Running head: PALLIATIVE CARE IN SURGICAL CRITICAL CARE ENVIRONMENT

Delayed Transition to and Implementation of Palliative Care in

Surgical Critical Care Environment

Jennifer Leuzinger

University of Central Florida

PALLIATIVE CARE IN SURGICAL CRITICAL CARE ENVIRONMENT 2

Abstract

Background: Although the mortality rate is said to be lower than medical critical care units,

palliative care is a very common practice in surgical critical care. Patients who have undergone

surgery are complex and the palliative care team is consulted often later than it should be.

Problem statement: Delays in consulting palliative care team/department, insufficient palliative

care education provided to the critical care staff, and short or limited discussions between

clinicians and patients/families perpetuate an inadequate transition to and implementation of

palliative care. Significance: Families, staff members, and patients are adversely affected by this

problem. Healthcare dollars spent can be reduced with earlier palliative care consultations.

Specific aims: The goal is for advance practice nurses to create effective on-site palliative care

teams responsible for coordinating multi-disciplinary meetings between clinicians and families,

as well as providing palliative care education to critical care staff. Kolcaba’s theory of comfort:

Focus is on providing individualized effective person-centered care resulting in a more positive

experience. Kolcaba’s CT applied: Comfort of critical care staff will be promoted through

palliative care education. Patient and family comfort will be facilitated through organized multi-

disciplinary meetings providing opportunity for expression of comfort needs. Summary and

conclusions: Advance practice nurses can advocate on behalf of patients and their families on

critical care units by developing on-site palliative care teams that focus on unit education, early

consultations, and follow-up with patients and families post-discharge.

Keywords: palliative care, advance practice nursing, critical care

PALLIATIVE CARE IN SURGICAL CRITICAL CARE ENVIRONMENT 3

Delayed Transition to and Implementation of Palliative Care

in Surgical Critical Care Environment

Background

A majority of deaths in intensive care units occur following the decision to either

withdraw or suspend life sustaining treatments (Lautrette et al., 2006; Keenan et al., 1998). With

this in mind, it is made apparent that the palliative department should be consulted sooner rather

than later, and that education for the staff is of high priority when it comes to caring for the most

critical cases. According to Coombs, Addington-Hall, and Long-Sutehall (2012) 20% of patients

die while in intensive care. Surgical ICU’s are said to have lower mortality, but that is dependent

on the types of surgery performed at a particular facility on a regular basis (Mosenthal et al.,

2012).

Since palliative care and end-of-life care continue to be contested internationally

(O’Connor, 2010), it is necessary for the purpose of this paper to differentiate between the two

types of care. The World Health Organization (2015) defines palliative care as “an approach that

improves the quality of life of patients (adults and children) and their families who are facing

problems associated with life-threatening illness. It prevents and relieves suffering through the

early identification, correct assessment and treatment of pain and other problems, whether

physical, psychosocial or spiritual.” This contrasts with end-of-life care, which takes into

consideration the patient’s prognosis and in which patients are strongly encouraged to consider

changing to a no-code status (Aslakson, Curtis, & Nelson, 2014). Although both palliative care

and end-of-life care are patient-centered with a goal of alleviating symptom distress, palliative

care can be provided concurrently with life-prolonging intensive care therapy (Aslakson, Curtis,

& Nelson, 2014).

PALLIATIVE CARE IN SURGICAL CRITICAL CARE ENVIRONMENT 4

On surgical critical care units it is difficult to promptly identify those patients who may

benefit from palliative care due to the complexity of their compounding medical condition, the

acute illness that required surgical intervention and the multiple disciplines managing their case.

Unfortunately for the patient and family, the palliative team consult is not seen as appropriate

until the patient becomes acutely ill (Pattison, O'Gara, & Wigmore, 2015). When surgery is

involved, it is hard for the practitioner to confidently differentiate the point when a patient truly

has a poor prognosis or may just require a longer time for meaningful recovery.

Recurrent problems that present often with delayed or lack of palliative consultation are

increased unpleasant symptoms experienced by the patient, prolonged and fragmented

discussions between clinicians and family coinciding with insufficient talk times, and lastly a

lack of support to the nursing staff which results in moral distress, burnout and depression

(Aslakson, Curtis, & Nelson, 2014). Prior to the palliative care consult on critical care units, the

family and patient are receiving a disservice by not being engaged in detailed discussions about

goals of therapy or not being provided thorough explanations of the patient’s possible outcomes

or extent of recovery (Aslakson, Curtis, & Nelson, 2014). Another barrier for families is the

conflation of end-of-life care with palliative care, or even that palliative care’s goal is to move

towards end-of-life (Aslakson, Curtis, & Nelson, 2014). Needless to say, the challenges are

abundant in regards to transitioning from strictly curative treatment to care for palliation.

