Year: 2024
Type: article
Abstract: Dr Alice Sacco is an Italian intensivist cardiologist and head of cardiac intensive care unit at ‘De Gasperis’ Cardio Center, ASST Grande Ospedale Metropolitano Niguarda, Milan. Together with her strong expertise in intensive care, she has a great interest in end-of-life management and bioethics. By winning an Italian grant with the project ‘Rights and care at the end of life—The terminal patient in cardiac intensive care’, her department has received specific training in palliative and end-of-life care. Considering her experience and skills in this field, we asked her some questions about the value of implementing palliative care in cardiac intensive care. Palliative care (PC) is a specialized medical area which aims to provide relief from symptoms, pain, and stress of a serious illness. Its main target is to improve patients’ and their caregivers’ quality of life (QoL). This approach is indicated in all the phases of a serious disease, and—if possible—it should be used together with the curative treatments.1 A PC team comprises physicians, nurses, health professionals, and spiritual advisors who received specific training on PC. Interventions for palliative concerns can by delivered by every physician, from general practitioners to hospitalists. Consultation of the PC team is often made for special situations, such as complex cases or difficult family dynamics. PC’s key elements are managing distressing physical symptoms; providing emotional, psychological, and spiritual support; communication; and shared decision-making. Integrating these elements in intensive care practice can lead to several advantages: firstly, it ensures that the medical team prioritizes the patient’s comfort equally with curative treatment. Sometimes, patients’ QoL is undermined by both the disease’s symptoms and the treatments’ ‘aggressivity’. Keeping the focus on QoL allows the physicians to guarantee patients’ comfort while treating them. Another advantage of the PC approach is the regular assessment of the patients’ and their families’ wishes in terms of withdrawal and withholding of life support therapies. This approach is particularly important both for chronic and acute diseases because it helps to balance the efforts and resources of the intensivists according to patients’ wishes and goals, but also to realistically redefine the expectations of the patients and their families. The results should be a shared decision-making and, whether possible, advanced care planning (ACP). PC counselling is fundamental in reaching this goal and relieving patients and families emotionally. Indeed, patients and their relatives have to face the challenges related to a potentially life-threatening and, of course, life-changing illness. To summarize, PC is a holistic approach encompassing the whole spectrum of care (medical, psychological, spiritual, social, etc.), which can be implemented in all settings (from home to intensive care). Furthermore, PC specialists could represent the fil rouge, which connects the patient’s management in outpatient clinic with the one in intensive care unit (by sharing ACP) and vice versa (e.g. by organizing home care after the patient’s discharge). In conclusion, intensive care and PC are not antithetical: intensive care does not mean relentless, aggressive therapy, and on the other way, PC does not automatically mean withdrawing or withholding healing treatments.2 There are several barriers: organizational, cultural, educational, infrastructural, etc. For example, from the organizational point of view, a reduced number of healthcare professionals limits the possibility of providing both adequate life-supporting/curative therapy and PC. In fact, when there is shortness of staff, even asking for a PC consultation can be extremely difficult. Another barrier can be the absence of a proper room in the intensive care department to communicate bad news to families. Intensive care units can be uncomfortable environments for patients and their relatives: the lack of privacy, distracting alarms, and noises undermine good communication and proper understanding. From a cultural perspective, as aforementioned, it is important to abandon the misconception that PC means just withholding or withdrawing therapies in the context of end-of-life care. Unfortunately, this misconception is diffused among lay people but also among healthcare professionals. Considering PC just for the terminal phases of a disease forbids its early implementation in the patient’s management, postponing the possibility of reaching some comfort for the patient. Another aspect to remember is that patients’ and their families’ socioeconomic status and spiritual beliefs influence their perception of the disease, medical treatment, and PC. This can cause a ‘cultural clash’ between healthcare professionals, patients, and their relatives; this risk may be avoided by developing soft skills, which can help forge an alliance between medics and patients. However, education and training are necessary to develop these skills, which are fundamental to PC. Last but not least, in order to guarantee the consistency of healthcare actions, protocols are necessary. The lack of standardized internal protocols to identify the patients who can benefit from PC (especially its early implementation), to thoroughly assess the patient’s need, and to apply PC actions are great obstacles. The hospital policy has a great impact on addressing all these problems. Indeed, it can promote courses to update doctors and nurses on soft skills; it can impose the development of flowcharts and protocols in each department to apply PC manoeuvres, etc. To summarize, in order to overcome all the aforementioned barriers, PC should be considered complementary to the curative/life-supporting treatments and not sequential. Yes, it is particularly important to introduce in the training and education of young doctors and medical students the principles of PC. In recent years, there has been a great technological development in cardiology and cardiac intensive care. This development has led to a hyper-specialization of cardiologists and intensivists, who are now able to do things that were unimaginable decades ago. However, a significant drawback of such rapid technological advancement is that ethical considerations tend to lag behind, with educational focus generally remaining on new technological achievements. In this scenario, medical students and young doctors may see death as just an endpoint and not as part of the course of a disease and a condition that they have to deal with during their jobs. Given its holistic and interdisciplinary nature, specialized training in PC equips young doctors to effectively treat patients and support their families. Together with the curative treatments, trainees will be able to deal with symptoms, identify psychological distress, and communicate with patients and families effectively. Indeed, communication is often hard in cardiology and cardiac intensive care because the trajectory of cardiac disease is not precisely predictable. Furthermore, by PC training, cardiologists and intensivists will learn how to withdraw mechanical circulatory or respiratory supports, limiting patients’ discomfort by using pharmacological and non-pharmacologic strategies. These skills are often learned by experience and clinical practice, while specific training standardizes treatments and helps clinicians not to feel unprepared.3,4 It is particularly important for clinicians not to feel alone. Therefore, the discussion of clinical cases with colleagues and shared decision-making can help a lot. Peer support groups have shown beneficial effects5 in fighting burnout and building resilience. Debriefing after a traumatic event and sharing past experiences of challenging cases with colleagues and mentors help healthcare professionals to both improve their practice and release stress. Especially for difficult cases, discussing with experts in bioethics and law would be helpful. Lastly, hospitals should provide free psychological support for their healthcare professionals. Dr. Alice Sacco Cardiac Intensive Care Unit ‘De Gasperis’ Cardio Center ASST Grande Ospedale Metropolitano Niguarda Milan, Italy Dr. Alessia Gambaro Division of Cardiology, Department of Medicine University of Verona Verona, Italy None declared. No new data were generated or analysed in support of this article.
Authors: Alessia Gambaro, Janine Pöss, Alice Sacco
Language: English
Field: Medicine
Domain: Health Sciences
Open Access status: bronze
OpenAlex ID: W4401714976