Increasing Critical Care Nurse Engagement of Palliative Care During the COVID-19 Pandemic

Findings show that nurses working in the ICU spend an estimated 86% of their in-unit time in direct patient contact, approximately 73% to 78% greater than that of physicians or other critical staff, respectively.⁸  Not only do nurses have more face-to-face time with patients, they are the largest component of ICU teams across the United States. There are more than 500 000 critical care nurses compared with approximately 130 200 respiratory therapists, 6000 to 7000 critical care pharmacists, almost 30 000 advanced practice providers, and the equivalent of approximately 20 000 full-time intensivists.⁹  In the era of COVID-19, critical care nurses are at extremely high risk of viral exposure, burnout, and moral distress and injury; they shoulder the overall challenge of being the most trusted first responder.

In many ways, ICU-level care has become the standard of patient care during the COVID-19 response. Contingency and crisis beds are being allocated outside of ICUs to strengthen hospital capabilities and effectively treat critically ill patients.¹⁰  With the surge in patient admissions nationally and internationally, hospitals are actively adapting medical-surgical floors and emergency departments into transitory ICUs to meet the needs associated with acute decompensation, symptom exacerbation, and rapid responses. Nurses are certain to be experiencing longer and more traumatic shifts complicated by cumulative patient losses, moral injury and distress in the setting of complex decision-making, resource constraints, and new and mounting responsibilities, among other considerations.¹¹ 

The risk of viral transmission is provoking fear across the workforce, particularly when many nurses are experiencing a lack of adequate personal protective equipment (PPE).¹¹  Visitors are being distanced from their loved ones to decrease COVID-19 spread and to improve safety standards, undoubtedly placing a strain on family dynamics and relationships between nurses and patients and their families. Care planning discussions for older patients, those with serious illness, and the immuno-compromised are understandably becoming more difficult to manage. As mortality rates soar during the COVID-19 outbreak,¹  proximity to the dying process, death, grief, and bereavement in the ICU carries a cumulative impact on the mental and emotional well-being of all clinicians. All the while, nurses will continue to be the frontline responders: combining skill, evidence-based practice, ethical integrity, technological savvy, endurance, and compassion. Critical care nurses are truly doing and seeing it all during the COVID-19 emergency, working at the intersection of the scientific knowledge and humanistic care that our patients, families, and communities so desperately require.

The COVID-19 pandemic has underscored the need for advanced skills related to management of ventilators, symptom control, delivery of complex medication regimens (often untested), and essential communication with families and within teams, because patients often decline rapidly. The COVID-19 pandemic has also wrought an emotional burden, overwhelming even nurses in the intensive care field who are accustomed to intensely demanding work. Nurses are speaking to family members who have little understanding of the disease, witnessing patients’ rapid physical declines, and seeing patients dying alone. Nurses are holding the phone as families say goodbye to dying patients and they then care for the ravaged bodies after ventilators and proning beds are discontinued. Nurses are also contributing to critical decision-making about sparse resource distribution amid health inequities and cultural divides, while risking their personal safety because of a lack of PPE.

In 2018, the International Association for Hospice & Palliative Care put forth a consensus definition of palliative care as

Effective, safe, and competent palliative care maintains certain characteristics and may provide a range of benefits to recipients, as shown in Table 1. Multiple organizations and expert-led initiatives call for universal access to palliative care as a human right that should be integrated throughout health systems, specialty areas, and at all levels in conjunction with curative treatments, when appropriate.^13,14 

Researchers suggest the global burden of serious health-related suffering will intensify by approximately 87% over the next 40 years.¹⁵  The need for universal palliative care as a crucial component of public health frameworks is becoming more evident against the backdrop of COVID-19. Multidisciplinary advocates have noted the essential role of nurses in achieving universal palliative care access by aligning with global health agendas at local levels; raising the profile and status of nurses; adapting nursing education to the practical needs of clinical settings; and supporting nurses as full interdisciplinary team members to ensure palliative care services.^16,17  Leaders concur that palliative care accessibility is an ethical and humanistic imperative to alleviate suffering during the COVID-19 pandemic and beyond.^18-20 

