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Print version ISSN 0103-507X
Rev. bras. ter. intensiva vol.24 no.2 São Paulo Apr./June 2012
Palliative care of elderly patients in intensive care units: a systematic review
Anelise Coelho da Fonseca; Walter Vieira Mendes Junior; Maria de Jesus Mendes da Fonseca
Escola Nacional de Saúde Pública, Fundação Oswaldo Cruz - ENSP/Fiocruz - Rio de Janeiro (RJ), Brazil
OBJECTIVE: The use of
interventionist medical technology in terminal elderly patients must be
associated with palliative care as a measure of clinical support in intensive
care units. Palliative care is an important component of end-of-life care, and
the assistance provided by the healthcare team should be guided by decisions
made by patients and their family members. Prolongation of life not accompanied
by therapies aimed at relieving symptoms, such as pain and dyspnea, contributes
to patient and family member stress suffering. The aim of the present study was
to survey advances made in the application of palliative care in intensive care
METHODS: Medline and Bireme were used to perform a systematic literature review of intensive care units-based palliative care for elderly patients.
RESULTS: A total of 29 articles describing palliative care in intensive care units were analyzed according to the variables "satisfaction of relatives when they participate in the discussions on palliative care" and "difficulties to implement such type of care due to lack of technical skills of the health caregivers."
CONCLUSION: Palliative care for elderly patients in intensive care units must be more thoroughly investigated to improve the relationships and communication among patients, their relatives, and the healthcare team. As greater numbers of elderly patients are admitted to intensive care units, the skills of health caregivers must improve to meet the challenges posed by the end-of-life care.
Keywords: Aged; Hospice care; Life support care; Palliative care; Critical care; Chronic disease
Palliative care (PC) comprises interventions to treat patients during the end of life. According to the World Health Organization (WHO), PC includes interventions that relieve unpleasant symptoms caused by treatment or disease progression.(1,2) Elderly people are the group most frequently subjected to such interventions, especially those undergoing long treatments for chronic diseases, such as dementia; neoplasia; and heart, lung, or kidney disease. The serious impacts of aging on health became more clear in Brazil starting at the end of the 1980s, and consequently, clinical approaches specifically targeting the elderly came to be considered as essential.(3) Nevertheless, despite improvements in the diagnosis, treatment, and prognosis of diseases, the subject of "death" looms large in the minds of the elderly and their attendants. One of the major concerns of healthcare professionals who treat the elderly is the manner in which death is experienced by the patients and their relatives. A large fraction of deaths occur in hospitals, especially in intensive care units (ICU). This is one of the reasons why the relationship between PC and ICUs must be understood from the perspective of shifting disease patterns and increased longevity.(4-6) The Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatment (SUPPORT) was a pioneering investigation that laid the groundwork for further research.(7) In Brazil, this subject came to the forefront when the British journal The Economist published a 2010 ranking on the quality of death in several countries. According to the selected criteria, Brazil was the third worst country to die in.(8)
When discussing end-of-life conditions in the elderly, we must take into account the symptoms of chronic diseases and their required care as the fundamental elements to afford relief from suffering and to maintain patient functional ability. The aim of referrals to the ICU is to make the most modern life-support resources available. However, even when technology is able to afford patients and their relatives symptom relief, it is insufficient for ameliorating their suffering and anguish.(9,10)
PC comprises a set of interventions independent from the motives of admission that afford comfort to patients and that might be performed simultaneously with ICU interventionist and "curative" actions. The healthcare professionals who assist patients with very severe diseases are aware that the most probable outcome is death.(11) When facing imminent death, instead of insisting on treatments for with recovery of the clinical picture reversion and prolonging life despite any resulting suffering, intensivist doctors and nurses should direct their attention toward treatments that promote relief and comfort. PC increases therapeutic options beyond traditional ICU care strategies. As an example, one might mention the combined use of a titrated dose of morphine and non-invasive ventilation with mask to treat dyspnea associated with chronic obstructive pulmonary disease (COPD) instead of orotracheal tubes. The use of non-pharmacological interventions such as physiotherapy, speech therapy, psychology, relaxing techniques, and music therapy might promote well-being while the patients are subjected to intensive treatment.(12) Respect for the autonomy of patients and their relatives by stimulating their participation in the decision-making process is also an initiative that might contribute to minimize anguish in a way drug therapies usually cannot.
