Author: Yvonne Muldowney, Trinity College Dublin

Keywords: Intensive Care Units (ICU), ICU survivors, integrating palliative care into ICU, PAL.M.ED approach

Introduction: The majority of patients in ICU are over 65 years, have chronic illnesses and multi-morbidities (National Office of Clinical Audit, 2020). ICU survivors can have life-limiting illnesses, poor quality-of-life and have a high mortality (Barreto da Costa et al. 2019; Detsky et al. 2018; Fontela et al. 2017; Myhren et al. 2010; Angus et al. 2001). Substantial evidence shows that patients in ICU have palliative care needs, such as family-clinician conflicts, spiritual distress, symptom burden and complicated grief (Jukić et al, 2016; Anstey et al. 2019; Puntillo et al. 2014; Su et al. 2018). The Irish National Clinical Programme for palliative care (2013), the European Association of Palliative Care (EAPC) (2019) and the World Health Organisation (WHO) (2015) advocates for early palliative care in conjunction with treatment for these types of patients. Yet, within evidence it is unclear whether these recommendations are being met in Ireland’s ICUs. In a systematic review of palliative care research on the island of Ireland (n=151 studies), the ICU population was not mentioned (McIlfatrick and Murphy, 2013). Also, no ICU policies, national strategies or auditing activities were found on the HSE or healthcare websites that considered palliative care integration in this area on the island of Ireland. In-fact, palliative care in ICU and Accident and Emergency (A&E) is a relatively new concept, and what it fully entails, what circumstances require it and who benefits the most from it in an acute setting is not widely studied.

There are evidence-based approaches developed for integrating palliative care into ICU (White et al. 2018; O’ Mahony et al. 2010; Mum et al. 2017; Zalenski et al. 2017). The majority use an educational package and screening-criteria to identify high-risk patients to prompt referrals. One such approach, the PAL.M.ED project (Tiernan et al. 2017) was effectively used to integrate palliative care into an urban academic A&E in the Republic of Ireland. This project found that integrating palliative care into an Irish A&E resulted in decreased length of stay (p < 0.005; −10.9 days (95%CI: −17.7 to −4.1) and increased referrals to palliative medicine services (p < 0.005; odds ratio: 10.5 (95%CI: 3.8 to 28.7).

Research Study

This PhD research project will adapt, implement and evaluate the PAL.M.ED. approach for the ICU. In collaboration with key-stakeholders the PAL.M.ED approach will be adapted (PAL.M.ED-ICU) and implemented into ICU. A scoping review and needs analysis will inform its adaptation. This pre-post project will be an intervention study examining through mixed methods the impact of integrating palliative care on patients’ outcomes. The setting will be an adult 18 bed -ICU in a large urban hospital. The study will include all patients admitted to ICU for three-four months before and after PAL.M.ED-ICU implementation. A pre-post audit will be used to collect data in order to establish a benchmark of current practice against a standard of care for ICU palliative care. Focus groups will assess clinicians’ experiences of palliative care in ICU prior to and post PAL.M.ED-ICU implementation.

Why this study is important: This study will result in an evidence-based approach for integrating palliative care into ICU to improve the standard of palliative care and to enhance the effective use of ICU resources.

This PhD study is in collaboration with Assoc. Prof. Eoin Tiernan, Consultant in Palliative Medicine, St. Vincent’s University Hospital. Supervisory team: Professor Anne-Marie Brady, TCD (primary supervisor) and Professor Peter May, Health Economics, TCD.

Full references will be provided on request – please email muldowny@tcd.ie.

This PhD study is funded by: