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Anne C. Mosenthal, MD, is associate professor of
surgery and chief of surgical critical care at UMDNJ-New
Jersey Medical School (NJMS). |
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Patricia Murphy, RN, PhD |
Bringing Palliative
Care to the Critically Injured
by Anne
C . Mosenthal, MD 
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Palliative care is the treatment of patients with advanced
and serious illness where alleviation of symptoms, whether
they are physical, emotional or spiritual, is paramount.
It has traditionally focused on relief of suffering
from chronic diseases at the end of life, such as cancer
and dementia, not on the care of those with sudden and
acute illness. As physicians caring for the severely
injured and the critically ill in the intensive care
unit (ICU), it seemed that palliative care would be
irrelevant to our patients. But in reality, 13% of our
trauma patients admitted to the surgical ICU will die,
many with unknown pain and suffering at the end of life,
and many with families in crisis. An additional proportion
will go on to have significant disability with impaired
quality of life. I began to realize that some components
of palliative care such as relief of pain and symptoms,
good communication, bereavement support and appropriate
withdrawal of life support, were essential to the care
of trauma patients. This realization raised the question
of not only how palliative care could be integrated
into trauma care, but when, and for which patients.
To research the application of palliative care to trauma
we needed to understand the epidemiology of death on
the trauma service. With funding from the Project on
Death in America, Patricia Murphy, RN, PhD, and I studied
the deaths in the ICU over a four year period. In particular,
we hoped to dentify a population of patients for whom
one could predict a poor outcome and who might benefit
from early palliative care intervention. In addition,
we assessed the existing care provided for any evidence
of palliative care, such as end of life decision making,
communication or withdrawal of life support. Among 108
deaths in the surgical ICU, 54% died with a do not resuscitate
(DNR) order in place and there was clear evidence of
communication and end of life decision making between
the physicians and family. Despite this, there was little
active palliative care for dying patients, and the vast
majority (91%) died on ventilator support. Furthermore,
when we tried to identify any objective factors related
to severity of illness, prognosis or patient characteristics,
only older age was associated with a DNR order. There
was great variability in physician practice in end of
life care. It was clear that among critically ill trauma
patients, there is great uncertainty as to who is dying,
and when, and if it is time to move to palliative care.
These realizations raised more questions. Was this
uncertainty in prognosis among trauma patients, in effect,
a barrier to good end of life care? Did it prevent trauma
surgeons from making the transition to palliative care
for their patients and if so, were there ways to affect
their practice? Educational programs alone are known
to have little effect on physician practice, so we developed
a peer review program on end of life care which was
integrated into the pre-existing morbidity and mortality
review and quality improvement program. After one year
we studied the effects of this program. Documentation
and discussion of end of life care in the mortality
reviews increased from 13% to 26%. More importantly,
while there was no change in mortality or DNR rate,
DNR orders were written two days earlier and withdrawal
of the ventilator from dying patients more than doubled.
Due to the uncertainty of prognosis in acute trauma
illness, we hypothesized that the best way to bring
quality care at the end of life was to apply the principles
of palliative care to all patients, regardless of their
likelihood of survival. This means providing pain and
symptom management, bereavement/family support and good
communication to all critically injured patients and
their families. While our previous studies taught us
a good deal about how and when trauma surgeons implement
palliative and end of life care, we still understand
little about the quality of care at the end of life
and what type of palliative care is important for patients
and families in the trauma ICU. Preliminary evidence
suggests that communication with healthcare providers
and attention to symptom management are as important
to patients and families as the level of medical care.
Studies on patient and family centered outcomes in the
ICU are ongoing. We are currently investigating pain
assessment and management in both survivors of trauma
care and those at the end of life. We also hope to better
understand the role of bereavement and family support
in the care of critically ill trauma patients and how
this affects end of life decisions, as well as long
term quality of life, for the surviving patients and
their families.
Anne C. Mosenthal, MD, is associate professor of
surgery and chief of surgical critical care at UMDNJ-New
Jersey Medical School (NJMS). She earned her MD from
Dartmouth Medical School in 1985. After completing her
surgical critical care fellowship at Massachusetts General
Hospital and surgical residency training at the University
of Massachusetts Medical Center in 1992, she joined
the faculty at NJMS. Over the last five years, her clinical
and research interests have focused on palliative care
and quality of life outcomes in trauma and critical
care. Together with Patricia Murphy, RN, PhD, she has
developed one of the first programs on palliative care
in trauma/critical care in the country. Dr. Mosenthal
was awarded a grant as Faculty Scholar for the Project
on Death in America by the Soros Foundation. Currently,
she and Dr. Murphy are funded by the Robert WoodJohnson
Foundation to develop and study palliative care in the
surgical ICU.
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