Enhancing Palliative Care Integration in the ICU

Topic: Education Strategies

Introduction:

Successful integration of palliative care (PC) in the ICU has been shown to improve the experience of patients and their families, shorten ICU length of stay (LOS), and reduce family’s psychological symptoms after death. The provision of appropriate, high-quality end-of-life care is a national focus, and we designed a quality improvement (QI) initiative to enhance the integration of palliative care at the 20-bed multi-specialty critical care unit at Kaiser Permanente Oakland Medical Center.

Methods:

Using the Plan-Do-Study-Act (PDSA) methodology, we reviewed existing literature and conducted semi-structured interviews with stakeholders including critical care staff, palliative care team members, patients and their families to identify the most valued aspects of PC consultations, barriers to integration of PC in the ICU, criteria on which the decision to consult PC is made, quality measures for PC services, and strategies for integration of PC within an ICU.

Results:

We identified barriers to effective integration of PC into an ICU across several domains. Key clinical barriers included practice variability in terms of timing and rate of consulting PC, variable utilization of evidence-based symptom assessment and prognostic tools, and competing time demands. Process barriers included frequent transitions of critical care physicians, fragmented care across disciplines, and lack of consistently scheduled family meetings. Patients and their families had a poor understanding of health care interventions, prognosis and the role of the PC team. Families of under-represented minority patients experienced lower trust in the healthcare system, a lack of diversity in PC teams, a lack of sensitivity to cultural values, and language barriers.

We addressed barriers with the following specific initiatives

•The ICU History and Physical admission note template was revised to include five specific screening criteria on which a PC consultation should be considered.

•The ICU Progress Note template was revised to facilitate documentation of specific communication milestones, prognostic discussions, and goals of care.

•An ICU welcome packet was developed to introduce PC services and encourage families to feel empowered to meaningfully engage the critical care team regarding questions around their loved one’s medical care and prognosis.

•Simulation training for resident physicians to build foundational communication skills focused on breaking bad news, discussion of prognosis, and medical decision-making.

•Intern orientation training on code status discussion and POLST form completion.

•Weekly meetings between ICU and PC physicians to foster ongoing collaboration and identify patients who would benefit from formal PC consultation.

Conclusion

Research shows successful integration of PC services in an ICU benefits the patients, their families, and the care teams. Initiatives designed to screen appropriate patients for PC consultation, train physicians in communicating with patients and their families, and enhance ongoing collaboration can overcome barriers to PC consultation and positively impact the care of patients in the ICU.

Author

  • Jules Vieaux, MD
  • Resident Physician
  • Kaiser Permanente Oakland Medical Center
  • 3600 Broadway
  • Oakland, CA 94502

Co-authors

  • John Taylor
  • Kevin Nguyen

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