Palliative care is a specialty of medicine that focuses on improving quality of life for patients with serious illness and their families. As the limitations of intensive care and the long-term sequelae of critical illness continue to be delimited, the role of palliative care for patients that are unable to achieve their original goals of care, as well as for survivors of critical illness, is changing and expanding. The purpose of this chapter is to introduce readers to the specialty of palliative care and its potential benefits for critically ill patients, and to present some of the issues related to the delivery of palliative care in surgical units.
TopI. What Is Palliative Care?
Traditionally, the goal of medicine has been to cure disease. Hospice and palliative medicine differ in that the goal is to improve quality of life. Palliative care is defined by the World Health Organization as “an approach that improves the quality of life of patients and their families facing the problems associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual.” As a specialty, palliative care arose out of the hospice movement. Hospice is a model of care for patients with limited life expectancy that focuses on palliation and symptom management, and often requires patients to forego curative therapies. Hospice is most often provided in a patient’s home, but can also be provided in hospice inpatient facilities. Unlike hospice, palliative care is appropriate for patients with serious illness at any time in the course of their disease, does not require patients to give up curative treatments, and can be provided in conjunction with other aggressive therapies.
Because the goal of palliative care is to improve quality of life and relieve suffering and stress associated with having a serious illness, the delivery of palliative care may involve many different domains that are utilized based on an individual’s specific needs. The use of palliative care addresses various needs for critically ill patients and their families including: 1) symptom management (e.g. pain, nausea, fatigue, thirst, depression, anxiety, existential distress), 2) conflict resolution (conflict between family members, or between the family and the medical team), 3) spiritual support, and 4) complex decision-making regarding goals of care. In the ICU, the role of palliative care has traditionally been as a part of delivering end-of-life care for patients who die in the ICU. However, there is an expanding role for palliative care in the management of patients who may survive their illness but are at risk for having significant symptomatology, such as patients with chronic critical illness.