The need to relieve patients’ suffering should not be the reason for withdrawing life-sustaining interventions in the ICU, Steven Z. Pantilat, MD, MHM, medical director of the University of California San Francisco (UCSF) School of Medicine palliative care service, told attendees at the “Management of the Hospitalized Patient” conference in San Francisco.
Patients in the ICU experience a lot of suffering, Dr. Pantilat said during a session on communication about serious illness. He underscored the importance of treating patients in the ICU as human beings, giving attention to their comfort and dignity, and addressing them by name.
“I’m not always sure they can hear me,” he said, “but there’s a humanizing element to it, as much to remind myself as for the patient’s benefit.”
Dr. Pantilat emphasized the importance of family conferences in communicating with patients and families, sometimes in advance of when important treatment decisions need to be made. The meeting should be documented in the EHR, with the note easy to retrieve.
“Resist launching in with what you know [about their case] until you ask what they know,” he advised. Dr. Pantilat tries to avoid expressions like “there’s nothing more we can do.”
“This is a subtle and difficult skill to get right, particularly the communication piece. People need practice and more training, just as you’d want to get better at putting in central lines or intubating patients.”
“[It’s] better to say, ‘I wish there was something we could do to make her lungs get better.’ Or, ‘I worry that your mother’s getting worse,’” he said.
He asks families what the patient was like before getting ill. And he always says, “We’ll take really good care of her.”
Many health professionals still associate palliative care with end-of-life care or withdrawing treatment, he said, rather than its self-defined role of relieving suffering and promoting quality of life for any seriously ill patient. Even so, he sees the hospitalists’ role in palliative care in the hospital growing.
“They are taking care of hospitalized patients who are sick; they are having lots of goals-of-care conversations; they are treating a lot of pain, a lot of dyspnea and nausea, and making referrals to hospice,” he noted. “So we know they are providing palliative care.”
Many hospitalists also work in more formal ways as palliative care consultants.
ICU patients represent 30% of referrals to his service at UCSF, which has initiatives underway to integrate palliative care into the practice of ICU nurses and into the work of the medical center’s advanced heart failure team.
Training in palliative care also is becoming a bigger part of medical education and residency programs, although medical residency graduates could benefit from additional training.
“This is a subtle and difficult skill to get right, particularly the communication piece,” Dr. Pantilat said. “People need practice and more training, just as you’d want to get better at putting in central lines or intubating patients.”
For the hospitalist, providing palliative care and “addressing issues of seriously ill patients around decision-making, talking about prognosis, treating their symptoms, [and] addressing their spiritual concerns, it’s good for the patient. It’s good for the family. It’s actually good for the hospitalist, as well. It’s very rewarding work,” Dr. Pantilat said. “Here’s this opportunity to do something incredibly meaningful that makes a huge difference. And, through your work, renew yourself and renew your commitment to your work while doing it. That’s a rare opportunity in the middle of a busy day.”