Integrating Palliative Care into the Pediatric Intensive Care Unit A Report from the IPAL-ICU (Improving Palliative Care in the ICU) Advisory Board

Every year at least 200 children per 100,000 require hospitalization in pediatric intensive care units (PICUs) to treat serious illness and trauma.(1) These settings are characterized by an intensive technological focus on life-saving procedures. Although the PICU is often used for short term postoperative stabilization, PICU clinicians also care for many chronically critically ill children with complex underlying conditions and others receiving intensive care for prolonged periods.(2) In one study, 1% of PICU patients accounted for 18% of PICU bed days. The median age of these patients was 4 months, and >70% of survivors had poor to very poor outcomes.(3) Approximately 90% of inpatient pediatric deaths occur in the ICU(2), often after withdrawal of life-prolonging medical therapy and accompanied by some degree of moral distress for caregivers and families.(1, 4) Providing care for critically ill children, and children at the end of life, can be a valuable opportunity to establish close relationships with patients and families. Incorporating palliative care into medical management for these patients can benefit patients, families, and staff. Palliative care focuses on enhancing quality of life, minimizing suffering, optimizing function, and supporting families in complex decision-making and communication. Different approaches to incorporating palliative care services into the ICU can broadly be divided into “integrative,” “consultative,” and “mixed” models.(5) The integrative model focuses on maximizing and standardizing the palliative care principles and interventions that all ICU clinicians are trained to incorporate into usual patient care from the time of diagnosis. The consultative model incorporates subspecialty palliative care teams as needed for complex speciality level-problems.(6) Mixed models includes features of both integrative and consultative models. A 2013 national survey suggests that approximately 60% of children’s hospitals have pediatric palliative care programs.(7) The purpose of this article is to highlight the benefits that patients, families and clinicians can expect to realize when palliative care service is intentionally incorporated into the PICU.