Care for the Older Adult: ICU or Not?!

**traumaRUs**, MSN, APRN

AN staff were recently able to interview Teresa Tarnowski Goodell, RN,CNS,PhD,ACNS-BC,CWCN,TCRN. She is a faculty member and board member for Visionem, Inc., an educational and consultation company that provides trauma nursing education throughout the United States with the course Trauma Care After Resuscitation (TCAR). She also has thirty years of clinical practice in intensive care. She has taught nursing at five colleges and universities, most recently at Oregon Health & Science University in Portland, Oregon, where she was associate director of the Hartford Center for Geriatric Nursing Excellence.

According to a 2011 study published in the Annals of Intensive Care; "There is currently an increasing demand for critical care resources, which may be explained by both underlying demographic changes and the growing prevalence of conditions that require intensive care management, such as severe sepsis or high-risk surgery."Do you think that there need to be exclusionary criteria for older patients? (The challenge of admitting the very elderly to intensive care)

I do not favor making any care decisions on the sole basis of age. We've all met the 90-year-old who feels and functions better than the chronically ill 60-year-old, and research does not support age alone as a prognostic indicator. We should keep in mind that the increase in severe conditions that require intensive nursing care is due, in part, to improved diagnosis. Sepsis, for example, is now defined as infection plus hypotension, altered mentation, and/or tachypnea - criteria that many patients meet:

Taking a broad, inclusive approach to diagnosing sepsis and other critical conditions has likely improved survival but also increased the apparent incidence of these conditions. Aggressive measures probably reduce deaths from infection and sepsis, although there remains only weak to moderate evidence for our current approach to sepsis treatment, and clinical practice guidelines are not tailored specifically to the older population.

It is crucial to take an informed approach to intensive care usage in older adults. Intensive care admission has been shown to have no benefit and to cause harm in some older adults. Therefore, the implications of measures associated with intensive care hospitalization, such as intubation and resuscitation, must be made clear to patients and families when the decision to admit to ICU is made. Nurses should take the lead in providing information to help patients and families make decisions about aggressive measures. Few health consumers understand what it means to have CPR, to be intubated and mechanically ventilated, or to experience the long-term cognitive and functional decline that happens after an ICU stay (the post-intensive care syndrome).

Full disclosure would entail warning patients and families about pain, depression, cognitive and functional decline, family stress, and other elements common in post-intensive care syndrome. Instead, physicians (who typically seek consent for procedures, although nurses may be guilty as well) still try to solicit patient wishes with phrases such as, "Do you want us to do everything?" This question ensures a "yes" answer; few people would answer that with a "no" in a crisis situation. Most consumers don't know what "everything" means; they just want healing and they hope it will happen quickly. Better information for consumers, and skilled communication about goals of care, are desperately needed. Nurses must remember that ICU admission is a crisis, and we must educate people from that standpoint. This means repeating information, soliciting opinions, values, and beliefs, and providing time to make decisions. Doing so is undoubtedly difficult in the intensive care environment, but it is as important as administering medications and preventing infection. Every nurse can and should discuss goals of care with patients and families. It is well within the scope of nursing practice, yet I have observed that nurses are sometimes reluctant to broach this topic, perhaps because it is traditionally considered the purview of physicians.

I would implore nurses to remember that consumers trust us and want to discuss goals of care. The Gallup organization has conducted a poll for years and, in 2017, for the 16th year, nurses were voted the most trusted profession in the United States. This trust gives us great responsibility and, potentially, great power to influence care. We cannot stand by and expect one profession to take full responsibility for establishing the goals of care. Nurses know patients and their loved ones better than any other health care provider in the hospital setting. We must advocate by informing consumers, soliciting their wishes, communicating with other health care professionals, and seeing that patients' wishes are implemented. Patient advocacy is a core nursing role.

Consumers who are informed will make decisions about aggressive measures that respect the patients' desires. An added benefit may be lower costs, as fewer older adults are admitted to the intensive care unit and provided with aggressive, but unhelpful, interventions.

