Introduction
Palliative care in the intensive care unit (ICU) was first intended to enhance hospice care. It has now become a vital aspect of ICU care. The ethical values of autonomy, beneficence, non-maleficence, fairness, and faithfulness should guide ICU palliative care.
There are three approaches to integrating primary and professional palliative care into ICU care management: integrative, consultative, and combined. Palliative care, including symptom management and collaborative decision-making, should be provided to all patients in intensive care units. More research is needed to determine how to give the best palliative care to intensive care unit patients and their relatives.
What Is Palliative Care?
Palliative care is patient and family-centered care that aims to improve the standard of life by identifying, avoiding, and alleviating suffering and offering thorough management of patients with incurable diseases regardless of age, diagnosis, or prognosis. Furthermore, palliative care focuses on concerns such as symptom distress (physical, psychological, and spiritual), the ability to interact with and share decisions, and caregivers' burden reduction. Palliative and intensive care appear at different ends of the care spectrum. However, there are similarities between care methods since both sectors may overlap in a virtuous circle to benefit ICU patients.
Why Is It Necessary to Include Palliative Care in ICU?
Most ICU patients have unrelieved and uncomfortable symptoms. In an exploratory study of patients in intensive care units at high risk of death, the prevalence of distressing symptoms ranged from 27 % to 75 %. Delirium was discovered in almost one-third of the patients who could be assessed. Similarly, the family revealed an elevated level of symptom distress, with 57 percent experiencing traumatic stress and 70 to 80 percent experiencing anxiety and sadness, in addition to physical and emotional symptoms, especially among the youngest. These findings imply that a palliative care assessment should begin as soon as feasible to allow for more focused measures to predict or reduce unnecessary pain.
Another study shows that end-of-life treatment in the ICU should encompass more than just controlling pain and symptoms but also promoting death with respect and honor, which are common difficulties demanding palliative care experience. The standard causes for palliative care consultation are thought to be met by 14 to 20 % of patients in intensive care units. Proactive palliative care participation on ICU rounds for high-risk patients has been linked to early ICU conversations with families and shorter hospital stays. Although few particular interventions have been identified to promote family satisfaction in the ICU, good-quality interaction, assistance for collaborative decision-making, and particular patient-care metrics have been linked to boosting contentment with end-of-life care. As a result, palliative care principles must be mandated in ICUs.
What Are the Ethical Considerations in ICU Palliative Care?
All critically sick patients should get palliative care till the final moments of their lives. ICU palliative care should adhere to the ethical values of autonomy, beneficence, non-maleficence, justice, and loyalty.
Autonomy: The idea emphasizes preserving patients' autonomic rights, especially for individuals who have lost the ability to make decisions. Each patient has the right to choose the type of care they receive and whether to receive life-sustaining treatment (LST).
Beneficence: Beneficence refers to efforts to aid people by curing illness, enhancing health, and alleviating pain, suffering, and anguish. The do-good concept stresses effective interventions that improve the individual's quality of life. In any case, ICU workers are responsible for providing their patients with the best possible care.
Nonmaleficence: The principle emphasizes preventing needless harm and reducing the danger of injury. Some treatments or surgeries in the ICU are unavoidably painful or dangerous, and the harm is justified provided the benefit outweighs the harm and the objective is not to harm the patient. Individualized monitoring and management of ICU patients is required.
Justice: The notion should ensure a fair allocation of healthcare assets and fairness in healthcare delivery. ICU medical personnel must argue for fair, equitable, and appropriate treatment for patients with life-threatening illnesses while minimizing unnecessary use of limited resources.
Fidelity: The concept of honesty necessitates that patients and their families be truthfully informed about their prognosis and the potential consequences of the disease, as well as given comprehensive details about the benefits, limitations, and drawbacks of various treatments to make the best decision.
Where to Provide Palliative Care?
