Evaluation of Palliative Care Initiatives in the Intensive Care Setting
Christopher Blais MD
Deborah Bourgeois APRN
Ochsner Health System
Palliative Medicine Brent House #305
1514 Jefferson Highway
New Orleans, Louisiana 70121
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Problem: Critical care staff is often morally distressed and frustrated by the end-of-life experience of patients while families are frequently dissatisfied with the palliative care provided.
Project design: A three phase approach was undertaken to assess satisfaction of palliative care for physicians, medical students, nursing staff and families. Survey methods were designed to assess patient/family, physician, and nurse satisfaction of palliative care service initiatives.
Patient and Family Satisfaction: The Ochsner Palliative Care Committee consulted with Press Ganey to develop a bereavement survey to assess family satisfaction with end of life care. The 40-question bereavement survey was produced with sections including: Time of Death, Visitors and Family, Physician, Nursing, Personal Issues, and Room. A Pre- palliative care consult service survey was conducted with baseline data retrieved between December 2005 and March 2006. Palliative care consultation services were then initiated. Post survey overall and unit based data has been collected since that time.
Physician Training Satisfaction: A survey was developed and administered to residents at the beginning and end of their rotation on critical care service to evaluate satisfaction and confidence with new palliative care educational initiatives. Case-based approach educational initiatives were utilized to foster resident confidence in delivering bad news, discussing poor prognosis, explaining the dying process, and providing palliative care within the medical intensive care unit.
Palliative Care concepts were taught via scheduled didactics, expert role modeling, hands-on care of dying patients, and mandatory participation, organizing and providing family conferences. Resident case-based discussion of specific patients was implemented as a debriefing for difficult end of life cases each month. Led by a critical care staff physician, palliative care medical director and palliative care APRN, these sessions provide a framework to reinforce the confidence of young physicians. Open-ended questions are employed to stimulate resident reflection on their decisions and to guide the discussion to reinforce palliative care principals’.
Nursing Satisfaction: Palliative Care APRN and critical care nursing developed and implemented a standardized order set for planned withdrawal of life support. A pre and post implementation survey was developed and utilized to evaluate nurses’ perceptions of withdrawal of life support with and without the order set.
- Phase I Patient and Family Satisfaction: ICU survey ongoing improvement is demonstrated from a 2006 baseline of 78.0% to 1st qtr 2011 score of 94.7%.. The institutional 2006 pre-Palliative Care score was 76.7%. Ongoing improvement seen 2007-2011 with 1st qtr 2011 score of 95.2%. ICU now uses bereavement survey as primary instrument in patient satisfaction quality improvement initiatives. Dying process sensitivity tools, bereavement trays, resource booklets, and other improvements were developed
- Phase II Physician Training Satisfaction: Post survey results showed increased resident confidence in providing palliative care, specifically in the areas of: delivering bad news, discussing comfort care, withdrawing life-sustaining treatment, and managing dying patients.
- Phase III Nursing Satisfaction: A strong positive linear and correlation between years in nursing and comfort level with withdrawal of life support was noted relating to order sets. Many critical care nurses at OMC have less than three years experience. Nursing satisfaction and perceived comfort were demonstrated in the post order implementation survey associated with the use of a standardized order set for withdrawal of life supportive therapies. Revised critical care ongoing nursing education and orientation which now includes palliative care lectures, withdrawal of life support procedure training, organ donation and therapeutic communication were instituted. System wide adoption of survey and order set implementation is underway.
Conclusion: All-around satisfaction of palliative care in ICU settings can be measured and improved.
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