What is Palliative Care?

I’m currently taking some time out of the hustle-bustle of the busy ICU to undertake a bit of an elective period in palliative medicine.  So I’ll be posting a bit on some of the aspects of palliative medicine that I think are relevant to the critical care clinician, be they doctor, nurse or paramedic.

The first thing I want to talk about may seem obvious, but I’m surprised how few people know the true answer… What is Palliative care?

I’m reminded of the episode of “The Big Bang Theory” where an oblivious Sheldon keeps responding to an increasingly exasperated Penny’s request to know what Leonard does for a living with the answer “What is Physics?”  I sometimes feel the same exasperation trying to explain what I do to my colleagues.

I guess the main misconception is that people are confusing palliative care with end of life care.  A Venn diagram come in handy here (When don’t they come in handy?)  End of life care is one aspect of palliative care, but that not all there is.

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So if it isn’t end of life care, then what is palliative care?  What about societies and college’s definitions?  They must be helpful.

“an approach that improves the quality of life of patients and their families facing the problems associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual.”

WHO

 “Palliative Medicine is the study and management of patients with active, progressive, far-advanced disease for whom the prognosis is limited and the focus of care is the quality of life”

Derek Doyle, Oxford Textbook of Palliative Medicine, 1st Ed

“the medical care of patients whose disease is not responsive to curative treatment”

Australasian Chapter of Palliative Medicine

The WHO definition seems a bit wordy.  The definition from AChPM is more concise, but I think that the essence of palliative care is best summed by Sir Raymond Hoffenberg, past president of the RCPE;

“Palliative medicine is no more, no less than the quality of care we should be offering all out patients every day – care tailored to their needs, skilled, compassionate.”

That’s all it is.  Good, meticulous, common-sense bedside medicine. Provided by compassionate, pragmatic doctors who don’t lose sight of the big picture.  Sounds a lot like intensive care doesn’t it.  Palliative care is medicine that doesn’t ignore the elephant in the room.  We acknowledge that the patient has an incurable illness.  We don’t dance around the topic of death.  We provide simple, effective treatments that are aimed at improving quality of life.  Still sounds a lot like intensive care doesn’t it?

The other thing I like about Hoffenberg’s definition, is that it reminds us that while being a specialty in it’s own right, the delivery of simple palliative care is an essential skill for all doctors.  More importantly, the delivery of good end of life care, is an essential skill for all health care professionals.  A palliative care consult should only be required for difficult, complex cases.  Unfortunately the increasing silo-isation of modern medicine means that very few doctors feel comfortable saying the word “death,” never mind providing end of life care.  The result of this of course, is that scores of patients who wanted to die at home end up dying in ICU without anyone ever asking them what they wanted.

Some of my colleagues are genuinely surprised when they see me ordering blood tests, or ordering a CT.  “Aren’t you the palliative care registrar?” They say with a tone of confusion.  As if the only thing I should be ordering is a huge dose of morphine.  But modern palliative care is more than just syringe drivers and laxatives (obviously that’s still a huge part of it though.)  We will do bloods to find things that we can treat to improve quality of life (hypercalcaemia or anaemia for example.)  We will do CTs to find things that we can treat to improve quality of life (big pleural effusions or ascites or bowel obstruction or biliary obstructions.)  One of the things I enjoy the most about palliative care is it allows you to think outside the box.  It allows you to use a drug for it’s side effects rather than it’s intended effect; to do a minimally invasive procedure knowing that the risk-benefit ratio almost always lies in favour of benefit.

Some patients receive palliative care for years and years (prostate cancer, motor-neuron disease) many receive palliative care while still receiving disease modifying treatment (myeloma, and indeed many solid organ tumours in the age of “-mibs” and “-mabs”) and some patients receive palliative care while simultaneously awaiting a cure (cystic fibrosis awaiting lung transplant.)  We look after a heterogeneous group of patients of all ages who don’t all have cancer.  In many ways it’s just good, general, internal medicine that doesn’t get bogged down in pointless minutiae.

The other aspect of palliative, of course, it the social and spiritual aspect.  Until recently I’ve never had to ask a patient if they’re religious (I actually ask “what’s important in your life”) or talk to a patient about their fears.  It’s both incredibly difficult and incredibly rewarding.

