DOI: 10.1097/01.CCM.0000059999.22466.CE

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PMID: 12682514

Issn Print: 0090-3493

Publication Date: 2003/04/01


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Irreconcilable differences?*

Michael A. Williams; Cynda H. Rushton; John H. Shatzer

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Excerpt

It has often been said that there are irreconcilable differences in the goals of critical care and palliative care—using aggressive, innovative, technological strategies and equipment to save lives that would otherwise be lost vs. using multiple modalities of standard therapies to alleviate pain, suffering, or burdens associated with illness and often to enhance end-of-life care. Critical care medicine, as a specialty, is aware of this issue. Indeed, the Society of Critical Care Medicine highlighted end-of-life care at the 2000 annual meeting in San Francisco. Furthermore, much has been written about palliative care in the critical care literature, including guidelines, research and educational agenda, and calls for incorporating palliative care into critical care education (1–4). However, it is one thing to identify the need and quite another to take on the task of teaching ourselves how to provide palliative care in the intensive care unit (ICU).
In this issue of Critical Care Medicine, Dr. DeVita and colleagues (5) report their 2-yr experience in teaching palliative care to critical care trainees. Although perhaps not the first to undertake this task, they may be the first to do so in an organized manner and to undertake the important process of assessing their educational intervention. They deserve credit for this accomplishment, yet there is much left to be done, and there are lessons we can learn from their experience.
In teaching palliative care to ICU fellows, Dr. DeVita and colleagues (5) used a two-pronged approach: 1) facilitated small group learning sessions with role play and a focus on communication skills and 2) a palliative care clinical rotation outside the ICU with the intent of immersion, like many clinical rotations. Almost without exception, it seems the ICU fellows rated the small group sessions highly and the palliative care rotation as lacking relevance—“useless” in the words of one fellow.
Irreconcilable differences? Perhaps. Perhaps not. There are many potential explanations for the discrepant assessments of the two educational interventions. It may be that this group of ICU fellows “just do not get it,” but such easy speculation is hard to prove and stems from a disparaging presumption. It would be better to give careful, constructive thought to the curriculum, its goals and objectives, and its methods.
The stated goals of the curriculum focused on ICU fellows’ knowledge and skills—symptom management, communication, and palliative care awareness. But there is more to it than a knowledge deficit. We suggest adding the goal of changing the attitudes and practices that perpetuate the irreconcilable differences of palliative and critical care, in other words, to integrate critical care and palliative care (6). Such integration requires both individual and organizational self-awareness of barriers to palliative care and commitment to new norms of practice that reward the simultaneous use of palliative and critical care strategies. This leads to several suggestions for enhancing the curriculum of Dr. DeVita and colleagues (5) and of others that may be in use or development.
Learning is best accomplished in a setting that is as close to the work setting as possible. Research in faculty development suggests that learners must be presented activities in the context of their professional work, which is based on their learning needs and includes feedback, reinforcement, and longitudinal follow-up to maximize long-term maintenance of new skills (7, 8). This important adult education precept undoubtedly underlies the success of small group learning and role play, and perhaps the failure of the palliative care rotation of Dr. DeVita and colleagues (5). It also suggests the importance of role modeling by ICU faculty in daily ICU rounds.
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