Palliative care in the critical care setting : a case study analysis

Abstract

Background: Palliative and critical care seem dichotomous; however, they share important therapeutic goals and values which are indispensable in the care of the seriously ill. Despite medical and technological advancements, mortality in Intensive Care Units (ICUs) remains high, further highlighting the need for compassionate palliative care (PC) in critical care. Aim: To explore ICU nurses’ and physicians’ understandings and perceptions about integrating PC in the critical care setting. Design: Explanatory sequential mixed-methods case-study research design. Methods: Quantitative data were collected through the End-of-Life Care in the ICU questionnaire (Montagnini et al., 2012) and analysed statistically. Qualitative data were generated through semi-structured interviews with consultant intensivists (n=2) and charge nurses (n=2), and through focus groups with nurses (n=6) and physicians (n=5) and analysed thematically. Results: The questionnaire response rate was 64.2%. On a 5-point Likert scale, participants felt most competent in Attitudes (mean=3.60) and Symptom Management (mean=3.34), and least competent in Emotional Support for Staff (mean=2.66), and Continuity of Care (mean=2.73). Nurses felt significantly more competent in Continuity of Care (p=0.037), Emotional Support for Patients and Families (p=0.029) and Spiritual Support (p<0.001), whereas physicians felt significantly more competent in Attitudes (p=0.001), Decision Making (p=0.015) and Emotional Support for Staff (p=0.005). There were no differences by gender or previous participation in end-oflife (EOL) care education. Participants’ self-perceived competences in EOL care increased with age and years of experience. Qualitative data revealed four overarching themes: Understandings of PC; Current PC Practices in the ICU; Barriers to Delivering PC in the ICU; and Unprecedented Pandemic Times. The final concepts derived from synthesising quantitative and qualitative data were The Dichotomy between Palliative and Curative Care, EOL Decision-Making, Supporting the Critical Care Professionals, The Critical Care Environment, and The Unprecedented Pandemic Times. Conclusion: Although local ICU nurses and physicians perceive PC to be an important part of their care towards critically ill patients, it is often considered secondary to curative care. ICU nurses and physicians require continuous support, particularly in EOL decision-making. The COVID-19 pandemic may serve as an eyeopener for the need for improved compassionate PC in the ICU.