LAUSR

Dear Editor, We read with great interest the article “Ten key points about ICU palliative care” in which the authors highlight ten crucial keys to palliative care in the intensive care unit [1]. The authors present an excellent condensed description and respective recommendations for palliative care on the ICU, which may serve as a guide for daily considerations of end-of-life (EOL) and palliative situations. In the second proposed key point, a mixed model in which primary palliative care is combined with specialist palliative care contributions is recommended. Although we certainly agree that this may be an option, we believe that this aspect needs reflection in the light of several differences between in-ICU care vs. palliative care situations outside of an ICU. In a palliative care setting outside of the ICU, patients and relatives are more likely to have long been confronted, have reflected, and coped with respective EOL situations. When admitted to an ICU, however, both patients and relatives are most often suddenly confronted with critical, life-threatening, and potential EOL situations and, given the abruptness in change of respective life situations, establishing of a link between ICU staff and patients/relatives becomes a key importance. Interestingly, a recent comparison of palliative care specialist-led vs. ICU physician-led family meetings did not influence the incidence of family anxiety and depression [2], which are considered key factors for development of ICU post-traumatic stress disorder (PTSD). We thus believe that when a “mixed model” is applied, an excellent prospective integration of palliative care consultants must then be aimed for. Keeping in mind many respective similarities, there are also very specific challenges to the ICU staff regarding palliative care, which must be focused on adequately. It appears that, first of all, adequate preparedness and EOL training should be provided to all professional ICU staff providing EOL care. Currently, most ICUs do not provide structured EOL training programs for physicians or fellows. This seems optimizable in the light of the fact that even short teaching sessions may improve self-confidence in EOL communication providers [3]. In addition, presence of a trained EOL provider may increase satisfaction of relatives in family meetings [4], and inadequate communication with relatives may result in PTSD and augmented grief [5]. However, whether training beneficially impacts on post-ICU PTSD in next-of-kin remains unclear. In conclusion, we are convinced that the current— mostly “ad hoc”—concept of EOL/palliative care and ICU-specific EOL education deserves revision. Preparedness and empowerment of professional ICU caregivers seem essential in an effort to set up professional EOL care which may, e.g., be guided on the basis of the “ten keys of ICU palliative care”.