When a 24-year-old man who'd suffered a devastating head injury in a car crash arrived in a coma at Harborview Medical Center, doctors quickly determined he likely would never wake up. If he did, he'd be forever dependent on machines to breathe and eat.

His wife, knowing he wouldn't want to live that way, was ready to withdraw life support. But his mother, hoping for a miracle, begged for every possible intervention.

At this terrible juncture, the intensive-care unit staff put modern medicine on hold and turned to what's called "palliative care."

Palliate means to mitigate, relieve and soothe, even when a disease can't be cured or the effects of an injury reversed.

A new focus on such care is changing the culture at the region's premier trauma center, where 23,000 people are admitted annually and many end up in intensive care.

In times past, intensive-care doctors and nurses simply took over. Armed with the latest technology, they fought to keep patients alive at all costs.

Lifesaving still is the mission. But now, the medical staff strives to maximize quality of life and minimize pain and suffering for patients and their families.

"There's been a growing realization that just because we have technology doesn't mean we should always apply it," said Dr. Randall Curtis, attending physician and director of the palliative-care initiative at Harborview. "The effect can be to prolong death or to save people for a quality of life that they don't find acceptable."

Changes in the ICU

Historically, hospitals have offered palliative care for cancer patients and through hospice. But it's a newcomer to intensive care. At Harborview's intensive care, it's brought a sea change in philosophy:

Staff at all levels, from doctors and nurses to social workers and chaplains, are being trained to work together to offer patients and families spiritual comfort, psychological support and help in making life-and-death decisions.

A palliative-care specialist is now employed by the hospital to handle the toughest situations, where pain is difficult to control, for example, or there's conflict over the goals of care.

Procedures for removing life support and administering end-of-life pain medication have been revised to be more ethical, safe and consistent. There is a clear protocol for removing a ventilator, allowing the nurse at intervals to make sure the patient is not in pain or experiencing shortness of breath. The nurse now has wider latitude to administer pain medication. Studies show the hospital now uses more pain medication while withdrawing life support, but it does not hasten death.

To personalize care, and give an identity to patients too sick to introduce themselves, new ideas — like a simple "get to know me" poster in the patient's room — may be employed.

Far-reaching goals

The palliative-care initiative at Harborview is part of "Promoting Excellence in End of Life Care," a project of the Princeton, N.J.-based Robert Wood Johnson Foundation, a philanthropy that works to improve the health and health care of Americans.

In 2003, the foundation awarded grants totaling $1.5 million for three-year demonstration projects at four hospitals — most affiliated with university medical schools around the country. Harborview is affiliated with the University of Washington.

The goal is to develop sustainable palliative-care models that can be replicated in intensive-care units nationwide.

"It's important to realize that in trying to save lives, it's not necessary to neglect a patient's physical comfort or their emotional and even spiritual well-being nor the well-being of their families," said Dr. Ira Byock, a palliative-care physician at The University of Montana and director of the Robert Wood Johnson Foundation's national program.

Palliative care already is offered at some other hospitals, and more are starting to use it, but not typically in the intensive care unit.

Over the next three years, Harborview expects to roll out its project on integrating palliative and critical care at 12 hospitals in King and Pierce counties, and it will continue its own program.

Communication

At the Harborview ICU, the family conference is a primary setting for delivering palliative care.

The conference takes place in a room plainly furnished with chairs around a long table — not an especially comforting atmosphere, but far better than in days gone by when these kinds of conversations took place in hallways, public waiting rooms or at the patient's bedside, said Curtis.

Participants include the patient's family — rarely, the patient is able to join the conversation — the doctors, nurse, social worker, chaplain and palliative-care specialist.

Behind closed doors, people introduce themselves and explain their connection to the patient. (This respectful start contrasts with what sometimes happened in the past when a doctor walked in and started talking not knowing who was in the room.)

The group reviews the patient's medical status, decisions to be made and the patient's own goals and values. Often, the task is to decide whether to end or withhold life support, both of which are legal in Washington when life-sustaining therapy is no longer indicated or desired, said Curtis.

It's often a time filled with grief and tears. Disagreement can arise between family members or between the family and the physician, who likely doesn't know the patient's preferences.

Conflicting cultural and religious beliefs can emerge. Satisfactory resolution depends on clear communication, negotiation and consensus-building.

"Is there anything you'd like to discuss today?" the doctor or palliative-care specialist is trained to ask at several different times, trying to give family members every opportunity to talk about their hopes and fears.

Deeper questions follow — generally from the physician leading the conference — as a prelude to deciding whether and how the patient's life should be sustained.

What is important to the patient? What gives her life meaning? What makes him who he is?

The young man in a coma from a head injury stayed for 10 days in the ICU, while his wife and mother worked with a palliative-care specialist. The wife had the legal authority to make medical decisions, but she wanted the situation to go as well as possible for the whole family.

Over several meetings, a step at a time, the mother came to understand that her son would never again be himself. She finally agreed that the ventilator should be turned off.

"It allowed them to have a peaceful death. The wife and mother were in the room at the same time," said Darrell Owens, an advanced practice nurse and palliative-care specialist.

In another case, the frustrated medical staff felt life support had gone on too long. But in a family conference they learned that the patient's Korean culture dictated that his children push for every lifesaving treatment available. Knowing that put things in perspective for the staff.

"Get to Know Me"

Palliative care isn't limited to people in imminent danger of death.

KEN LAMBERT / THE SEATTLE TIMES A poster with personal information about him hangs in the hospital room of ICU patient Ernest "Bob" Bobko. Made by his family and including tidbits such as his favorite TV show, it's intended to help staff better relate to Bobko.

Take Ernest Bobko, who was in Haborview for about a month, hooked up to a ventilator most of that time. He could only nod.

A few years ago, his medical team might have treated him as just another very sick older man. They might have addressed him as "Mr. Bobko," or even the dreaded "Ernest."

Instead, whoever walked in his hospital room could see right away that he goes by "Bob." They also knew he retired as an Army lieutenant colonel and elementary-school teacher. His favorite TV show is "M*A*S*H." Favorite book: the Bible. Favorite foods: "If it's Hungarian, good!" They knew what cheers him up: family, the grandkids' dog Maggie, and German chocolate cake. And what stresses him out? Broken bones, not being home.

It was all on the big "Get to Know Me" poster filled out in by his family.

The poster looked like a well-done kindergarten project. But it made Bobko a real person to the staff and helped keep him oriented if he got a little confused. It also was a starting point for conversation.

"The things that are written told me how his faith community is important to him and how he misses being home," said the Rev. Andrew Schoenfield, a hospital chaplain.

The chaplain used those statements to talk about what was meaningful and what was difficult for the patient.

The poster didn't help Bobko physically. He's still critically ill, and has been transferred to another hospital for specialized respiratory rehabilitation.

"But it sure does an awful lot mentally, maybe even spiritually," said his son John.

And it might have something to do with his strength at this point.

"There's a lot of pride on that board. The man's almost unbreakable," said John.

The poster also revealed an incentive to dangle.

"I see you like German chocolate cake. You've got a birthday coming up," his nurse teased. "Maybe if you work at this and that you might get some of that cake."

Even this small exchange is what palliative care is about.

"We are dealing with people who experience incredible grief and tragedy in their lives making decisions about care," said Theresa Braungardt, nurse manager for medical and neurosurgical intensive care.

"We're trying to make this as human and personable as possible."

Marsha King: 206-464-2232 or mking@seattletimes.com