Before the COVID-19 pandemic, approximately 29% of Medicare beneficiaries²¹  and 36% of nonhospice patients with cancer with poor prognosis received ICU care in the last 30 days of life.²²  These statistics suggest that critical care nurses are not strangers to suffering, dying, or death. However, we presume these figures will consistently increase throughout the COVID-19 pandemic and as a result of future health crises, increasing critical care nursing proximity to patients at the end of life. Although the focus of admission to critical care is often life-sustaining treatment at all costs,

providing comfort to patients should accompany all ICU care, even during aggressive attempts to prolong life…. The transition from aggressive care to death preparation has not been well operationalized…. Therefore, it is important for health-care professionals to integrate palliative care principles early in the patient’s ICU stay.^{23(pp624-625)}

There are a number of key palliative care points to consider during any ICU stay that are in alignment with the domains of the Clinical Practice Guidelines for Quality Palliative Care²⁴  (Table 2). Many of these care points require distinct attention during the COVID-19 outbreak.

Recommendations with relevant resources to direct critical care nurses and health care leaders are provided in the paragraphs that follow. A wealth of resources from experts in the fields of palliative and critical care exists. In addition, professional societies have centralized resources and has made most of them available free of charge amid a socially distanced and strained environment.

First, critical care nurses deserve to practice in a healthy work environment, which includes resources for their own self-care, during times of crisis and times of normalcy. As defined earlier in this article, palliative care is a person-centered approach to alleviating health-related suffering.¹²  To sustainably foster environments in which palliative care can be holistic, of high quality, and consistently delivered, nurses working in critical care settings with increased exposure to suffering must care for themselves.^20,25,26  Both healthy work environments and clinician self-care are critical factors in delivering safe patient care.²⁷ 

Health care system leaders employing nurses are responsible for promoting and sustaining a healthy work environment. The COVID-19 crisis has underscored this basic need. Though leaders play a critical role in implementing these standards, each team member owns the health of the team and unit. The American Association of Critical-Care Nurses (AACN) developed the AACN Standards for Establishing and Sustaining Healthy Work Environments: A Journey to Excellence (Table 3).²⁸  The 6 standards are Skilled Communication, True Collaboration, Effective Decision Making, Appropriate Staffing, Meaningful Recognition, and Authentic Leadership.²⁸ 

• We recommend that nurses, teams, and health care system leaders access the free, web-based survey to assess the health of an individual work unit (Table 3).

• We recommend mechanisms to promote transparent, open, respectful, and nonretaliatory communication among critical care nurses, all levels of management, and multidisciplinary partners to ensure health and sustainability for all frontline critical care nurses and colleagues.

Beyond considerations for the work environment, nurses (and all members of the ICU team) cannot care for patients and families if they cannot care for themselves. Critical care nurses and the teams they work with are frequently faced with moral challenges. During a national crisis such as the COVID-19 pandemic, these challenges are intensified. Moral distress and burnout have been recognized by AACN and the Society of Critical Care Medicine. These critical care societies provide effective resources for critical care nurses and all health team members. The Critical Care Societies Collaborative (CCSC) comprises 4 critical care societies: AACN, the Society of Critical Care Medicine, the American College of Chest Physicians, and the American Thoracic Society. In 2016, CCSC published a call to action to address the epidemic of burnout in critical care professionals,²⁹  followed by a 2020 report on the national summit to address burnout in critical care.³⁰ 

Before the COVID-19 pandemic, many clinicians experienced burnout, anxiety, depression, and substance abuse. National attention was being focused on strategies to address this serious workforce issue and promote clinician resilience and well-being.³¹  Now, experts are aware the COVID-19 pandemic is creating even greater workplace stress and moral dilemmas. Each clinician is much too valuable to the workforce, and critically ill patients cannot be cared for if nurses and physicians leave the discipline because of burnout.

The critical care nurse is the interface between advanced lifesaving technology and patient- and family-centered care. The pressures related to the COVID-19 crisis are likely exacerbating moral distress. Nurses and their teams are strongly encouraged to use the recently published AACN position statement, “Moral Distress in Times of Crisis”³²  (Table 3). Nurses are also directed to the websites listed in Table 3 and are encouraged to use tools from the CCSC or National Academy of Medicine sites during this COVID-19 crisis and in the future.

Second, care of patients during the COVID-19 pandemic requires a skilled blend of critical care, palliative care, and ethically based care. Table 2 provides several specific suggestions to help integrate palliative care throughout critical care nursing practice. Critical care societies and federal agencies are providing position statements, research, and other resources to guide practice.