The use of PC in ICU is not new. There is ample literature to support its use, and thus, there is no reason for patients to suffer at the time of death. The aims of the present review were to systematically assess the literature for advances made in PC in ICUs and to suggest that PC options be implemented as protocols in conjunction with clinical guidelines that are already available. An example of these protocols is the protocol that directs the measures for the prophylaxis of pneumonia associated with mechanical ventilation.
We performed a systematic literature review of descriptive studies assessing PC for patients >65 years old in ICUs. Articles in English, Spanish, and Portuguese were analyzed, but published editorials and letters were excluded. The National Library of Medicine (NCBI) and Virtual Health Library (Biblioteca Virtual em Saúde - BVS) were used, and the following databases were searched: Cochrane Library, IBECS, Scientific Electronic Library Online (SciELO), and PubMed. All articles published between January 1960 and November 30 2011 were analyzed. The search keywords used were "cuidados paliativos" and "unidade de terapia intensiva" in Portuguese; "palliative care" and "critical care" in English; "unidades de cuidados intensivos" and "cuidados paliativos" in Spanish. The English keywords were Medical Subject Headings (MeSH) Terms from the US National Library of Medicine (NLM).
We considered the following variables during our analysis: type of study, i.e., whether it was based on qualitative or quantitative methods; aims; and results and conclusions. To analyze the methodological quality of the studies, the following guidelines were used: PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) and STROBE (STrengthening the Reporting of OBservational studies in HYPERLINK "http://www.cochrane.org/glossary/5#term226" Epidemiology).(13,14)
Studies identified in the initial search were selected based on their titles and abstracts, which were independently and blindly assessed by two researchers. Selection was performed in two stages: first, the title and abstract of all located studies were assessed, and those that met the requirements were assessed in full. Inter-examiner disagreement as to the selection of articles was solved by consensus; when consensus could not be achieved, the articles were included for full-text assessment.
Studies that focused on specific pharmacological interventions or did not discuss the relationship between both terms (palliative care and critical care) were excluded. Studies that did not provide abstracts were also excluded.
The present systematic review located 333 studies. After selection by title and available abstract, 57 studies remained, and 28 of these were excluded because they were editorials or letters or did not address the relationship between the two subjects of interest. A total of 29 articles were selected for full-text assessment. Figure 1 depicts the flowchart of the article selection process. Notably, the number of publications addressing both subjects of interest increased in the last 10 years (Table 1).
The selected articles are described in charts 1, 2, 3. We chose to classify them in three groups: studies that used qualitative methods; studies that used quantitative methods; and studies comprising reviews, descriptions of experiences, or the theoretical foundations of PC.(15-43) The results of the main selected articles are provided below.
Singer et al.(15) performed a qualitative study that administered a questionnaire to the coordinators of specialization courses in intensive medicine. The aim of this study was to identify and describe the elements corresponding to domains of quality in end-of-life care from the patient perspective. Five domains were identified: a) control of pain and appropriate symptom management, b) avoidance of inappropriate prolongation of life that causes unnecessary suffering due to the application of curative measures, c) maintenance of patient autonomy, d) stress relief, and e) strengthening of relationships with the patients' relatives. These dimensions are also a component of PC interventions. The study by Dawson(16) on the theoretical foundations of PC discusses the notion of PC and the complexity of terminal patients within the context of a case report. It points to the importance of understanding the mutual relationships among PC caregivers, the elderly, and ICU caregivers, because PC is centered on the patients and their relatives. Thus, the interventions facilitated by PC might improve the quality of life of the patients. That study further stressed that PC is directed toward physical, intellectual, emotional, social, and spiritual needs and that it favors patient autonomy, as well as access to information needed for making decisions regarding care. The author asserts that the ICU, as a place designed for preserving life, focuses reversing the clinical condition using instruments that might cause more damage than the intended benefit. For this reason, interventions that might provide essential comfort to the elderly, who are usually the most fragile patients, are sometimes inadvertently neglected. The study concludes with a series of recommendations for applying PC in the ICU and stresses that the initiative ought to be taken by nurses, who are the closest health caregivers to patients.
