SICU and Palliative Care

Back to regular blogs. When I was on the surgical ICU service, I struggled a lot with the issue of palliative care. Compared to the medical ICU, palliative care was consulted much less, if at all. This is a cultural bias among surgeons. There is the sentiment that if we start talking about the end of life, comfort options, or reasons not to pursue aggressive treatment, then we have failed. This, of course, is not true. Palliative care is not a binary decision; one can involve principles of palliation while pursuing curative treatments. However, not everyone views it this way.

Although patients on the surgical ICU service are more likely to recover than patients on the medical service, we still have extremely sick people. Patients with severe traumatic injuries leading to brain damage, multiple re-operations for cancer, and severe comorbid diseases often end up in the SICU. I strongly feel that a balanced presentation of medical options is the most appropriate, and this often means talking about the end of life. No matter how good the surgeon, how careful our care, we cannot stave off death forever. I am aggressive in trying to understand a patient's wishes, especially around cardiac arrest and resuscitation. I want to know if we are setting them up for a future they do not want.

This is not to say that I want to "pull the plug" on our patients. In fact, our sickest patient on the service was someone who had cardiac failure after a cardiac arrest, severe pulmonary hypertension with pulmonary pressures equal to system pressures (a scenario many would call fatal), renal failure, liver failure, and systemic infections. We found out after a week of being intubated on a mechanical respirator that he would not want to be dependent long-term on such machines. After long talks with his durable power of health care, we proceeded to treat him aggressively. Another week later, we extubate him. He starts talking the following day. When we put his illness in the context of his wishes, we still felt it was worth putting him through the ICU stay. The important thing here, though, was the conversations we had to weigh the risks and benefits of all we did and talk about palliative care as a real possibility.

In talking to the surgeons over the course of the month, I realized that their mentality is very different from medicine doctors. For the most part, a surgeon takes a patient to surgery because he thinks he can make her better. By removing the gallbladder, taking out the cancer, or replacing the joint, his aim is to improve the patient from her baseline. On the other hand, most inpatient internal medicine hospitalists are reactive. A patient comes in with pneumonia, heart failure, or a stroke, and the goal is to get her as close to her baseline as possible. We cannot get them better than their pre-illness state. For the medicine patients, some won't do well, and palliative or comfort care may be appropriate. With the surgical patients, however, to talk about the end of life or giving up is tantamount to saying that we have offered something elective in hopes of improving life but wound up worsening it. There is a sense of guilt, shame, and silence.

I hope that having a multidisciplinary surgical ICU helps balance these intense cultural factors. Our goal is to care for our patients as best we can, and sometimes involving our palliative medicine specialists is critical.