Third, palliative care is critical care. Thus, critical care nurses and their teams should provide primary palliative care to each patient and consult palliative care specialists in complex cases. Primary palliative care includes pain and symptom management; patient-centered communication; elicitation of the patient’s goals of care and alignment of those goals with the treatment plan; family communication and support; skilled and compassionate end-of-life care; and the assurance that ethical standards are abided by at all times. Critical care nurses will have different levels of skill in fully integrating palliative care.

The End-of-Life Nursing Education Consortium curriculum contains 8 complimentary modules providing essential palliative care knowledge and skills related to communication, self-care, symptom management, loss, grief, and bereavement (Table 3). Palliative care competencies are considered essential for all undergraduate and graduate nursing students. The End-of-Life Nursing Education Consortium team developed an online curriculum, titled “Competencies and Recommendations for Educating Nursing Students,” comprising six 1-hour modules to help students develop 17 essential competencies (Table 3). These competencies build on the recommendations from the American Association of Colleges of Nursing and are intended for graduate students.

The Center to Advance Palliative Care has advocated the expanded use of palliative care over the past 2 decades and provides extensive resources and toolkits on its website. Some resources are for members only, but many are free at Center to Advance Palliative Care COVID-19 Response Resources (Table 3). Resources include symptom management protocols, pocket cards, team tools, resilience-building strategies, and patient and family support resources. The Center to Advance Palliative Care convened palliative care and critical care experts to develop Integrating Palliative Care in the ICU. Resources, research, articles, and quality improvement toolkits can be found on the center’s website (Table 3).

Skilled communication with patients and families during the stress of an ICU admission is essential to patient-centered care. When the uncertainty and high ICU mortality rate of COVID-19 are added, skilled and effective communication becomes as critical as the use of lifesaving technologies. In addition to the aforementioned resources, Integrating Multidisciplinary Palliative Care Into the ICU is also an excellent tool (Table 3). This program is intended for bedside ICU nurses and is a communication skills training program to help integrate palliative care.

The 500 000 critical care nurses that compose the workforce are essential to the care of critically ill patients during the COVID-19 public health emergency and in the future as we care for an aging population. All the recommendations made and resources suggested in this section are relevant to include in the education of new registered nurses and advanced practice nurses. Nurse educators are encouraged to integrate selected materials in their programs and curriculums.

Critical care nurses have always answered the call to care for the most vulnerable and technologically dependent patients in the health care system. The myriad consequences of the COVID-19 crisis have illuminated several important aspects of the delivery of high-quality critical care, including the need for palliative care integration across all care settings amid this public health emergency.^19,20,33 

Nurses and their teams must have the guidelines, equipment, and PPE to provide high-quality care and to be safe in the setting of contagious transmission. Next, though most nurses did not choose the critical care specialty to provide end-of-life care, this pandemic is a stark reminder that death is common in the ICU. Nurses and their teams must integrate primary palliative care for each patient and access specialist palliative care in more complex cases. Palliative care should be routinely practiced by all ICU clinicians as a component of high-quality critical care.³⁴  The use of symptom management protocols, communication frameworks, and goals-of-care discussions as the standard of care, not the exception, is essential. Finally, care of the caregiver—nurses, advanced practice nurses, intensivists, and all members of the ICU team— must be a priority during this crisis, at the unit and system levels, and in the future.

The call to action is clear: it matters that nurses spend the most time with critically ill patients and their families and lead care teams during both normalcy and crises. Critical care nurses can drive full integration of palliative care into the care of all patients, including patients with COVID-19, because they have always put the patient and family at the center of their practice. Palliative care is critical care and the time for separation or waiting is behind us.

The COVID-19 pandemic has made explicit the need for palliative care integration throughout settings in hospitals and communities worldwide as the suffering of patients and families is exacerbated. We call for palliative care integration throughout the practice of high-quality critical care to ensure the holistic needs of patients and families are met in these uncertain times. Achieving this ideal will require leadership, advocacy, persistence, and a rapid shift in perspectives and protocols. Palliative care is critical care; and critical care nurses are ideally positioned to ensure this congruence is realized, disseminated, and empathically translated into practice toward improved quality outcomes and person-centered care.