Introducing the palliative care ICU

I think we are overly limited by our descriptive terms.  We throw around concepts like hospice and palliative care, but in reality the medicine I practice is much more a hybrid.  Many of my patients are elderly, demented, and plagued by metastatic disease.  Often when one of them becomes ill, it is unclear if they are merely treading water, or about to drown.  The problem with our modern definitions is that they leave little room to pivot.  Pivoting, it turns out, is critical to delivering humane, dignified, high quality care.  And our patients don’t want  to be pigeonholed.  They want aggressive doctoring when it will be helpful, and hospice when chances are slim.  Unfortunately our crystal ball rarely provides the answers we are looking for.

With these ideas in mind, I would like to introduce the concept of the palliative care ICU (PCU).  Less an actual place than a state of mind, the PCU is a philosophy of doctoring that allows physicians to treat both aggressively and palliatively at the same time.  In other words, short term, intense, pain neutral interventions are carried out acutely with an eye on pivoting to hospice versus aggressive care depending on short term response.

In order to illustrate, lets consider Tom, an 85-year-old in a nursing home with metastatic lung cancer.  Although he is getting weaker, he still is able to ambulate and enjoy time with his wife and daughters.  One evening he develops fever and somnolence.

Tom has a fairly limited prognosis based on his aggressive malignancy.  On the other hand, his family has been enjoying visiting with him, and would hate for him to die prematurely from a treatable infection.  The patient himself has resisted hospice because he wants to continue getting chemotherapy.

If this is Tom’s time to die, all parties agree to make him comfortable, and let him go.  On the other hand, if medical intervention could prolong his life and maintain a semblance of quality, no one would argue with intervening.

What is Tom’s physician to do?

PCU concept 1: Shelter in place

Tom will die soon from his cancer regardless of the outcome of the current infection.  The last thing his family wants is for him to spend his last moments in an ICU being poked and prodded by strangers wearing isolation gowns.  Thankfully, there really is no reason to move him out of the comfort of his nursing home bed.  Given today’s current medical climate, high level care can be delivered not only in extended care facilities but also in people’s homes.  IVs can be placed, antibiotics given, and pain levels monitored.  If Tom were at home he could be attended to by an home health company or palliative care program.

Maintaining Tom’s location is critical to the PCU concept.  It allows humane, dignified medicine without the trauma of escalating the place of care.  When possible, home patients stay at home, nursing home residents remain in the nursing home, and floor patients remain on the floor and avoid the ICU.

Tom’s family and doctor decided to sign a do not hospitalize form and manage the current crisis in the comfort of his own room.

PCU concept 2: Pain-neutral interventions

Because Tom’s quality of life was still reasonable, his physician and family felt that drawing blood tests, placing an IV, and beginning intravenous antibiotics was reasonable.

Each intervention was discussed among all parties and decided that the amount of discomfort was minimal compared to the possible benefit.  CPR and artificial ventilation and feeding, however, would clearly be painful and therefore were forbidden.

Although Tom continued to decompensate, he appeared comfortable and no worse for the wear given the current levels of treatment.

PCU concept 3: Pivot, pivot, pivot 

Tom’s physician reviewed the lab results with the family the next morning.  The kidneys were shutting down, the liver tests were abnormal, and Tom hadn’t shown any signs of waking up.  He started to moan occasionally during the night and morphine was started.  The nurse carefully placed a few milliliters of medicine under his tongue every few hours, and he quickly became peaceful.

During a family meeting, Tom’s wife and daughters understood clearly that recovery was unlikely and that little benefit would come from hospitalization.  Hospice was consulted.

Tom died quietly, surrounded by his family and friends, a few days later.

Conclusion

Conversely, if Tom had a limited infection like a UTI, he may have responded quickly to antibiotics and recovered uneventfully in the nursing home.  Either way, he was given high quality, judicious care that allowed nature to declare itself.

The future of healthcare is here.

We have to learn to drop our preconceived labels and adapt more hybridized models.

With this intention, I introduce the palliative care ICU.

Jordan Grumet is an internal medicine physician and founder, CrisisMD.  He blogs at In My Humble Opinion.

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  • PoliticallyIncorrectMD

    Agree very much with this approach and have been practicing it. The limiting factor is commonly the unwillingness / lack of training of the health care providers to address the end-of-life issues. Also, not clear how PCU concept is new as, for years, we have been admitting patients for aggressive treatments, but limited invasive interventions (such as intubations, central lines, CPR, etc.) Can you please explain.

  • ninguem

    I guess it’s a good idea, I just can’t shake this idea of a STAT aromatherapist consult to the Palliative Care ICU.

  • Tiredoc

    Sorry, you just participated in a death panel. By stating explicitly that he wanted chemotherapy, Tom said he wanted to fight. Unless you had explicit instructions from Tom in what to do if he got an infection, you are substituting your opinion for his. You, his physician, and his family gave up on him without his permission. He was not in hospice. He was not capable of consenting to anything. You decided for him and called the ghouls who dutifully performed their slow euthanasia.

    The absolute bedrock principle of palliative medicine is the patient decides. It’s not about the quality of life you would agree to, or the quality of life the family agrees to. It’s about what the patient wants or has previously expressed.

    If what you mean by PCU is a following a detailed living will, count me in. If you want me to wait until the patient is comatose and then decide what I think best, count me out.

    • PoliticallyIncorrectMD

      While following patient’s wishes is critical, it is absolutely ethical to withhold / not offer interventions which are futile. Tom was not denied appropriate treatment, he was not offered one which would not change the outcome. On the contrary, subjecting him to life sustaining measures without hope for recovery would be cruel and unethical. If he requested lung transplant, would you set him up for one? In addition, even if he “wanted to fight” given his underlying condition, sings changed now, that he developed a life threatening infection. As he is unable to express what his wishes in current situation, it is perfectly ethical and legal for his family to make this decision.

