Guidelines for Family-Centered Care in Neuro-ICU Populations: Caveats for Routine Palliative Care

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We read with great interest the article published in a recent issue of Critical Care Medicine by Davidson et al (1). Of particular note, we wanted to clarify under item number 4.1: “Proactive palliative care consultation be provided to decrease ICU and hospital length of stay (LOS) among selected critically ill patients (e.g., advanced dementia, global cerebral ischemia after cardiac arrest [CA], patients with prolonged ICU stay, and patients with subarachnoid hemorrhage [SAH] requiring mechanical ventilation).” We are particularly concerned about the recommendation to have palliative care consultation in CA and SAH patients based on financial issues like LOS. These two patient subtypes can be vulnerable early in their hospitalization and require specialized care and careful prognostication. In fact, American Heart Association and Neurocritical Care Society guidelines, along with other publications, suggest waiting a few days in “indeterminate” CA cases (2, 3). The rationale is to allow the effect of drugs that may falsely depress the CNS temporarily clear especially with the use of hypothermia. To prognosticate coma in the setting of such drugs would be erroneous. Furthermore, SAH patients with acute hydrocephalus may recover dramatically (in 24 hr) after ventriculostomy placement and regain consciousness. For hospitals without adequate volume, expertise, and teams trained in managing these patients that achieve better outcomes, the danger is in declaring a self-fulfilling prophecy similar to do-not-resuscitate (DNR) orders. DNR orders, for example, in intracerebral hemorrhage are independently associated with higher mortality and regardless of risk-adjusted data (5). This begs the question if healthcare teams stop caring for them holistically despite DNR only being specific to CA status in the hospital. The second area of concern was under Evidence Summary, which mentioned that the references (numbers, 182–186) suggest the quality of the data surrounding this statement is very low (that practice consultation of palliative care decreases ICU and hospital LOS) in these selected ICU subpopulations. Therefore, if the quality is low, we want to clarify that for CA and SAH patients, similar to trauma systems of care, it may be best to refer such patients to centers with proper expertise and specialists to help individualize the prognosis, rather than reflex consultation with palliative care early on. We certainly understand the importance of palliative care consultation in improving the quality of life of families and patients with severe acute illnesses, and also in cases of terminal and often futile healthcare in the ICU. However, we must also be sure to give enough time for reliable prognostication and put this above healthcare costs.
Overall, we commend the authors on this important work and this excellent guideline for family which heretofore has been lacking from the ICU. The general purpose of the article was to help healthcare providers and families deal with such important issues. We believe our additional comments about these particularly vulnerable neuro-ICU patients help clarify the proper timing of palliative care specialists in neuro-ICU patients.
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