So what is palliative care?  It’s medicine.  The way it should be.  Delivered by caring, compassionate doctors and nurses (and paramedics) who understand the big picture, can communicate with patients about spirituality as well as symptoms, and have an understanding of pharmacology and pathophysiology that allows them to prescribe simple effective treatments focused on quality of life.  That’s all.  We don’t ignore the elephant in the room, we embrace it.

ANZICS ASM 2012 Adelaide Day 1

I’ve spent the last few days in Adelaide, SA at the Australia and New Zealand Intensive Care Society (ANZICS) annual scientific meeting.  ANZICS is known throughout the acute medicine community worldwide for their amazing mutli-centre clinical trials that enrol thousands of patients (SAFE, NICE-SUGAR, CHEST) and this is their annual meeting and a highly regarded ICU conference.

Day one kicked off with Prof. Warwick Anderson, CEO of the Australian National Health and Medical Research Council (NHMRC) talking about the gap between basic science and bedside clinical medicine and highlighting new initiatives from NHMRC to help translate new research into clinical practice.  It is widely accepted that it can years or even decades for research to filter down to the front lines of medicine, so hopefully the NHMRC can help to combat this.

Next was Prof. Gordon Rubenfeld from Sunnybrook in Toronto on the global burden of critical illness.  Prof. Rubenfeld highlighted some of the issues associated with carrying out epidemiological studies in critically ill patients.  By way of example he commented on a ten fold difference in incidence of ARDS that has been noted between different medical systems.  Of course this does not mean that the actual number of cases of ARDS is different, but that in order to be diagnosed with ARDS, you have to be in an ICU.  In the developing world this can be a bit of a rarity.  He then went on to discuss the provision of critical care in the developing world, and stated that we need to develop “simple, robust, inexpensive technology” citing the example of the BIll and Melinda Gates foundation as a charitable trust that strives to improve the plight of those in the developing world and suggesting that in addition to clean water they should be providing cheap ventilators.

He gave an interesting analogy to ventilation in ARDS, stating that we should be recruiting care in the developing world while avoiding overdistention of care in the developed world.  We were grounded, however, with the fact that while apparently unnecesary care in the ICU costs ~$40,000,000 dollars per year, unnecessary imaging costs $33 billion!

Next was Prof. Christina Jones from Liverpool in the UK.  Prof. Jones is a nurse consultant who has done a PhD in post-ICU rehabiliation.  She spoke on the various physical and psychological scars that can remain in ICU survivors.  In addition to physical rehabilitation programmes, she spoke about ICU diaries as a method of decreasing the incidence of PTSD in survivors.

Next Prof. Randal Curtis from Harborview in Seattle spoke about advanced care planning in ICU.  Prof. Curtis is an intensivist with an interested in palliative and end of life care.  He spoke on the well known phenomenon of elderly, co-morbid patients spending their last days in ICU receiving aggressive treatment with curative intent rather than receiving aggressive palliative care.  He spoke on research carried out by his group and others on end of life communication with critically ill patients and their families. Some of the sobering statistics that he gave included the 1 in 5 deaths in the USA occur in ICU, but that if clinicians get involves in early discussions with family and patients, ICU admissions are decreased and family satisfaction with dying process increases (a so-called “good death”).

He went on to discuss techniques for conducting ICU family meetings, citing research carried out by his group showing that families only talk 29% of the time in meetings, and that family satisfaction was increased if they said more in the meeting.  He spoke on the balance between paternalism and autonomy in decision making process and factors such as prognostic and diagnostic certainty that may affect this balance.

The final talk of day 1 was from Prof. Geoff Chase, an engineer from Canterbury University in NZ.  He works with ICUs to provide engineering solutions to clinical problems, with research interests including closed loop systems for glucose management and breath to breath analysis of lung compliance in ventilated patients.  Interesting stuff and perhaps a glimpse into the future?

Stay tuned for day 2.

You can’t use ETCO2 to confirm tube placement in cardiac arrest – MYTH BUSTED!

Thinks to twitter buddies @keeweedoc and @paramedickiwi for inspiring me to write this.

Cardiac arrest is one of the more common indications for endotracheal intubation, indeed for many health professionals, like paramedics in jurisdictions without prehospital RSI, it may be essentially the only indication.  Over the last few years, the use of continuous, or waveform end-tidal CO2 monitoring has pretty much become ubiquitous, both inside the hospital and out. I think you would struggle to find an ambulance in a first world country that doesn’t have a defibrillator capable of waveform ETCO2.

