When to “Phone-A-Friend” When Patients are Sickest in the ICU

Young May Cha, MD, MS

Every intensivist strives to provide high-quality, compassionate, and effective care to all patients in the intensive care unit (ICU). But resources are limited, disparities of care exist, and patients and families are suffering from anxiety, depression, and even posttraumatic stress disorder (PTSD) after a complex ICU stay. Moderator Rebecca Aslakson, MD, Chair and Professor of Anesthesiology at the University of Vermont Larner College of Medicine, opened the discussion with the newly published practice guidelines from the Society of Critical Care Medicine on family-centered care. The new evidence provides support for the use of decision aids, and strengthens the recommendation for incorporating family members on rounds. The three panel speakers then explored when to consider including palliative care specialists, when to discuss the financial implications of ICU hospitalization, and how to improve the skills of intensivists.

Rachel Hadler, MD, Assistant Professor of Anesthesiology at Emory University, reviewed how the evidence on palliative care consultation in the ICU is mixed. Qualitative studies have shown a benefit. Quantitative analyses have shown possibly improved concordant goals of care, an increased discharge to hospice, improved documentation, but no impact on length of stay or mortality. Some studies even suggest increased anxiety and depression among family members with routine palliative care consultation. Even the use of clinical triggers for palliative care consultation did not improve the likelihood of identifying patient needs. These mixed data may be due to the difficulty in defining what a protocolized interaction of palliative care should look like.

Instead, Dr. Hadler suggests using a more personal approach when considering palliative care consultation. Palliative care specialists are a small and often heavily consulted workforce. They can be useful when there is a need for a neutral third party to help navigate complex interpersonal or intrafamily dynamics. They can also be useful to help patients and families navigate particularly complex medical care. They can be engaged preoperatively to help with preparedness planning or when there is ambivalence regarding the procedure. In the preoperative phase, palliative care specialists can help clarify what the long-term outcomes of a surgical procedure may mean for the patient and family. Perhaps it is in these situations with uncontrolled symptoms, concerns about anticipated survival, and high levels of distress that palliative care consultation can be most effective.

Next, Nita Khandelwal, MD, MS, Associate Professor of Anesthesiology and Pain Medicine at the University of Washington, discussed the impact of financial hardship after ICU hospitalization.  Healthcare expenditures are highly concentrated and the top 5% of Americans account for 50% of total US healthcare expenditures. This financial hardship affects the patient as financial toxicity and continues beyond the dollars spent. It results in lost income, lost assets, increased debt, bankruptcy, and is an independent risk factor for mortality. Financial stress can impact clinical status. Patients with fewer than 12 months of financial reserves report greater pain, more symptoms, and worse quality of life. Unfortunately, large scale interventions to address financial hardship will require changes at the policy level.

In the meanwhile, Dr. Khandelwal recommends incorporating screening for financial risk and to normalize discussions about cost into decision making. Clinicians, however, have concern about perceived conflicts of interest that may arise when cost is discussed. No one wants a family to think their loved one is receiving different care because of their insurance or financial status. Dr. Khandelwal encourages us to normalize discussions of financial hardship with the hope that routine screening will create an environment conducive to patients and families raising their financial concerns to the ICU team. Some institutions are incorporating the use of financial navigators to provide individualized assistance to patients and families to overcome the financial barriers to timely, high-quality care. These are a promising intervention beyond social work that can help lessen the onset, severity, and duration of financial toxicity.

Allison Dalton, MD, Associate Professor of Anesthesia and Critical Care at the University of Chicago, then rounded out the panel with a discussion of how intensivists can improve the care of ICU patients. Resources for specialists are limited. Also, not every patient in the ICU requires this level of expertise. Many of the domains of palliative care, such as the management of physical symptoms, shared decision-making, and educated prognostication are skills routinely used by anesthesiologists. Palliative care specialists document psychosocial and spiritual care more frequently, so that is one area for improvement for intensivists. Dr. Dalton introduced specific skill training in medical ethics, conflict management, and communication skills to improve the palliative care that intensivists are already providing in the ICU. This more integrative model of ICU care, in which palliative care principles and interventions are part of the daily practice by the ICU team, has been shown to decrease ICU length of stay, decrease duration of mechanical ventilation, increase patient and family satisfaction, and decrease family and patient PTSD.