Thread by @WhistlingDixie4

It’s 16:40 - I’ve come to palliative care session

I *think* (but cannot be sure) that it won’t mention biomarkers

Impressive turnout for such late session. It’s actually nearly full!

#LIVES2022

First speaker Hartog said she’s surprised by the turnout ☺️

She comments that the WHO definition of palliative care (PC) doesn’t mention death

She directs us to concept that it accompanies curative care - then takes overtakes it - and eventually, no even continues after death

She points to this paper and graphic.

(You should know now the room is so full that people are standing, which is tiring imagine- but good to see for such an important topic)

link.springer.com/content/pdf/10…

It’s hard to consistently quantify the PC needs of our pts

This study: 14-20% ICU admissions meet triggers for specialised palliative care in their ICU stay …

ncbi.nlm.nih.gov/pmc/articles/P…

But numbers vary- we hear 40% in one study (family Identifier) 60% in another (clinician identified)

And this paper points out that tools that recognises *dying* may not represent those that need *palliative care*

pubmed.ncbi.nlm.nih.gov/35050358/

And we hear about a study that shows protocolised family communications leading to reduced length of ICU stay…

And a huge systematic review by Metexa which seems a pretty useful read, if you pick just one pubmed.ncbi.nlm.nih.gov/31228954/

Her talks ends with summary of issues:
🔹Different triggers ID different patients
🔹The outcomes are variable
🔹Undefined overlap between palliative care and ICU care

(That last one rings a lot of bells for me) 🔔

And so to move forward we need to:
🔹Define a what *we* say PC is
🔹Train clinicians in ICU 🎉
🔹Develop ICU specific triggers to identify patients

❓Audience member asks should we call it something more acceptable…supportive care?

Hartog says no - call it what it is

❓Another Q asks how to handle bad reaction, but i don’t grasp a clear answer

(My answer = patient empathetic communications, but be true to what it is)

We’re hearing from @JosLatour1 now whose talk is about team work. He talks about the NHS definition of palliative care

And specifies it is broader than EOL care

Who are ‘we’ in the team?
—> includes family (chosen or otherwise)

He says Pts and family are at the forefront and referenced a recent patient speaker at @BACCNUK condense who said ‘my relatives always felt awkward and in the way’ (sorry 😞)

He ask should we involve them palliative care team?

He says he is both a ‘Never’

And a ‘Never say Never’

They should be involved before ICU where the condition is long term…

But with acute life limiting conditions admitted to ICU…. No never (but maybe not never never)

He says we should actively cultivate that culture of inter professional team work

This paper is linked and he talks of having strategies to create the necessary climate

(I get this, the right culture change doesn’t happen without effort)

pubmed.ncbi.nlm.nih.gov/31169620/

A pathway to collaborative working with relatives…

(Not sure I’ll use the wheel but like an example about enhancing family confidence to get involved in care - reminds me some things that stay with and also makes me sad to remember what families were deprived of the pandemic )

He says we should follow up experiences with those whose relative died

I agree

(We do this and nursing staff lead it but there isn’t ‘consultant time’ allocated. I wonder if we can make more use of the potential for feedback)

Closes with this paper

ccforum.biomedcentral.com/counter/pdf/10…

❓Audience Q now leads to an answer to effect that a pt admitted to ITU just to die, shouldn’t be admitted

(I don’t agree - there are circumstances where it is the right thing for that patient in that hospital)

Actually - 2nd audience member has now stood up and said just that

We’re now on to Van Dijk and whole person palliative care…

Does it work?

Well the research is often observational, qualitative and single author

(So we’re skeptical, is the vibe I’m getting)

There is an RCT (not ITU) that showed a moderate improvement in experience (substantial loss to follow up- outcome at 6 mths….)
pubmed.ncbi.nlm.nih.gov/28133973/

This systematic review again

(And so I definitely want to read this now so hopefully will remember it is here 🐘)

I am frustratingly unable to access my @ESICM account at the moment so can’t get into @yourICM. So it will have to keep fro a rainy day.

pubmed.ncbi.nlm.nih.gov/34652465/

Prognostication is expected by families …but we fail to achieve the communication they need

And Families frequently doubt accuracy

Cue conflict 🥊

But with correct approach this can be resolved

And empathetic comms is valued by families

pubmed.ncbi.nlm.nih.gov/11268231/

He says the best way to improve your comms skills quickly is to

🤫 keep quiet 🤫

Less talking = more satisfied families

(I’m consciously doing this lately: feels like it has positive impact, but ye know - not evidence)

But there is evidence! 😃

pubmed.ncbi.nlm.nih.gov/15241092/

He talks about

‘in for a penny in for a pound’

attitude seen with (some) surgical patients & their teams (don’t jump me, I’m reporting the news)

Mularski then on the 4 phases of broaching PC:

pubmed.ncbi.nlm.nih.gov/11228568/

So now Michalsen asks do we need training in ethics and we’re short on time which is a shame 🕰️ (curse of the final slot)

THIS NOT A SOFT SKILL it requires
🔹 inter professional comms, 🔹decision making in uncertainty
🔷leadership that creates a good ethical climate

Decision making in uncertainty needs to be an integral part of the landscape of medical education and care

(I’m here for that 👇🏻)

https://twitter.com/WhistlingDixie4/status/1584100080470360064

Room for one more tweet in this thread - so to end, I like this ‘TRICC’ -experts can do things unconsciously & then lack skill to make it teachable

The closing statement - no clear way ahead but (I paraphrase) we need to to move ahead anyway with what we can do
Ends
#LIVES2022