ETCO2 is now considered a standard of care both for confirming correct ET tube placement, and for guiding ventilation to appropriate ETCO2 targets once intubated.  But there is still some doubt amongst practitioners as to the utility of ETCO2 in confirming tracheal intubation in cardiac arrest.

I was taught many years ago by an intensivist (who I have a great deal of respect for, I must add) that there is no role for ETCO2 in confirming tube placement in cardiac arrest.  Yes, ETCO2 can be used once the tube is in to assess the adequacy of chest compressions and to prognosticate, but the ETCO2 will be too low for it to reliably tell you if you have but the tube in the right hole.  The theory is that in a low cardiac output state, so little CO2 will be delivered to the lungs that you will get lots of false negatives and pull out tubes that were in the trachea to begin with.  Other (unreliable) methods of tube confirmation are advocated,  like auscultation and (o)esophageal intubation detectors (EIDs, eerily similar to IEDs, which you shouldn’t use to confirm intubation).

Over the last couple of years though, the teaching has changed.  Large-ish studies have shown that in fact ETCO2 can be used to confirm tube placement in cardiac arrest and of course NAP4 has shown that not using ETCO2 can lead to disastrous outcomes.  This has changed my practice and even led me to demand change in a hospital that I worked in and get a defibrillator capable of ETCO2 measurement brought to every cardiac arrest.    But the myth is still out there.  I’ve attached a reference to a letter in Anaesthesia from last year (I’m very much a believer in level 5 evidence) which, I think, will render the myth well and truly busted after reading. Its by arguably 2 of the biggest names in anaesthesia and ICU, Tim Cook and Jerry Nolan.  It’s superbly written, with quotes like;

“When intubation is undertaken within 30 min of cardiac arrest, failure to detect exhaled CO2 using wave- form capnography during CPR indicates that oesophageal intubation is very likely. ”

“In the better of the two studies supporting the use of capnography in cardiac arrest, there was 100% sensitivity and 100% specificity in identifying correct tracheal tube placement among 246 cardiac arrest patients (including four oesophageal tube placements) ”

“In the setting of CPR, all caregivers should assume a flat capnograph is due to a misplaced or blocked tube.  The message is simple: do not assume that failure to detect CO2 is because of cardiac arrest. ”

I couldn’t have put it better myself.

http://www.ncbi.nlm.nih.gov/pubmed/22070599

Cook, T. M. and Nolan, J. P. (2011), Use of capnography to confirm correct tracheal intubation during cardiac arrest. Anaesthesia, 66: 1183–1184. doi: 10.1111/j.1365-2044.2011.06964.x

Tension what?

Tension pneumothorax is a not-uncommon and much feared complication of major trauma.  Anyone who looks after trauma patients in the course of their clinical practice must consider the possibility of a tension pneumothorax in all patients with shock or respiratory distress and actively seek to rule it out or treat it.

I’d hope that we all think of tension pneumothorax in these situations, and given the increasing ubiquity of ultrasound as an extension of clinical examination it is becoming easier to rule it out.

Recently I saw a condition that, to be honest, I had previously doubted the existence of. A tension haemothorax.  Presented just like its airy cousin, but with blood instead of air.  Near instant improvement in circulation and ventilation once drained.

There isn’t much written about tension haemothorax, just case reports really.  So it’s pretty rare.  But it was a lesson for me that you always need to consider a secondary cause of shock, particularly an obstructive cause in a patient who’s response to treatment isn’t going as expected.  So I just wanted to write a short post telling everyone that tension haemothorax really exists.

Clinical Education in the 21st Century

Here’s a Prezi I gave to a group of St. John Ambulance volunteers about the future of clinical education.  A fairly lighthearted look at the use of social media and simulation in clinical education.  Enjoy.
Updated – here’s the video.

Behind the Mask

Here’s an article I wrote last year for the popular EMS journal/magazine JEMS.

http://www.jems.com/behind-the-mask
Or, if you’d prefer a downloadable online pdf format…

http://jems.epubxp.com/i/34750

I got into intensive care for the resuscitation and the trauma.  I stayed for the arguments and the controversy ;)  And yes I really was taught as a youngster that oxygen was an analgesic.