COMMENTARY

Palliative Care for ICU Families--More Harm Than Good?

Greg Martin, MD

Disclosures

November 09, 2016

Chronic Critical Illness and Family Distress: Is Palliative Care Helpful?

Delivering patient- and family-centered care is increasingly being promulgated and adopted in intensive care units (ICUs) worldwide. Family caregivers of patients with chronic critical illness can experience significant psychological distress, including anxiety, depression, and posttraumatic stress reaction.[1,2] A recent study[3] sought to determine whether family informational and emotional support meetings led by palliative care clinicians would relieve anxiety and depression in family caregivers. They enrolled adult patients from medical ICUs who had received at least 7 days of mechanical ventilation and randomly assigned their caregivers to at least two structured family meetings led by palliative care specialists and provision of an informational brochure (intervention group) or only provision of an informational brochure and routine family meetings conducted by ICU teams (control group).

The study was completed by 312 family surrogate decision makers (average age, 51 years; 71% women). At 3 months, there was no significant difference in anxiety and depression symptoms between surrogate decision makers in the intervention group and the control group. Posttraumatic stress disorder (PTSD) symptoms were higher in the intervention group (P = .0495). There was no difference between groups with respect to the discussion of patient preferences, the median number of hospital days, or 90-day survival. The investigators concluded that among families of patients with chronic critical illness, the use of palliative care informational and emotional support meetings compared with usual care did not reduce anxiety or depression and may have increased PTSD among caregivers.

Viewpoint

The medical community has widely believed that providing information and support to families of acutely and critically ill patients during periods of the illness is both appropriate and beneficial to the family. This study is the first multicenter randomized trial of a palliative care support intervention for family surrogate decision makers, particularly in patients with chronic critical illness, and these findings do not support routine use of palliative care-led discussions of goals of care for all families of patients with chronic critical illness. Moreover, these findings suggest that providing palliative care could even be harmful to the family caregivers by creating additional distress that endures and leads to PTSD.

It is possible that these results occurred by chance or that they only occurred with this specific group of patients and were the result of the very specific intervention that was delivered in this trial. However, it's more important to consider these findings in the broader context of how we ensure the best care for both patient and family: the goals of patient- and family-centered care. We continue to struggle with knowing what patients and families understand and want during the course of critical illness. This study forces us to step back and ask some very basic questions: What information should we convey to patients and families, what is the best way to do it, and what is the purpose of doing it? With this new study in mind, we need to reconsider how we use ancillary information-sharing and decision-making services (like palliative care experts) in the ICU and reconsider our approach based on our shared goals. In this way, we can provide the best care without further increasing distress among patients and family members.

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