Problem Statement

Transition to and implementation of palliative care continues to be prolonged in critical

care units. Delays in palliative care consults, inadequate talk times between families and

clinicians (Curtis et al., 2008) and lack of palliative education and experience of the nursing staff

(World Health Organization, 2015) perpetuate the less than adequate transition for patients and
PALLIATIVE CARE IN SURGICAL CRITICAL CARE ENVIRONMENT 5

their families as they proceed with palliative care, as well as contribute to a higher amount of

health care dollars spent.

Significance

Patients and their families, nursing staff and hospitals are all adversely affected by the

delay in consults made to the palliative care department in surgical critical care units. Family

members are being met with reluctance due to the staff feeling inadequately prepared to handle

discussions broaching treatment goals or prognosis (Schmidt & Azoulay, 2012). According to

the World Health Organization (2015), only about 14% of patients who need palliative care are

receiving it. Lack of training and awareness amongst the healthcare providers is considered a

barrier to providing adequate palliative care (World Health Organization, 2015).

According to Schmidt and Azoulay (2012) “up to 40% of bereaved family members had

symptoms of general anxiety, major depressive disorders or complicated grief one year after the

loss of a loved one in the ICU.” Through surveying critical care nurses and following up with

families it is no surprise to see that nurses and families have long lasting effects as a result of the

transition from curative care to palliative care. Nurses struggle with families who demonstrate

reluctance in palliation against what the nurse perceives as the patient’s wishes (Fridh, 2014).

Due to the prevalence of this moral dilemma in critical care and the inadequate support offered

by facilities, nurses are more inclined to burnout and experience depression (Aslakson, Curtis, &

Nelson, 2014).

In one study, with palliative care involvement by trauma day two on the critical care unit,

the ICU length of stay has been reduced from 11 to 7 days (Walker, Mayo, Camire, & Kearney,

2013) which would lead to a decrease in healthcare dollars spent. Delayed palliative consults

also result in an increased number of tracheostomies and percutaneous endoscopic gastrostomy

PALLIATIVE CARE IN SURGICAL CRITICAL CARE ENVIRONMENT 6

procedures (Toevs, 2012); moderate sedation and invasive procedures that may have otherwise

been avoided by the patient.

Specific Aims

The purpose of this paper is to contribute to the development of best practice standards

between palliative care and critical care. Level 1 and level 2 trauma centers with a highly

complex patient population on their critical care units should have direct access to palliative care

teams that are readily available and employed by the hospital, rather than being contracted out.

These teams can consist of physicians and advance practice nurses working side by side in order

to facilitate a smooth transition to palliative care for patients and their families.

With the palliative care team becoming highly visible on the critical care units, these

clinicians are to assume responsibility for arranging multiple multidisciplinary meetings as

needed with the families throughout the course of the patient’s critical care experience. Also, the

palliative department will provide education to the nursing staff and intensivists on the critical

care units with an emphasis on therapeutic communication, active listening, and discussion of

goals of therapy.

Lastly, the palliative team is going to continue to follow up with families and critical care

survivors up to one year following discharge from the hospital. During this time resources will

be made available to families and patients including repeated opportunities for grief counseling

and group therapy. During this follow-up process, surveys will be provided to the patients and

families to ascertain ways to improve the palliative care process.

Kolcaba’s Theory of Comfort

Kolcaba (2010) defines comfort as “the immediate experience of being strengthened

through having the needs for relief, ease, and transcendence met in four contexts of experience
PALLIATIVE CARE IN SURGICAL CRITICAL CARE ENVIRONMENT 7

(physical, psychospiritual, social, and environmental).” The ultimate purpose of comfort theory

is to facilitate “individualized and efficient care” ideally resulting in a “more positive patient

experience” (Kolcaba, 2010). The major defining concepts of CT are as follows; comfort,

comfort care, comfort measures, comfort needs, health-seeking behaviors, institutional integrity,

and intervening variables (McEwen, 2014). CT is still considered a middle-range theory because

it has a narrower scope than a grand theory, but maintains a higher level of abstraction than a

practice theory. According to Kolcaba (2010), once each concept is operationalized across

settings only then will it be labeled a practice theory.

An integral proposition of CT is that in order to provide optimal patient care, there are

intervening variables to take into consideration while designing the patient’s individualized plan

of care. Kolcaba (2010) identifies several variables that may interfere with implementation of the

patient’s care plan, such as; financial limitations, lack of social support, and patient’s prognosis.

