Palliative Care in the MICU
CASE STUDY: Mr. K has advance COPD and is well known to the MICU because of frequent admissions for acute exacerbations. He was recently discharged after a two-week hospitalization including five days in the ICU requiring intubation. At this admission he states that he would accept any treatment necessary to reduce his breathlessness, except intubation. He does not want to be resuscitated. He states that he is aware that he could die and recognizes that his condition is deteriorating.
Mr. K reports profound dyspnea. He displays accessory muscle use, paradoxical breathing, he is tachypneac at 40 breaths/minute. His oxygen saturation is 83 percent on non-rebreather mask and his lung sounds are distant, but clear.
The Palliative Care Committee includes, from left, Susan Glennon, BSN, RN; Barbara Eaton, BSN, RN, CCRN; Mary Ann Dillon, RN (seated); Jacqueline Feeney, BSN, RN; and Carol Daddio Pierce, RN. Not pictured are: Diana Phillips, BSN, RN; Kathy Mazza, RN; Mary Ann Folan, RN; Jennifer McIntyre, BSN, RN; and Karen Meyers, RN.
The commitment to providing the best care for the sickest of patients in the Medical Intensive Care Unit has led several MICU nurses to incorporate certain elements of palliative care into their practice and to share what they are learning with their peers.
Linda Delaporta, BSN, RN, CCRN, and Barbara Eaton, BSN, RN, CCRN, staff nurses in the MICU, delivered a Nursing Grand Rounds presentation on palliative care and its impact on nursing care in the MICU. They discussed communication, pain and symptom management, ethics and clinician support, and they detailed the application of palliative care techniques and practices to patients like Mr. K.
“Communication with patients, their families and our fellow clinicians is integral to delivering the highest-quality care to our patients,” said Delaporta.
Eaton detailed the difficulty in shifting from curative and aggressive care to comfort-driven care. “But they’re not mutually exclusive,” she said.
Open communication between clinicians and patients and families is just as crucial as communication among care givers. Patients and families need information to make decisions, and they need to feel listened to and reassured while understanding the goals of treatment. It helps to identify family decision makers, determine and address any ethical issues or conflicts early on, and assure continuity and consistency in the message delivered to the patient and his or her family.
Using open-ended questions helps to build bonds of trust with the patient and family, Delaporta said. Asking a patient: “How are things going for you?” or “What has been most helpful to you?” helps open a conversation. For families, questions like, “How do you think your loved one is doing? What is your understanding of your loved one’s disease?” do the same.
Laura Thomas, RN, at right, discusses a patient case during a recent meeting of the Palliative Care Committee, which includes Martha Jurchak, PhD, RN, of the BWH Bioethics Center.
During the last few years, family meetings with care givers have become routine within the first 48 to 72 hours of an admission to the MICU. Staff from multiple disciplines meet with family and the patient when able to discuss prognosis and the plan of care. Staff and the patient set reachable goals and determine the patient’s wishes for care. Delaporta recommends including Social Work, Chaplaincy and members of the Palliative Care and Ethics teams in these meetings.
Pain management is a major issue and involves taking into account the patient’s medical history, gender, culture, religion and other personal factors when trying to manage and alleviate pain. “Pain means different things to different people, and it’s our job to probe further,” Delaporta said.
Studies have shown that approximately half of hospitalized, terminally-ill patients report moderate to severe pain most of the time. In addition, critical care procedures and routine nursing care that cause pain in patients include positioning, turning, catheter placement, sheath removal, suctioning, wound care and wound drain removal, said Eaton, citing various studies.
She stressed the importance using pharmacological therapies for pain relief and how staff should strive to prevent and treat side effects such as nausea and constipation.
Eaton also discussed end-of-life (EOL) care in the MICU and its ethical impact on staff, as she was part of a MICU team to compile EOL guidelines over the summer. “Ethical dilemmas emerge continuously in the critical care setting, and they’re a significant source of care-giver burnout,” she said. “Focus should be on preventing the occurrence of conflicts and early identification of issues. We should consult the Ethics Team early on.”
The Palliative Care Committee meets monthly, and all BWH staff are welcome. This meeting, along with monthly ethics conferences and compassionate care conferences, provide staff with opportunities to discuss the challenging issues of caring for the sickest patients.
In addition, MICU staff are working with staff on 12C in the Cardiac Critical Care Unit and the medical step down unit on Tower 14 to implement certain aspects of palliative care.
“This is about the quality of life for our patients and making sure it’s the best it can be,” Eaton said.
Eaton, Feeney ELNEC Trainers
Barbara Eaton, BSN, RN, CCRN, and Jacqueline Feeney, BSN, RN, both of the MICU, have been certified as ELNEC (End-of-Life Nursing Education Consortium) trainers. In November, they both completed the consortium sponsored by the American Association of Critical Care Nurses.