Center to Advance Palliative Care

In the IPAL-ICU Portfolio, you will see reference to an in-press (journal is Critical Care Medicine) article by our Project Team, entitled "Models for structuring a clinical initiative to enhance palliative care in the intensive care unit: A report from The IPAL-ICU Project." This article will be available as an e-publication (ahead of print) within the next couple of weeks and I hope it will be helpful to you. In Table 1 of the article, we list various triggering criteria that have been used in 5 separate initiatives reported in the literature. An example is the report by Norton et al, in Crit Care Med 2007, in which the triggers were: 10 days or more in the hospital before the ICU, age over 80 yrs if 2 or more co-morbid conditions, Stage IV malignancy, status post cardiac arrest, and intracerebral hemorrhage with mechanical ventilation. As we discuss in the article, triggers can include baseline patient characteristics (e.g., advanced age, pre-existing functional dependence), selected acute diagnoses (e.g., prolonged dysfunction of multiple organs, global cerebral ischemia after cardiac arrest), and/or healthcare use criteria (e.g., specified duration of ICU gtreatment, referral for tracheotomy for failure to wean). I am hopeful that if you go through the steps I suggested in the audioconference today, beginning with the creation of an interdisciplinary workgroup (which would be involved in determining triggering criteria), you will make progress in demonstrating the value of the palliative care consults in the ICU. As your question implicitly recognizes, the improvement effort will be most successful when the culture is supportive, and when there is mutual trust and respect between the palliative care and ICU teams. The supportive culture can be fostered, both by nurses and others in the ICU, and by the palliative care team itself. The trust/respect can also be built, by strategies including regular involvement of the palliative care consultants in ICU rounds. Change happens slowly but it can definitely happen.