As our population ages, palliative care is becoming part of ICU care. How do staff nurses advocate for patients with life-limiting diseases or injuries?

This familiar dilemma speaks strongly to the goals of care conversation. Nurses spend more time with patients and their loved ones than anyone else in the hospital. We have a professional responsibility to elicit and to communicate patient and family wishes. Communication should always be the first priority in determining the course of care, especially in end-of-life situations.

There is misunderstanding, even among health care professionals, of palliative care. Palliation means symptom relief. This is important for nearly every hospitalized person. It does not mean end-of-life care, although I personally have had physicians resist palliative care consultation on the grounds that "the patient isn't dying." So educating all health care personnel is important.

Protocols for palliative care are helpful. Many institutions have developed these and some are published. Aside from medical orders for oxygen, analgesics, laxatives and such, protocols should include resources for providing comfort care, like a family journal, family discussion guides, social work referrals, and, at death, a way to preserve a lock of the deceased one's hair, or a kit for making a handprint.

Support for bereavement must be included, whether or not the patient qualifies for hospice. People who are not expected to die within 6 months will not qualify for hospice, per Medicare regulations, but many others are contemplating death and want to change the usual course of care by avoiding hospitalizations, declining surgeries, or halting non-essential medications. Nurses can support patients and families as they make these decisions with information and acceptance of their decisions. Every nurse has known patients who will confide in her, but not in the physician. This means that nurses must act as advocates when the medical team suggests advanced life support, surgery, or other interventions that the patient may not want.

In my experience, stopping the speeding train that is the medical plan of care can sometimes be difficult, but physicians and others will respond when the goals of care are made clear. We all want the best for each patient; focusing on shared goals can help gain consensus on the treatment plan.

How should staff nurses handle multiple requests from multiple family members? AN has recently had a thread about this and it was very popular.

In our practice environment, nurses have little control over our time, and rarely is there time for therapeutic extras like moisturizing skin and giving backrubs (although these are effective nursing interventions!) In the push to get everything done on time while enduring countless interruptions, nurses often find family demands frustrating.

The nurse is the most accessible health care team member to families, and thus fields the most questions and demands. I try to remember that a hospitalization is a crisis. Families arrive with all the dynamics that they developed over the years, some of which may be dysfunctional. A hospital stay, of course, does not turn families into well-functioning, coherent teams that communicate and treat each other with respect. In fact, the crisis of a severe illness may exacerbate family dysfunction. So the family may not communicate with one another, and the stress response decreases their ability to retain new information, especially since few members of the public are familiar with "medicalese." Thus, the repeated questions.

Solutions to the bombarding of nurses with multiple, repetitive questions include family conferences, where all members hear the same information simultaneously, and written materials. Asking the family to appoint a spokesperson who will volunteer to communicate with the rest of the family can be helpful. Sometimes, in my experience, this solution fails because of distrust among family members, or simply because the spokesperson becomes overwhelmed with the task.

Many intensive care units have opened visiting hours to include team rounds, which is another way of ensuring family members get accurate updates at least once a day. Other places use a care journal, where visitors and nurses write down events of the day and future plans, such as "More alert today. Sedation decreased," or "Extubation planned for tomorrow morning." Visitors can read the journal to get updates instead of asking the registered nurse.

Delirium, dementia and "sundowning" are all real issues in the ICU. What measures have you found to be effective in combating these issues?

First, distinguishing dementia from delirium and depression is key. Only about 5-10% of the older adult population has dementia (long-term cognitive decline), so most hospitalized patients have either delirium or depression. "Sundowning" is a symptom of delirium, and depression may mimic hypoactive delirium. Nurses are usually more concerned about hyperactive delirium because of the risk of injury, so hypoactive delirium is more often overlooked and untreated. A great resource for learning about the differences and similarities is found on the Hartford Institute's website: Confused | ConsultGeri

