ICS SOA 2015

1. Judith Nelson, MD, JD
Interim Chief, Palliative Medicine Service
Attending Physician, Critical Care Service
IntegratingPalliativeCare
inRapidResponse(MET)
CriticalCare

2. » Paradox of RRT
» Unique challenges for palliative care
» Observations from field
» Strengthening clinicians and systems

3. Hosp Med MD: I have been very impressed with our
RRTs’ ability to introduce palliative care concepts. … It
seems to me like a fair number of our RRTs end up in a
DNR order, a palliative medicine consult, a focus on
comfort and maybe a hospice discharge.
[murmurs of agreement from other participants]
ICU MD: I find that comment interesting because ….
Focus Group re Rapid Response
Palliative Care: ICU/RRT Clinicians, 7/2015 (n=7 x 2)

4. ICU MD: … When you look at the history of RRTs and
medical emergency teams, the idea was, if we pick up the
physiologic derangement, hours earlier, we have a better
chance of turning it around …
Hosp MD: Yeah.
ICU MD: … and preventing codes and improving overall
survival, which we’ve never been able to show.
Hosp MD: Yeah.
ICU MD: But rather, here, we actually [chuckle] seem to
be doing the opposite – we seem to be recognizing a dying
patient quicker and doing something about it …

5. Hosp MD: Yeah! Although, I think that’s very
valuable!
ICU MD: Very convoluted.
[several speaking at the same time, in agreement]

6. Tan & Delaney. Medical emergency teams and
end-life-care: a systematic review. Crit Care Resusc 2014.
“In one study, limitation of medical treatment
(LOMT) was the most common intervention performed
by the MET. … Initiation of LOMT was performed in
many of the studies more commonly than ICU
interventions such as endotracheal intubation, basic
and advanced life support, and vasopressor and
inotropic support.”

7. Palliative Care
» Relieve symptoms
» Exchange information
» Align plan with values
» Support caregivers
» Smooth transitions

8. AND not OR

9. Whatpalliativecareissuesariseinrapidresponse?
“Of course, symptom management …. But I think a lot of it
has to do with the goals of care and this may be a potential
turning point in the illness that the patient and family may, or
may not, have been prepared for. …
What I hear, commonly, from nurses and physicians on the
floor, is that things may not have been discussed up until that
point. So, it is a trigger, … an introduction to a discussion
that’s been needed for quite some time. That crisis point
makes it complex because these patients are in a life and
death situation and having to make decisions on information
that’s being provided to them, right at that time, rather than
something that was built up over a period of time.”
ICU Nurse Practitioner, Focus Group Participant

10. Special Challenges
» Patient unable to participate
ACP not accessible/applicable
» Surrogate unavailable/unidentified
» Primary clinician(s) unavailable
» Crisis conversations/decisions

11. “We have zero relationship with the family …the
patients, provider even. We’re just coming in out of
left field. … There’s no trust. We have to establish
trust immediately, sound authoritative, and also have
fairly good knowledge of the entire case, which may
be six or seven years long and you have to get that in
about six or seven minutes….”
ICU MD, Focus Group Participant

12. Decisions re Escalation of Care:
Complex and Crucial
» No prognostic model
» Controversy re ICU admission criteria
» System, clinician, patient-level factors
influence triage
--Unrecognized factors
» Ethical challenges arise

13. Epidemiologic Data (Australia)
• Between 10-25% patients go to ICU
after RRT
Jones. Resuscitation 2013
• Approximately 25% hospital mortality
overall, vs. 5% overall for pts not
receiving an RRT call
Jones. Anaesthes Intens Care 2014

14. Male, N % 547 (54)
Age, median, yrs 63
Service, N (%)
Medicine 653 (65)
Surgery 242 (24)
Neurology, Pediatrics, Other 116 (11)
Resusc status - DNR Pre-RRT Post-RRT
Yes 69 (7) Δ Y → N = 10 106 (11)
No 942 (93) Δ N → Y = 47 892 (89)
Family present 500 (50)
Primary team present 852 (85)
Memorial Sloan KetteringRRTs: 2014 (N=1011)

