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Palliative Care and the ICU

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Post Triggers
Author: ceaelle
Date: Jun 16, 2010 2:00 pm
Can you give some specific examples that should trigger a palliative care referral from the ICU? If we used a nursing-based model for screening measures, how many triggers should we use? If this is done on admission to ICU, if and when should follow-up occur to see if change has occured (ie. follow-up of triggers)? How do we get physicians to see the worth of the palliative care consult once the nurse identifies the positive screen based on the triggers to give the order, despite multiple MD marketing and educational efforts?
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Re:Triggers (by Judith_Nelson on 06/16/2010)
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.
Re:Triggers (by sjcrump on 06/18/2010)
Response to question re: triggers in ICU.
I would agree with the reply and comments by Dr. Nelson. Our institutional experience is that we continue to educate as to benefits of palliative care and the establishment of a workgroup that includes the ICU physicians is a great start. Sounds like you may want to examine the RN/MD culture of the institution and do a needs assessment as to what the MD’s feel would help them to make the decision for a palliative care consult. Maybe find out what are the barriers and how to address these with their input if you have not already done this. We have a great relationship with our ICU attending and trainees but do not currently use triggers in the ICU setting especially not upon initial admission to the ICU.
Good luck.

Joyce Crump, Program Manager
on behalf of
Rodney Tucker MD, MMM, Associate Professor and Medical Director UAB Inpatient Palliative Care Services
Palliative Care Leadership CentersTM
The University of Alabama at Birmingham

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