Do Interventions Improve Symptoms Among ICU Surrogates Facing End-of-Life Decisions? A Prognostically-Enriched Systematic Review and Meta-Analysis.

OBJECTIVES: Evaluate the efficacy of interventions to improve symptoms for ICU surrogates at highest risk of developing psychologic distress: those facing end-of-life care decisions. DATA SOURCES: MEDLINE, CINAHL, PsycInfo, Embase, Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov were searched through April 16, 2022. STUDY SELECTION: Following an a priori protocol, randomized trials of interventions delivered to surrogates of adult ICU patients who died or had high likelihood of mortality evaluating surrogate symptoms were identified. DATA EXTRACTION: Two reviewers performed screening and data extraction and assessed risk of bias (Cochrane Risk of Bias [RoB] 2 tool). Trials were eligible for meta-analysis if group mean symptom scores were provided at 3 or 6 months. Pooled effects were estimated using a random effects model. Heterogeneity was assessed (Cochrane Q, I2 ). Certainty of evidence was assessed (Grading of Recommendations Assessment, Development and Evaluation). DATA SYNTHESIS: Of 1,660 records, 10 trials met inclusion criteria representing 3,824 surrogates; eight were included in the meta-analysis. Overall RoB was rated Some Concerns. Most ( n = 8) interventions focused on improving communication and enhancing psychologic support in the ICU. All trials measured anxiety, depression, and posttraumatic stress. Significant improvement was seen at 3 months (depression, mean difference [MD], -0.68; 95% CI, -1.14 to -0.22, moderate certainty; posttraumatic stress, standardized MD, -0.25; 95% CI, -0.49 to -0.01, very low certainty) and 6 months (anxiety, MD, -0.70; 95% CI, -1.18 to -0.22, moderate certainty). Sensitivity analyses suggest significant findings may be unstable. Subgroup analyses demonstrated differences in effect by trial location, interventionist, and intervention dose. CONCLUSIONS: Communication and psychological support interventions in the ICU yielded small but significant improvement in psychological symptoms with moderate to very low certainty evidence in a prognostically-enriched sample of ICU surrogates facing end-of-life care decisions. A new approach to interventions that extend beyond the ICU may be needed.

Integration of Palliative Care Advanced Practice Nurses Into Intensive Care Unit Teams.

BACKGROUND: Referrals to palliative care for patients at the end of life in the intensive care unit (ICU) often happen late in the ICU stay, if at all. The integration of a palliative medicine advanced practice nurse (APN) is one potential strategy for proactively identifying patients who could benefit from this service. OBJECTIVE: To evaluate the association between the integration of palliative medicine APNs into the routine operations of ICUs and hospital costs at 2 different institutions, Montefiore Medical Center (MMC) and Rush University Medical Center. METHODS: The association between collaborative palliative care consultation service programs and hospital costs per patient was evaluated for the 2 institutions. Hospital costs were compared for patients with and without a referral to palliative care using Mann-Whitney U tests. RESULTS: Hospital nonroom and board costs at the Weiler campus of MMC were significantly lower for patients with palliative care compared with those who did not receive palliative care (Median = US$6643 vs US$12 399, P < .001). Cost differences for ICU patients with and without palliative care at Rush University Medical Center were not significantly different. CONCLUSION: Our evaluation suggests that the integration of APNs into a palliative care team for case finding may be a promising strategy, but more work is needed to determine whether reductions in cost are significant.

Interventional pain management in the palliative care patient.

For the majority of patients, cancer pain can be treated using the World Health Organization cancer pain guidelines; however, for 10-20% of patients with advanced cancer, adequate pain control cannot be achieved using these methods owing to disease pathophysiology preventing administration/absorption of pain medications or intolerance due to opioid toxicities. The need to expand analgesic treatment when oral, transdermal, and intravenous therapies fail requires exploration of interventional pain management techniques such as neuraxial (e.g. epidural and intrathecal) infusion therapies and neurolytic interventions. Nurses caring for patients with cancer pain should develop their knowledge of these multimodal approaches to cancer pain management.

Nurses leading the response to the crisis of palliative care for vulnerable populations.

All nurses are prepared to be generalists in palliative care. Within the discipline there are nurses who seek advanced educational preparation and develop clinical expertise in palliative care nursing. These are our leaders in palliative care nursing who can exert influence in all health care settings to support nurses providing palliative care. It is nurses and advanced practice nurses in partnership who are capable of developing and advocating for palliative care across settings. The focus of care is the person, not the diagnosis or the setting. The viewpoint that "all nursing care is palliative care" can transform health care with nurses taking the lead.

Assessment and management of gastrointestinal symptoms in advanced illness.

Primary care clinicians increasingly encounter patients with advanced illness, many suffering from symptoms other than pain. Key principles that guide palliative care must be incorporated into a plan of care for each patient and family. Although medical management continues to be the mainstay of treatment, the generalist in palliative care needs to be familiar with the patient's preferences and goals of care. This article provides an overview of gastrointestinal symptoms including anorexia, cachexia, nausea, vomiting, and constipation. Advanced progressive illnesses are defined here as incurable conditions that have significant morbidity in the later stages of illness.

Symptom management in palliative care and end of life care.

There is a need for generalist- and specialist-level palliative care clinicians proficient in symptom management and care coordination. Major factors contributing to this need include changed disease processes and trajectories, improved medical techniques and diagnostic testing, successful screening for chronic conditions, and drugs that often prolong life. The rapid progressive illnesses and deaths that plagued the first half of the twentieth century have been replaced in the twenty-first century by increased survival rates. Conditions that require ongoing medical care beyond a year define the current chronic illness population. Long years of survival are often accompanied by a reduced quality of life that requires more medical and nursing care and longer home care. This article reviews the management of selected symptoms in palliative and end of life care.