      • Tiredoc

        Oh, it’s legal alright. Ethical, not so much. No one is obligated to provide futile care. But if Tom wanted two more weeks and it’s possible to provide two more weeks, we do so if Tom asks. If Tom didn’t want that, he needs to say so. Waiting for Tom to pass out and then asking the family what they think is not ethical, or brave. It’s pathetic.

        It’s all there in the article. The PCU called in when the patient is dwindling and can’t say no. Surround the family with multiple experts, all trained in saying the same thing: goner. Once consent is obtained, the quick handoff of care to the ghouls and the walk-away. Clean. Practiced. Efficient. Revolting.

        Death panel.

        • PoliticallyIncorrectMD

          Possibly he wanted two more weeks of life, unlikely he wanted two more weeks on life support, in coma, with tubes stuck in every body orifice – nobody would. And what about all this drama? Get off your high horse already!

          • Tiredoc

            “Nobody” appointed you the arbiter of what anyone would want. I don’t want my last days as a physiology experiment, and have said so, in writing.

            I don’t have a problem with letting pneumonia act as a friend. I have a problem with lacking the gonads to actually inform the patient what palliative chemotherapy really means. Then, the conversation with the family is, “you know this is what Tom wanted.”

            It’s one thing to have the family meeting about a patient who hasn’t had the capacity for independent thought in years, but calling in the PCU crew “stat” right as Tom conveniently fades into a septic fog doesn’t peg more than a 1 on the 10 point scale of

          • PoliticallyIncorrectMD

            Unfortunately , we have to be the arbiters often (in collaboration with family) when the patient’s wishes under the specific circumstances are not clear. Most of us do it having patient’s best interest in mind, so, please, don’t make it sound like there is a conspiracy. You might have years to figure it out when you practice Physical Medicine, however, when treating critically ill, you do not have this luxury. Given your attitude, it seems that you are not treating the patient. You are treating your own discomfort with end-of -life care. This is hardly an ethical position. If you are not comfortable with this role, get away.

          • Tiredoc

            It is true that Physical Medicine does have more time than most to sort out patient wishes and family dynamics. I’m not sure why you think that serving as primary care physician to the disabled insulates me from end-of-life care. Unlike most specialties, there is no illusion of complete recovery or permanent deferral of mortality.

            My gripe with the critical care crew is that they too often make choices for the patient based on what the doctor would want, rather than what the patient would want.

            It is common for people with disabilities that their doctors find horrifying to report high levels of contentment. It is also common for their family members to be very, very tired of caring for them.

            It is shockingly common for such cognitively intact patients to be admitted for treatable illnesses and hospiced to death out of purported kindness, despite their well documented wishes.

            The line between end-of-life care and euthanasia is very narrow. Taking a team approach ensures groupthink and dispersal of blame. I am quite comfortable with my end-of-life care approach, which is based on informed consent.

          • PoliticallyIncorrectMD

            I don’t think primary care physicians are insulated form end-of-life discussions. In fact, I think it is their primary responsibility to establish what the patient’s wishes are long before their health fails, as they know patient the best. Unfortunately, those discussions are infrequent and at best are limited to asking the patient to check the boxes next to options most of them don’t understand or asking meaningless question “do you want everything done?” – who in the right mind would say “No”. I would consider neither option to be an informed consent. Don’t even get me started on living wills, which are totally useless in cases of acute critical illness. What I was questioning is the validity of your critique of the end-of-life care in critical care setting, while you likely to have very limited experience with this. How do you know what is “shockingly common” in the ICU setting spending most of your time in the outpatient office?

          • Tiredoc

            The “shockingly common” is my experience with my own patients. Of course a check-box living will is useless. It’s the conversation that matters.

            I am objecting to three things about the article.

            First, the team approach. Groupthink is a well established logical fallacy and is particularly worrisome when applied in discussions with participants with asymmetric educations and under stress.

            Second, the concept of palliative ICU, or waiting until the patient can’t communicate and then triggering the end-of-life discussion. By the article, there was time to determine informed consent with a cognitively intact patient.

          • PoliticallyIncorrectMD

            Some would view team approach as a safety measure to assure that there are no misinterpretations or abuse.

            As far as your second point, making end-of-life decisions is a dynamic process. As patient’s condition changes, it is not only reasonable but necessary to reevaluate the goals of care. In the scenario above, patient developed acute changes in mental status as well as multiple organ system failure, likely irreversible. He also appeared uncomfortable. It seems like very appropriate point to reevaluate goals of care, approach the surrogate decision makers about their opinion and, according to their wishes, institute comfort measures.

          • Tiredoc

            We’re arguing different points. To be clear, from the information in the article, the medical care was appropriate. The end-of-life discussion was sloppy and not a model that should be encouraged.

            Physical Medicine is well acquainted with the team approach. In my opinion, the team approach will almost universally degenerate into either an indecisive mess or a board that would agree to comfort measures only on every patient in the hospital.

  • Michael Wasserman

    I’ve been doing this for the past 25 years, thanks for sharing! We need to educate more physicians on how to offer their patients choices. As I always tell my patients and their families, we live in America and people have a right to whatever they want. If they want their lives prolonged despite increased or prolonged suffering, they have a right to choose that. If they want the most quality of life and comfort regardless of actual time spent living, they can choose that direction. We never know for sure and can only give them approximate odds, but then again, we’re just doctors, not G-d. Thanks again!