease trajectory, regardless of the expected outcome. Although the PICU is often used for short term postoperative stabilization, PICU clinicians also care for many chronically ill children with complex underlying conditions and others receiving intensive care for prolonged periods. Integrating palliative care delivery into the PICU is rapidly becoming the standard for high quality care of critically ill children. Interdisciplinary ICU staff can take advantage of the growing resources for continuing education in pediatric palliative care principles and interventions.

A Review of the Integrated Model of Care: An Opportunity to Respond to Extensive Palliative Care Needs in Pediatric Intensive Care Units in Under-Resourced Settings

“…Contrary to the first myth, evidence shows that PC has major implications for the well-being of patients, their families, and practitioners ( 4 , 5 , 9 , 18 – 25 ). PC is an interdisciplinary field that seeks to prevent and relieve the multifaceted suffering that critically ill patients and their families experience as a result of acute, chronic, life-limiting, and life-threatening conditions.…”

“…The tendency to isolate medical specialties under this framework has led to a division between intensive and PC—two branches of medicine that are essential to the treatment of critically ill patients in ICUs. This common practice has contributed to the perception that adding PC tasks to intensivists’ daily responsibilities will burden them, unnecessarily absorb valuable time and resources, and take away from their “real care goals.” On the contrary, a breadth of evidence shows that adopting a holistic care strategy can conserve valuable resources in the ICU ( 2 – 4 ) and improve patients’, their families’, and caretakers’ well-being ( 5 ).…”

“…As a part of normal daily operations, team members simultaneously initiate PC and critical care, screen for PC needs regularly, and design plans to meet those needs as they arise. Although the consultative model is overall more common ( 5 ), the IMOC appears to offer distinct benefits to patients with pediatric palliative care (PPC) needs and, in pediatric ICUs, “is rapidly becoming the standard for high quality care of critically ill children” ( 4 ). While both models can make PC available in ICUs and pediatric intensive care units (PICUs), the IMOC may be more beneficial to patients/their families and may be better suited to under-resourced settings where hiring outside specialists may be impossible.…”

“…PC addresses physical, psychosocial, ethical, spiritual, cultural, familial, and communication-related distress, as well as death and bereavement issues ( 21 , 26 – 28 ). The timely initiation of PC is associated with (1) improved symptom management ( 18 – 20 ), (2) positive outcomes in patients ( 4 , 18 , 20 ), (3) improved quality of life for patients, families, and caregivers ( 18 , 20 ), (4) better communication between professionals, patients, and their families ( 1 , 4 , 29 , 30 ), and (5) longer life survival times among patients ( 4 , 29 ).…”

“…Furthermore, PC belongs in the PICU/ICU because virtually all critically ill patients exhibit some level of PC need throughout their hospitalization ( 4 , 5 , 14 , 31 ); to meet patients’ extensive PPC needs, PICUs may benefit from making PPC universally accessible through an IMOC. PC is indicated in a wide range of patients, not only those confronting the terminal stages of illness ( 4 ). Because PC is inaccurately equated with hospice, it is commonly and erroneously thought to signal imminent death and therefore may provoke anxiety among patients, families, and practitioners.…”