A theoretical study by Costa-Filho et al.(17) discusses PC as a philosophy of care that complements the curative treatments of modern medicine. The authors highlight the barriers that hinder the implementation of PC in ICUs, while stressing that PC affords an opportunity to act with dignity and purpose, especially for intensivists. They conclude that educating health caregivers in the field of palliation is of paramount importance for the promotion of PC in ICUs and state that research is needed to increase the dialogue of this subject in intensive medicine.
Mularski and Osborne(18) discuss the grounds of PC for severely ill elderly patients and its relationship with the ICU. They comment on the need to assess the conditions that lead to the decision to admit these elderly patients to the ICU from several perspectives, including the considering the feelings of the patients and their relatives.
Prendergast et al.(26) conducted a survey on end-of-life ICU care. The authors conducted interviews and quantified the frequency of cardiac resuscitation maneuvers and discontinuance of life-support interventions. Protocol definitions were lacking in 30% of ICUs that participated in the study, and the authors were unable to quantify the frequency of use of resuscitation maneuvers. Moreover, there was not always a record of decisions to discontinue interventions at the end of life. Those authors observed that there was a lack of regarding palliative actions and PC training programs. They concluded by suggesting the need for ICU managers to make an effort to understand the reasons for variations in medical decisions and to propose protocols that might contribute to improve the quality of assistance.
Mosenthal et al.(27) performed a prospective study in a trauma ICU to assess the inclusion of a PC team in supporting end-of-life care and to establish whether structured and early communication with the patients and their relatives as a systematized intervention might be helpful. They found that implementing these changes improved relative participation by 32%, which resulted in a higher number of consensual decisions between doctors and relatives regarding the intended goals. Those authors concluded that this type of intervention resulted in early consensuses and that the study contributed to changing the culture of care in that ICU.
Bloomer et al.(28) performed a retrospective cohort study in an Australian ICU to investigate the end-of-life process and the involvement of the patients' relatives. That study included 70 patients with an average age of 69 years old and expected mortality of 86% (as a function of severity indicators), and relatives were present in 66% of cases. Resuscitation maneuvers were not performed in 85% of the deaths. The family participated in the discussions regarding end-of-life decisions in 90% of cases, and in 49% of cases, the decision to discontinue curative treatment was respected. Those authors emphasize that although the study was conducted in a single ICU, it showed that PC in ICUs might be approached from several perspectives. This includes the participation of relatives, nurses, and doctors in the decision-making process, which makes the approach to care more patient specific. The authors conclude that death was predictable in that ICU and that the modality of end-of-life care was decided jointly by the patients' relatives and their health caregivers.
Kuschner et al.(29) described the practice of PC in ICUs aimed at reducing communication problems between doctors and nurses. The authors verified that the ICU doctors felt uncomfortable when the goal of care was palliative. The nurses reported that despite feelings of discomfort, the interventions suggested were not excessive, and the authors concluded that assistance standardization is a path that must be taken into account to improve the quality of ICU PC.
In an interventional study, Curtis et al.(30) assessed the quality of assistance in a model of integrated PC in the ICU as an approach to improve patient care. The authors applied a series of educational actions related to PC grounded on the premise of the "self-efficacy" theory. Their hypothesis was that changes in the attitude of the healthcare team, including proactive behavior, with regard to patients and valorization of relative participation might result in routine PC provision with consequent improvement of the quality of end-of-life care. The main results of the study were reduced length of hospitalization before death, improved PC application by the nurses, and greater relative satisfaction.