Accurate diagnosis is essential because the causes and treatment approaches differ. Dementia is a chronic condition and delirium is acute. Delirium has many causes, but it shares a common trait with dementia: patients may be hyperactive, anxious, and at risk of self-injury or injuring others. This presents management challenges for nurses. Historically, the treatment for agitation and risk of injury was restraint. Now we understand that restraint increases risk of injury, and altering the internal or external environment to improve safety is preferable. Environmental alteration is fundamental to nursing practice. It may include correcting hypoxemia or electrolyte imbalances, treating pain, altering drug regimens, providing simple activities to occupy the person, padding siderails, and placing padding on the floor around the bed to reduce injury in case of fall. Assisting with hydration and elimination are effective independent nursing interventions that can reduce delirium related to dehydration and help ensure the patient does not try to reach the bathroom independently.

Part of the aforementioned post-intensive care syndrome is post-traumatic stress disorder. Frightening memories may return to an acutely ill older adult who has experienced past trauma, contributing to anxiety and mimicking delirium. Removing or reducing sedation once a day ("sedation vacation") helps reorient the person to reality and may help mitigate agitated delirium.

No-cost resources for professionals and laypersons regarding intensive care delirium have been developed by the ICU Delirium and Cognitive Impairment Study Group4 . These emphasize the ABCDEF bundle, which is aimed at preventing multiple common ICU complications, including dementia.

The most important point is that confusion is always significant. Older adults do experience neuronal atrophy as a normal part of aging, but it does not normally cause disorientation and behavioral disturbances. If these occur, something is wrong. The causes of confusion are numerous, from urinary tract infection to medication side effects to Alzheimer's-type dementia. I think the bottom line is: identify whether the issue is dementia, delirium or depression, then figure out the cause, then treat it accordingly. Sedation should be a last resort, and restraint use limited to very specific situations only. (Such as to prevent self-harm until the cause can be addressed.)

Side note: personally, I'd love to see an end to the term "pleasantly confused." Confusion is always pathologic. That phrase merely means that the patient's behavior is not disruptive to the healthcare provider.

As we all know, POAs are sometimes appointed by patients without seriously considering that they may need to make care decisions. How should nurses communicate with the POA?

I think communicating with the person who has medical power of attorney should simply follow guidelines for good therapeutic relationships. Communicate clearly, compassionately and frequently. Write things down. Remember that the POA is shouldering a stressful burden. Stress reactions induce fight-or-flight responses, which slow the learning process. The crisis of an intensive care admission can induce insomnia and fear, which also interfere with learning and executive function. It is crucial that healthcare professionals remember this when communicating with the POA.

Rather than POAs who haven't seriously thought about their profound role, my experience has predominantly been of next-of-kin who appreciate the gravity of the situation and feel overwhelmed by their responsibilities. Most people do not discuss dying with their families, and the POA may feel unqualified for the job. When families disagree about goals of care, this gets much more complex, of course.

Here are two stories of things I've done that have helped. Years ago, while practicing in a medical ICU, I cared for an elderly man with a poor prognosis. His wife said to me, "I don't know how to make this decision. What should I do?" I asked her if they had raised children together. She replied, "Yes." I said, "Then you have made difficult decisions before. You can do it again." And she was reassured by that.

I have also reassured POAs by reminding them that they are the very best person on the planet to make difficult care decisions for their loved one. They know the patient best. No health care provider can do that better. These simple phrases seem to help.

References:

1. Rhodes, A , et al. Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock 2016. Critical Care Medicine. 2017; 45 (3): 486-552 doi: 10.1097/CCM.0000000000002255

2. Guidet, B. et al. Effect of Systematic Intensive Care Unit Triage on Long-term Mortality Among Critically Ill Elderly Patients in France: A Randomized Clinical Trial. JAMA. 2017;318(15):1450-1459. doi:10.1001/jama.2017.13889

3. Society of Critical Care Medicine. Post-intensive Care Syndrome. n.d. Patients and Families | SCCM |

Post-intensive Care Syndrome

4. ICU Delirium and Cognitive Impairment Study Group. n.d. Medical Professionals | ICU Delirium and Cognitive Impairment Study Group

Care for the Older Adult: ICU or Not?!

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