Palliative Care in Critical Trauma Patients: Challenges and Nursing Roles

Abstract

A critical trauma is a life-threatening condition that can lead to sudden death. When curative treatment is unresponsive, palliative care becomes a viable alternative that can enhance quality of life from the onset of care to the end of life. However, providing palliative care in critical trauma-intensive care settings remains a significant challenge due to the complex, sudden, unpredictable, and rapidly evolving nature of traumatic injuries. This article aims to identify multidimensional challenges and nurses’ roles in delivering palliative care to critical trauma patients in trauma-intensive care units. One of the initial challenges in trauma palliative care is the communication of bad news to families following sudden and severe incidents. Nurses must be attuned to the psychological and emotional states of families, requiring advanced communication skills and the ability to observe and respond to emotional cues. Ethical considerations are paramount when patients and families opt for palliative care. Nurses must uphold the principle of autonomy in obtaining informed consent. In cases where patients are unconscious, it is essential to establish goals of care (GOC) and advance care planning (ACP) through surrogate decision-makers. Nurses must ensure care aligns with the principles of beneficence and non-maleficence, adhering to the patient’s goals and ACP, while also ensuring justice by providing equitable care comparable to other critically ill patients. Age-related differences present another layer of complexity. In pediatric patients under 18 years, societal expectations of growth and development contrast with the elderly, who may have already prepared for end-of-life care. In Thailand, palliative decisions for minors require parental consent, unlike older adults who can make autonomous healthcare decisions. Nurses must therefore understand the unique challenges across age groups. Although the American College of Surgeons, through its Trauma Quality Improvement Program (TQIP), has developed specific guidelines for palliative care in trauma patients focusing on symptom management, patient- and family-centered care, psychosocial and spiritual support, and effective interdisciplinary communication, the role of nurses in this context remains underdefined. By integrating the autonomous role of nurses with TQIP recommendations and the ongoing care process for critically injured trauma patients, this article outlines five key nursing roles: 1) Promoting Person-Centered Care: Nurses must deliver holistic care that addresses both physical and emotional needs. This includes identifying a proxy decision-maker within 24 hours and establishing GOC and ACP within 72 hours of hospital admission. Nurses should provide continuous information about the patient’s condition and palliative options and assess religious or spiritual needs at the end of life; 2) Fostering Therapeutic Relationships: Nurses should build trust through active listening, allowing families to express grief and identify conflicts regarding palliative care decisions. Ethical considerations must be addressed, and nurses should act as mediators to ensure effective communication among interdisciplinary teams and families; 3) Clinical and Technical Competence: Nurses must manage critical symptoms such as pain, dyspnea, and thirst using evidence-based practices. Accurate assessment tools and interventions are essential to improve the quality of life for critically ill patients; 4) Clinical Leadership: Nurses should assess the informational needs of families and facilitate family-care team meetings. In complex cases, nurses must coordinate with palliative care specialists for appropriate referrals, and 5) Environmental Management: Nurses should ensure privacy and create a peaceful environment for end-of-life care, family meetings, or the delivery of bad news, providing necessary amenities for both patients and families. Some patients may survive the critical phase, and palliative care should not be viewed solely as end-of-life care. Sustainable palliative care systems require collaboration with families and communities. Nurses play a central role in coordinating interdisciplinary teams and must continuously develop their knowledge, empathy, and sensitivity to cultural contexts, particularly in Thailand, where palliative care is often misunderstood as a sign of hopelessness. Institutions should support structured training programs to enhance nurses’ competencies in delivering high-quality, specialized palliative care. Critical care nurses, particularly those caring for trauma patients, must also engage in research to inform policy development, as evidence-based support for trauma palliative care remains limited.