St. Michael’s Hospital has introduced a compassionate new policy that gives critically ill patients the option to spend their final moments on the palliative care unit, if that’s what they or their families prefer. Developed in close collaboration with families, this approach allows patients who are intubated on a critical care unit (ICU) to be safely transferred and extubated – disconnected from a ventilator – in the comfort and privacy of the palliative care unit, ensuring dignity and autonomy at end-of-life.

This new policy – believed to be among the first-of-its-kind in a Toronto hospital – develops a coordinated approach between the ICU and palliative care unit teams, supporting safe patient movement and comprehensive comfort care in one of their most vulnerable moments. 

“Many patients have great relationships with their critical care team and their families decide to extubate in the ICU,” says Dr. Jonathan Ailon, Medical Director, Palliative Care at Unity Health Toronto. “For other families, when they make the difficult decision towards a comfort-focused approach to care, they want their loved one to be transferred quickly and safely to an environment designed to support quality of life and comfort in death. The option to extubate in the palliative care unit can provide a sense of peace that they’ve done everything possible to ensure comfort.”

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A few members of the team behind the new policy at St. Michael’s.

This coordinated approach between the ICU and palliative care teams was developed in response to requests from families who hoped their loved ones could be extubated in the more peaceful environment of the palliative care unit.

“It’s a very personal choice to decide where your loved one will die,” says Swanee Tobin, who was a Nurse Practitioner, Palliative Care at St. Michael’s, at the time of this interview. “We follow many outpatients longitudinally and sometimes, if we have a good relationship with them and they end up intubated in the ICU, bringing them here for extubation provides an end-of-life experience in a more home-like environment.”

When families express their wish to have their loved ones transferred, the palliative and critical care teams come together to thoughtfully review each request and work closely with the family to plan the timing and details of the patient’s transfer and extubation.

On the day of extubation, the critical care team accompanies the patient to the palliative care unit and, with the support of respiratory therapists, gently carries out the extubation process. In the moments that follow, the critical care team remains on the unit to help manage any symptoms that may arise, ensuring comfort and support. Once the patient is stable, the palliative care team takes over their care. 

“This requires a lot of inter-team coordination,” says Tobin, who has since left Unity Health. “That’s really been the theme. Even from the beginning, we had a lot of stakeholder engagement, buy-in and support. We have several critical care units at St. Michael’s so everyone needed to be on board.”

It’s been a couple months since the coordinated approach was formalized, and Tobin says she’s grateful that patients and families can now consistently be supported in this way.

“This approach was really driven by families,” she says. “This is often one of their final wants and wishes for their loved one, and we’re pleased that we can support them with that.”

By: Anna Wassermann

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