15. ICU All RRT
Hosp Admission to RRT,
Median, d 12 6
Hosp LOS, Median, d 31 10
Admittedto ICU, N (%) 243 (24)
Hematologic 92 (39)
Solid Tumor 142 (61)

16. During RRT 35
In ICU 65
After ICU tx 26
No ICU 104
Total, N (%) 230 (23)
RRT PatientsDying in Hospital

17. RRTs are also called for patients already
with LOLST – which may be appropriate.
Coventry. Resuscitation 2013.

18. Acute, Time-Pressured
Decision-Making: View via Simulation
Uy et al. Crit Care Med 2013.
98 audiotaped encounters –
AMCs in 3 US regions
– Hospital-based MD (EM, hospitalist, ICU) with
simulated patient and surrogate
– 78 yo man with met gastric CA and crisis
hypoxemia/dyspnea (VS would prompt RRT)
in ED/on ward

19. Scenario
• Readmission after recent long hospital stay
• No advance care plan in MR
• Patient awake, has capacity, but dyspneic
• Patient and wife know prognosis (3-6 mos, no
cancer-directed treatment)
• Patient prefers to avoid ICU and intubation
• Patient prefers making decisions independent of
MD; wife would ask for recommendation if options

20. What They (MDs) Said
» 43% asked re understanding of disease or discussed
prognosis if survived acute illness
» < 40% mentioned >1 potential treatment option
» < 5% discussed outcomes of different treatment
strategies before eliciting preferences
» > 80% focused on specific interventions/ procedures >
broader life values/goals

21. Roles They Played
Informative
Discusses condition, prognosis,
treatment options
1 %
Facilitative
Clarifies values
Applies to decision
49%
Collaborative
Shares in family deliberation
Makes recommendation
37%
Directive
Assumes all responsibility for
decision
12%

22. What They Did:
Barnato, Crit Care Med 2008.
Decision re ICU (N=27)
Yes
N (%)
No
N (%)
Admit to ICU 8 (30) 19 (70)
Dypsnea tx 3 (37) 13 (68)
Document resusc status 2 (25) 5 (26)
Intubate 1 0

23. Rapid ResponsePalliative Care Framework: REACT
R Relieve symptoms
E Exchange information
A Align plan with values/goals
C Support Caregivers
T Smooth Transitions

24. What is needed to prepare and
support RRT for optimal (primary)
palliative care delivery
?

25. » Knowledge and skills
» Informatical support
Optimizing a Single, Brief, Encounter

26. Quickly, but Skillfully
» Assess
– Urgency
– Capacity
» Communicate
– Clinicians
• Afferent/Efferent
– Patient/Family
• Establish rapport, express empathy,
explain situation, elicit values/concerns
» Manage
– Dyspnea, pain, anxiety

27. Nelson et al. Chest 2015.

28. System Supports
» Readily accessible documentation of advance care
planning
» EMR supports afferent and efferent communication
» Interprofessional involvement in RRT support (e.g.,
chaplaincy, mental health professionals)
» Review and feedback of RRT outcomes (including
symptoms, documentation of preferences for LST)

29. Nelson
Evaluation of RRT Improvement Effort
Nelson. Chest 2015.

30. Selected References
• Nelson JE, Mathews KS, Weissman DE, et al Integration of palliative care in the
context of rapid response. Chest 2015; 147:560-9.
• Sulistio M, Franco M, Vo A, et al. Hospital rapid response team and patients
with life-limiting illness: a multicentre retrospective cohort study. Palliat Med
2015;29:302-9.
• Jones D, Moran J, Winters B, Welch J. The rapid response system and end-of-
life care. Curr Opin Crit Care 2013; 19:616-23.
• Jones DA, Bagshaw SM, Barrett J, et al. The role of the medical emergency
team in end-of-life care: A multicenter, prospective, observational study. Crit
Care Med 2012; 40:98-103.