Intensive Care Staff Perceptions of Palliative Care Delivery in their Intensive Care Units
Catrin Manon Lewis , MBBCh
End of life discussions occur daily in most intensive care units (ICU). This survey aims to explore the perception of the delivery of end of life care (EoLC) in ICU, to identify staff members feelings regarding palliation, and whether EoLC is thought to be delivered well.
47 staff members from three adult intensive care units within one hospital (General, Neuro and Cardiothoracic ICU) participated via a structured interview/questionnaire. Clinical intensive care doctors and nurses of all grades and experience were included. Data was collected, then thematic analysis was applied to generate exposed meaningful patterns.
Five members of the hospital palliative care team were also asked the same questions regarding their perceptions of ICU delivery of EoLC. Due to small numbers and clinical experience, their responses were analysed separately to ICU staff.
46 participants (98%) felt EoLC was part of ICUs responsibility. 34 participants (72%) reported feeling comfortable and competent managing EoLC.
22 (46%) participants would seek additional advice from the hospital palliative care team (PCT).
34 participants (72%) believe EoLC is delivered well on their ICUs.
All members of the HPCT believed EoLC was part of the responsibility of ICU, however more than 60% (n=3) believe ICU staff are uncomfortable or lack competence managing patients at the end of life. 40% (n=2) believed that palliative care was poorly delivered on intensive care units.
The main theme demonstrated was the perceived delay in active withdrawal of treatment. Reasons for this include varying EoLC experience amongst doctors. Delays were also attributed to a perceived reluctance from seniors to withdraw care from patients who’s families were against palliation, either for cultural or religious reasons. Although this unease was clear, there was no mention of litigation or complaints. Numerous nursing staff reported a lack of timely DNACPR form completions, clear ceilings of care and timely withdrawal plans.
Secondly, there was resistance amongst staff to reduce physiological monitoring during withdrawal. Multiple staff members suggested this reluctance was related to the stigma of the Liverpool Care Pathway. It was felt that without numerical values inadequate assessment of symptoms was made. No member of staff made reference to the ICU end of life qualitative symptom chart which is available on the unit.
Finally, there was discordance regarding referral to palliative medicine. Some staff members looked directly to the PCT to advise on EoLC, whereas others would seek guidance within ICU. This discordance may be related to a lack of evidence based gold standards for EoLC in ICU.
Common themes amongst HPCT members were reluctance from ICU staff to change to subcutaneous infusions of medications, and to stop artificial nutrition. Amongst senior team members it was felt referrals were made too late in the dying process with high expectations for expedited discharges to home or hospice without regard for the practicalities.
Positives commented upon was the caring nature of the nursing staff in ICU, and the number of patients who remained in intensive care in the last few days of life though they no longer required specialist intensive care.
Improved EoLC in ICU needs better guidance and education to empower senior decision making. Principles, rather than tick box guidance may resolve the unease related to end of life care and allow for sufficient flexibility to individualise palliation of complex ICU patients.
This guidance should be based on a combination of palliative care and ICU withdrawal gold standards in order to produce excellence in evidence based standardised care.