Role of Palliative Care for the Intensive Care Unit Nurse Practitioner

End of life care and communication deficits are frequent sources of conflict in the intensive care unit. Lack of communication leads: to dissatisfaction, mistrust, conflict, and anger. Families report poor quality and communication with critical care and other hospital clinicians [6]. Family members of patients who died in the intensive care unit report dissatisfaction with information about diagnosis, cause of death and consequences of illness. Additionally symptoms of anxiety, depression and spiritual suffering may impair the patient and their family’s ability to understand the medical condition and decisions about treatment [7-10].

Patients dying in the intensive care unit desire symptom relief, honesty, and to be in the presence of their loved ones. They want trust and confidence in their medical team. This includes trust that heroic measures will be avoided (e.g. life support) when there is no meaningful recovery. Despite these wishes, many patients suffer the agony of unnecessary, painful interventions rather than allowing the individual to die with dignity. Through a trusting relationship and effective communication with patients and family members much of these needless interventions can be avoided.

Predicting end of life can be ambiguous in patients who suffer from illness such as heart failure, stroke and chronic obstructive pulmonary disease. Among elderly patients this can be particularly difficult because of multiple medical comorbidities. Prognostic indicators are often complicated by technical difficulties, bias, failure to predict mortality and technical limitations. Increasing disability and frailty of symptoms may be the most useful signal for palliative care assessment. It is imperative to be honest with families about these barriers with emphasis on appreciating the present [11].

If left to chance, it is often too late for the patient to make a lucid decision regarding end of life treatment. Often times family members are left to make these difficult end of life decisions (i.e. facing the decision of whether or not to make their loved one a do not resuscitate [DNR] status). This may cause family members spiritual suffering, depression, and emotional distress. Decisions regarding end of life should be discussed with the patient when they are relatively well. Determining such decisions when in crisis is often wrought with anxiety, indecision, and turmoil.

Nearly one fifth of Medicare fee for service beneficiaries discharged from the hospital in 2003-2004 were readmitted within 30 days and 34 percent were rehospitalized within 90 days [12]. To help combat this issue Centers for Medicare and Medicaid Services Quality Improvement Organization Program, Community Based Care Transition Program and Hospital Readmission Reductions Program are penalizing hospitals by reducing payments for patient readmissions rates for particular conditions. This initiative, has demonstrated success in reducing hospital readmission rates [2].

When presented with these facts the practitioner may feel pressed to make end of life decisions based on financial remuneration, placing them in an ethical and legal conundrum. This should not be the case. Acknowledging these financial facts should indicate to the practitioner that we have historically failed in our role to help patients prepare for end of life decision making. This is an indicator that we have work to do in this sensitive subject matter.

The Institute of Medicine’s “Dying in America” reports that we should focus on quality of care and the wishes of the patient and their family. Ceasing to provide treatment that is unlikely to benefit patients will free up funding to further support end of life care. These funds can be used for caregiver training and nutrition services, ensuring better quality of life for those approaching death. We need to provide encouraging services that support patients and their families for those who would prefer to die in the home. More emphasis should be on improving quality of care at end of life. Due to the lack of the availability of these services to meet the patients and families needs during this hard time is an issue that must be pushed to the forefront.

The Institute of Medicine noted three impediments in health professions education and development that have obstructed quality end of life care. Curriculum deficits, lack of interprofessional collaboration and neglect addressing communication skill [11]. Each will be addressed below and how they are related to the nurse practitioner working in an intensive care unit.

The first is curriculum deficits in nurse practitioner training. Many intensive care unit nurse practitioners enter the field with minimal understanding of how to treat a patient near end of life. This is something that must be priority, as noted previously many patients spend their last days in an acute care hospital. And although hospice and palliative care medicine is more established when compared to 10 years ago, there remains a significant shortage of approximately 6000 to 18,000 hospice and palliative care medicine specialists [11]. Not only is there a shortage of palliative care and hospice specialty practitioners, they were never created to assume the full care of the patient. They were created to serve as a consultant who can provide additional resources. Intensive care unit nurse practitioners are often the ones who encounter the patient the most during their hospital stay. Many community hospitals in particular do not have access to a palliative care/ hospice team which underscores the need for proper education on this issue.

There is a paucity of literature about palliative care for the intensive care unit nurse practitioner. A pilot study consisting of 49 nurses and acute care nurse practitioners examined the beliefs and perceptions of end of life and palliative care show that most graduate nurses had not received any palliative care continuing education within 2 years [13]. This is concerning when looking at the aging population. A survey among neonatal nurse practitioners demonstrated that neonatal nurse practitioner felt inadequate to deal with end of life care [14]. Forty percent noted that topics related to end of life were not in their program. The survey identified three areas that were perceived as needing additional education: decisions about resuscitation, balance between giving parents false hopes and removing all hope, and ways to communicate bad news to families. The majority of neonatal nurse practitioners did not consider their education on end of life issues to be adequate [14]. A study examining 455 health care facilities in South Dakota found that 80 % of the facilities had no palliative care training and 73 percent had no training in end of life care. In effort to address this issue a grant was awarded to allow interdisciplinary palliative care workshops to health care professionals [15].

Additional impediments identified by Institute of Medicine are a lack of interprofessional collaboration. Interprofessional collaboration emphasizes aborting individual interest to the team, valuing collective input. Interdisciplinary education is a key player in palliative care however this concept is not at the core of nursing and medical schools. This can lead to lack of interdisciplinary team work, misunderstanding between health care workers and avoidance of collective responsibility which can consequently interfere with patient and family interest. Some suggest team based competencies be a core part of health professional’s education.

Being able to communicate effectively encompasses the skill to communicate empathetically, with respect and in a way that allows the patient and family to truly understand the depth of the matter. According to the Institute of Medicine, many physicians avoid the topic of end of life out of fear that it will destroy hope. A study of 196 physicians caring for 70 patients revealed that 86 percent knew their patients were close to death but only 11 percent reported speaking with the patients about dying [16]. Thus it is no surprise studies indicate that families are unlikely to engage in decision making unless presented with clear and informative options [17,18]. Palliative care meetings conducted prophylactically increase satisfaction and improve resource utilization. This is likely to lead to substantial resource utilization savings and more importantly prevent unnecessary patient and family suffering. Effective communication skills can be taught, but unfortunately there is a lack of leaders teaching this vital skill. To better serve patients who are hospitalized in the intensive care unit, nurse practitioners can undergo palliative care training. Once trained intensive care nurse practitioners can facilitate training others to further combat this issue.