It is essential to be cognizant of these variables in order to increase the potential for success in

carrying out a mutually agreed upon care plan between patient and healthcare provider. Once the

patient and family’s needs are met, enhanced comfort can be attained and potentially lead to an

increase in health seeking behaviors or alternatively, a peaceful death (Kolcaba, 2010).

Application of Kolcaba’s Theory of Comfort

Advance practice nurses will start advocating for the 86% of patients that should be

receiving palliative care by establishing on-site palliative care teams (World Health

Organization, 2015). Staff members on the critical care units will complete the Advance

Directive Questionnaire (Kolcaba, 2010) so that the palliative care team can determine the staff’s

knowledge gaps and level of comfort in broaching palliative care discussions. After reviewing

the surveys, the team will develop palliative education for the nursing staff and intensivists on
PALLIATIVE CARE IN SURGICAL CRITICAL CARE ENVIRONMENT 8

the unit incorporating active listening, therapeutic communication and promoting earlier

conversations clarifying advance directives.

Each day on the unit nurses will continue to do what they have always done; assess,

establish plan of care, implement, reassess, and adjust plan of care as needed. However, with the

new understanding of palliative care, nurses will be able to provide more of a holistic approach

to their nursing care and will be more person-centered and comfort-focused (Kolcaba & Fisher,

1996). The nurse’s initial assessment will also include inquiring as to any spiritual needs of the

patient or family, which may lead to calling the hospital chaplain. Once an institution adopts and

implements the CT as its model of care, it has been shown that nurse comfort and satisfaction

improves and is directly linked to an increase in patient comfort (Kolcaba, 2010).

The staff’s knowledge of the benefits as a result of prompt palliative team involvement

for patients and families will promote earlier consults in order to get the specialists involved in

the case to aid in facilitation of multidisciplinary care meetings sooner rather than later. These

meetings will provide an opportunity for lengthy discussions to anticipate and reduce the barriers

to providing palliative care by allowing the advance practice nurse, surgeon, intensivist and

family to voice their concerns, establish goals of care, and discuss possible outcomes given

hypothetical interventions. These open conversations will also provide an outlet for the families

and patients to voice their present and anticipated comfort needs given the situation. These

meetings will serve as a means for patient and family to begin to process what is to come and aid

in the potential for transcendence.

According to Kupensky, Hileman, Emerick and Chance (2015), earlier palliative care

consults, specifically by post-trauma day two, result in shorter length of stays, improved

symptom management (physical relief) and an increase in well-defined advance directives. Once
PALLIATIVE CARE IN SURGICAL CRITICAL CARE ENVIRONMENT 9

patients are either discharged from the unit, or experience a peaceful death, the palliative care

team will assume responsibility for following up with families and the ICU survivor up to one

year following their admission. This is an opportunity to ascertain room for improvement in the

palliative care process, as well as a chance for the clinician to provide resources that will assist

the family and patient in working through or avoiding “post-intensive care syndrome” (Aslakson,

Curtis, & Nelson, 2014).

Nurses maintain the mindset that they are to be advocates for their patients by upholding

their patient’s right to be informed and right to be involved in the decision-making process

(Wilson, Ingleton, Gott, & Gardiner, 2014). Sometimes to the contrary, physicians aim to do

what is in the “best interest” of the patient regardless of patient preference (Wilson, Ingleton,

Gott, & Gardiner, 2014). This approach to patient care and holistic comfort made by nurses is

the reason why advance practice nurses should take control of adopting the CT model at their

institution and focus on the development of effective on-site palliative care teams.

Summary and Conclusions

Delayed transition to and implementation of palliative care adversely affects all of those

involved with the patient during their stay on the critical care unit. Delays in palliative care

consults results in poor symptom management and longer length of stays. The fragmented

discussions between clinicians and families lead to a decrease in patient and family comfort and

satisfaction. Gaps in palliative care education for the staff create a level of discomfort in

broaching important conversations regarding advance directives and goals of therapy with

patients and families.

Advance practice nurses can play an integral role in the development of on-site palliative

care teams. These teams will be responsible for educating all staff members on the critical care
PALLIATIVE CARE IN SURGICAL CRITICAL CARE ENVIRONMENT 10

units of the purpose and goals of palliative care. By promoting a CT model in their practice

setting, the comfort needs of patients, families and staff will be reduced. Over time and with

revisions, this effective palliative care team implementation will ultimately lead to increased

patient and family satisfaction, improved comfort of staff and patients, and a reduction in

healthcare dollars spent due to shorter length of stays.

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