Finally, Lloyd et al.(31) performed a prospective cohort study with 50 elderly patients over 80 years old with acute aggravation of chronic disease and approximately a 50% chance of dying. Their aim was to investigate the influence of the following variables on the decision to perform "invasive" interventions: 1) patients' reports on their quality of life before admission, 2) possible quality of life after ICU admission and mortality prognosis, and 3) length of hospitalization and most likely needed invasive interventions. Those authors conducted interviews with the patients and presented two scenarios of risk: one consisted of a 14-day hospitalization with mechanical ventilation, and the other was a hospitalization longer than one month with mechanical ventilation, tracheostomy, and enteral nutrition. The results showed that patients who initially expressed preference for interventionist measures chose not to accept "invasive" interventions after the odds of mortality and possible quality of life were explained. The authors concluded that their study made clear the need to make the wishes of the patients known to the ICU staff. Respect for patient autonomy has become an important part of the discussion since the SUPPORT study.(7)
PC in the ICU is a relevant topic for several reasons, including increased prevalence of chronic diseases, the difficulty of healthcare teams in providing end-of-life treatments, and rapidly aging populations, which is particularly important in a country with a demographic profile like Brazil's, where 25% of the population will be considered elderly in the next 30 years.(7,44,45)
There is theoretical justification to advocate for and apply PC in the ICU. Indeed, there are journals specifically devoted to PC that also contribute to the update of multidisciplinary interventions in pharmacological therapy and the organization of physical spaces favorable for such actions. The fact that the number of publications addressing both subjects together is small compared to studies addressing each one separately underscores the need to widen the debate and perform research on and include PC in intensivists' work routines. It is possible that PC will become a medical specialty in Brazil in the near future, as has already happened in the United Kingdom, Australia, and Canada. The first step in that direction was taken in Brazil at the beginning of 2010, when PC was acknowledged as a specialty field in geriatrics, anesthesiology, community medicine, pediatrics, and clinical medicine; it has also been added to the code of medical ethics.(46,47)
Nevertheless, despite the available evidence on the importance of PC in the ICU and advances made regarding discussions on ethics, autonomy, and death, the elderly still die with much suffering and pain.
Two issues stood out in the present literature review: first, there are only a small number of quantitative studies correlating PC, satisfaction of relatives, team communication, patient quality of life, and length of ICU hospitalization. Second, PC should be applied in the ICU because it improves quality indicators and helps in the construction and consolidation of positive relationships among ICU health caregivers, patients, and their relatives. PC might be adopted if intensivists receive technical training to apply palliative measures. Because the number of deaths in ICUs is high, discussions on how to perform PC must be conducted and incorporated into caregiver work routines. The present review indicated several paths for achieving these goals, including protocol development, health caregiver training, and the addition of this subject in medical residency programs.
The addition of the subject "PC in the elderly with chronic diseases at end-of-life in the ICU" will stimulate thoughts on how to focus ICU interventions in this subset of patients. PC represents an opportunity to intervene from another perspective that affords comfort, relief, and respect to patients and their relatives.
The number of publications on PC has increased in the last 10 years, and noticeably, only 2 of the 29 articles selected were published before 2000. The impact of aging on overall population demographics and the increasing prevalence of chronic degenerative diseases contribute to this trend. However, other motives might be considered, including that although the United Kingdom was the origin of the modern hospice movement, palliative medicine was only acknowledged there as a medical specialty in 1987. Issues such as the high number of patients who suffer and die in the ICU, the conflict between advances in artificial life-support techniques and ethical issues, and the participation of relatives in decision making emphasized the importance of debating the use of PC in intensive medicine (as a subject of research) beginning in the late 1990s and early 2000s.
Another frequent subject addressed by the selected studies was the important role of nursing in PC. Nurses participated in 12 out of the 29 selected studies, which stressed the fact that nurses play an essential role in palliative interventions. Nurses are in charge of directly assisting the patients and promoting the active participation of the full ICU team in such assistance. Multi-professional PC teams include other types of professionals who are each important in their respective field. However, nurses stand out because they often lead PC planning.
Several barriers must be overcome for PC to gain wider implementation, including the beliefs and lack of technical training of ICU teams; the resistance of the patients' regular doctors, who sometimes oppose the suggestions made by intensivists; the managers of hospitals where the ICU is located; and finally, the patients' relatives when they have not been properly informed.
The present study was limited in regard to the search sources. The authors were aware that some relevant studies would not be located because the search was restricted to just two databases. However, the two portals are the best-known sources and are important in the terms of the journals they include and the frequency of access by healthcare professionals.
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Corresponding author: Submitted on January 13, 2012 Conflict of interest: None
Anelise Coelho da Fonseca
Escola Nacional de Saúde Pública, Fundação Oswaldo Cruz
Rua Leopoldo Bulhões, 1.480, 8th floor, room 818 - Manguinhos
Zip Code: 21041-210 - Rio de Janeiro (RJ), Brazil
Accepted on June 14, 2012
Submitted on January 13, 2012
Conflict of interest: None