Patients deemed unfit for further harsh therapies may be transferred to an advanced palliative care environment, where physicians are certified in hospice and palliative therapy and withdrawal processes are widely utilized in end-of-life care patients. This type of treatment needs to be thoroughly recorded and is challenging to coordinate, in part because hospice care is frequently provided in non-hospital settings. Acute palliative care units may help with the transition of care.
In a current perspective, the essential domains of palliative care, such as symptom relief, productive discussion about treatment objectives, patient-centered decision-making processes, caregiver assistance, and continuity across care venues, should be performed in the ICU.
What Are the Modes of Palliative Care in the ICU?
Basic palliative care and professional palliative care are the two types. Any health provider can give primary palliative care, which involves symptom management and discussion about the ACP, such as the disease status, treatment objectives, and outcome. A team of specialized professionals with advanced education provides professional palliative care. There are various methods for incorporating primary and professional palliative care into the intensive care unit patient management, and the approach chosen should be dependent on the resources and demands of the various ICUs and the institutions in which they are housed.
Integrative Method: Basic palliative care principles and actions are incorporated into the everyday tasks of the ICU treatment team, which serves all critically ill patients and their families. Prior family meetings conducted by the ICU team, regular palliative care evaluation, integrating trained workers into the ICU team, boosting training for ICU team members, and increasing education and support for ICU patients family members are among the primary treatments.
Consultative Method: This concept uses a professional palliative care team that concentrates on intensive care unit patients at high risk of dying. Palliative care specialists have regular access to the ICU to evaluate and recognize patients who may benefit from professional palliative intervention, and they frequently rely on the expert opinion of the ICU physicians to initiate professional palliative intervention. Acute disease conditions and patient variables such as age and disease stage are reasons that prompt consultation.
Combination Method: The consultative strategy necessitates proper palliative care knowledge and resources, but the integrative model places "extra" expectations on ICU staff. Combining intensive care and palliative care is the most effective strategy to integrate the two concepts. ICU staff provides primary palliative care; expert palliative care is sought when necessary. To satisfy the need for palliative care, it is critical to strengthen ICU medical staff's ability to offer primary palliative care and to grow the professional palliative care team. The mixed model assures standard palliative care quality and consistency of care even after patients depart the intensive care unit (ICU).
How Do One Control Symptoms in Palliative Care?
The three most prevalent symptoms are addressed in the following sections.
Targeted Analgesia: Pain that is not eased is physically and psychologically detrimental. To control pain, an appropriate tool for a thorough evaluation should be chosen. The gold standard for assessment is the patient's self-description of pain. However, critically ill patients' verbal communication or cognitive function is impaired, even unconscious, affecting their expression of pain. The Critical Care Pain Observational Tool is useful for assessing pain in ICU patients who cannot express themselves. The decision about using analgesic or non-pharmacologic therapy should be based on pain evaluation and represent the patients' requirements and aspirations. Opioids continue to be the drug of choice for targeted analgesia.
Terminal Sedation: Terminal sedation involves injecting certain medications into end-stage patients to lessen their consciousness level to relieve symptoms in patients who have not responded to other techniques. In contrast to euthanasia, the objective of terminal sedation is to relieve pain at the end of life rather than to hasten death. Midazolam and Propofol are the most widely utilized medications, and opioids are sometimes added.
Dyspnea: Dyspnea constitutes one of the most prevalent indicators in the terminal period, and it is linked to pain, weariness, anxiety, and an increased risk of death. Opioids and oxygen are often considered the cornerstones of treating dyspnea in terminally ill individuals.
Conclusion
Palliative care is not a replacement for illness therapy but is not limited to terminally ill patients. Palliative care involves relieving physical and emotional symptoms and making patient-focused decisions. To integrate treatment with patients' values and preferences, prompt and effective interaction with patients and their family members about treatment goals, ACP, and the change from curative to comfortable care is required. Currently, palliative care in the ICU is not universally accepted, and more research is needed to investigate how to deliver the most effective palliative care for individuals and their family members in the ICU environment, focusing on medical outcomes and individual and family member satisfaction.
