Penguins and palliative care: facilitating cultural change in the ICU.

Critical Care Medicine www.ccmjournal. org 2443 In his book, Our Iceberg is Melting, Harvard Business School Professor John Kotter tells the story of a colony of penguins faced with a melting iceberg and the need to quickly change their cultural and institutional beliefs to save their home and lives (1). The penguin which first appreciates the danger learns that to facilitate change, it must create a sense of urgency by informing others and engaging a team of key stakeholders who can support the plan at the highest leadership levels. As a result, the penguins decide to leave the iceberg, where previous generations had thrived, to adopt a new nomadic life. Leadership and vision, as well as tremendous support and follow-up, was essential to change their old traditions. Palliative care teams wishing to promote their role in the ICU may benefit from a similar approach. Approximately 20% of Americans die during or immediately after an ICU stay, often with significant suffering (2, 3). ICU use in the last month of life is increasing—29.5% in 2009—and may lead to negative outcomes such as decreased hospice use and shortened hospice length of stay (4). ICU survivors may experience lasting consequences, including impaired functional status (5, 6) and posttraumatic stress disorder (7). More than half of survivors recall episodes of moderate to severe pain during their ICU stay (8). Suffering extends to families: in one study, one third of family members whose loved one died in a medical ICU developed a major psychiatric disorder (9). Palliative care teams—defined as multidisciplinary teams composed of physicians, social workers, chaplains, and nurses with the expertise to address the comprehensive sources of distress, including, physical, psychological, social, and spiritual sufferings—can be key collaborators in efforts to mitigate suffering among patients and families. The field of palliative care has evolved considerably over the past 25 years. Palliative care interventions were previously reserved for the last stage of life in the form of hospice care, but as the field has expanded, its focus has evolved toward integrating palliative care interventions throughout the course of serious illness, even if cure is likely. The stage of disease dictates the type and degree of palliative care intervention. Organizations such as the Center for the Advancement of Palliative Care (CAPC) have recognized the challenge of educating the public, as well as medical providers, to appreciate this broader definition of palliative care. Marketing research techniques have led to promotion of the term extra layer of support to the care being provided for your loved one to highlight the idea that palliative care should be fully integrated with intensive care and not separate from or opposed to potentially life-saving treatment. Despite this evolving understanding of the goals of palliative care, plans to build collaborations between palliative care and ICU teams face challenges. Some ICU teams may be concerned that palliative care consultants may focus on withdrawing life support prematurely or in opposition to the primary team’s plan. Some may not perceive the benefit of consulting palliative care, particularly if ICU teams are confident in their ability to manage distressing symptoms and discuss goals of care. ICU teams may also be concerned about the unintended message families, and patients may perceive if palliative care is consulted (i.e., “we are giving up on you, there is nothing more we can do”). Finally, it may be challenging to identify patients who might benefit most from palliative care involvement. Organizations such as the CAPC and the National Institutes of Health recognize the need to develop cohesive models of integrated palliative and ICU care and have supported programs such as the Improving Palliative Care in the ICU (IPAL-ICU) Program. The mission of IPAL-ICU is “to provide a central venue for sharing expertise, evidence, and tools, along with links to colleagues, organizations, and informational recommended best practices for critically ill patients. Crit Care Med 2007; 35:1696–1702 13. Black MD, Schorr C, Levy MM: Knowledge translation and the multifaceted intervention in the intensive care unit. Crit Care Med 2012; 40:1324–1328 14. Dellinger RP, Levy MM, Rhodes A, et al; Surviving Sepsis Campaign Guidelines Committee including the Pediatric Subgroup: Surviving sepsis campaign: International guidelines for management of severe sepsis and septic shock: 2012. Crit Care Med 2013; 41:580–637