Renee D. Boss

Models for structuring a clinical initiative to enhance palliative care in the intensive care unit: A report from the IPAL-ICU Project (Improving Palliative Care in the ICU)

Objective:To describe models used in successful clinical initiatives to improve the quality of palliative care in critical care settings. Data Sources:We searched the MEDLINE database from inception to April 2010 for all English language articles using the terms “intensive care,” “critical care,” or “ICU” and “palliative care”; we also hand-searched reference lists and author files. Based on review and synthesis of these data and the experiences of our interdisciplinary expert Advisory Board, we prepared this consensus report. Data Extraction and Synthesis:We critically reviewed the existing data with a focus on models that have been used to structure clinical initiatives to enhance palliative care for critically ill patients in intensive care units and their families. Conclusions:There are two main models for intensive care unit-palliative care integration: 1) the “consultative model,” which focuses on increasing the involvement and effectiveness of palliative care consultants in the care of intensive care unit patients and their families, particularly those patients identified as at highest risk for poor outcomes; and 2) the “integrative model,” which seeks to embed palliative care principles and interventions into daily practice by the intensive care unit team for all patients and families facing critical illness. These models are not mutually exclusive but rather represent the ends of a spectrum of approaches. Choosing an overall approach from among these models should be one of the earliest steps in planning an intensive care unit-palliative care initiative. This process entails a careful and realistic assessment of available resources, attitudes of key stakeholders, structural aspects of intensive care unit care, and patterns of local practice in the intensive care unit and hospital. A well-structured intensive care unit-palliative care initiative can provide important benefits for patients, families, and providers.

Choosing and using screening criteria for palliative care consultation in the ICU: A report from the improving palliative care in the ICU (IPAL-ICU) advisory board

Objective:To review the use of screening criteria (also known as “triggers”) as a mechanism for engaging palliative care consultants to assist with care of critically ill patients and their families in the ICU. Data Sources:We searched the MEDLINE database from inception to December 2012 for all English-language articles using the terms “trigger,” “screen,” “referral,” “tool,” “triage,” “case-finding,” “assessment,” “checklist,” “proactive,” or “consultation,” together with “intensive care” or “critical care” and “palliative care,” “supportive care,” “end-of-life care,” or “ethics.” We also hand-searched reference lists and author files and relevant tools on the Center to Advance Palliative Care website. Study SelectionTwo members (a physician and a nurse with expertise in clinical research, intensive care, and palliative care) of the interdisciplinary Improving Palliative Care in the ICU Project Advisory Board presented studies and tools to the full Board, which made final selections by consensus. Data ExtractionWe critically reviewed the existing data and tools to identify screening criteria for palliative care consultation, to describe methods for selecting, implementing, and evaluating such criteria, and to consider alternative strategies for increasing access of ICU patients and families to high-quality palliative care. Data SynthesisThe Improving Palliative Care in the ICU Advisory Board used data and experience to address key questions relating to: existing screening criteria; optimal methods for selection, implementation, and evaluation of such criteria; and appropriateness of the screening approach for a particular ICU. Conclusions:Use of specific criteria to prompt proactive referral for palliative care consultation seems to help reduce utilization of ICU resources without changing mortality, while increasing involvement of palliative care specialists for critically ill patients and families in need. Existing data and resources can be used in developing such criteria, which should be tailored for a specific ICU, implemented through an organized process involving key stakeholders, and evaluated by appropriate measures. In some settings, other strategies for increasing access to palliative care may be more appropriate.

Integrating Palliative Care in the ICU: The Nurse in a Leading Role.

Palliative care is increasingly recognized as an integral component of comprehensive intensive care for all critically ill patients, regardless of prognosis, and for their families. Here we discuss the key role that nurses can and must continue to play in making this evidence-based paradigm a clinical reality across a broad range of ICUs. We review the contributions of nurses to implementation of ICU safety initiatives as a model that can be applied to ICU palliative care integration. We focus on the importance of nursing involvement in design and application of work processes that facilitate this integration in a systematic way, including processes that ensure the participation of nurses in discussions and decision making with families about care goals. We suggest ways that nurses can help to operationalize an integrated approach to palliative care in the ICU and to define their own essential role in a successful, sustainable ICU palliative care improvement effort. Finally, we identify resources including The IPAL-ICU ProjectTM, a new initiative by the Center to Advance Palliative Care that can assist nurses and other healthcare professionals to move such efforts forward in diverse critical care settings.

Integrating Palliative Care in the Surgical and Trauma Intensive Care Unit: A Report From the Improving Palliative Care in the Intensive Care Unit (IPAL-ICU) Project Advisory Board and the Center to Advance Palliative Care

Objective:Although successful models for palliative care delivery and quality improvement in the intensive care unit have been described, their applicability in surgical intensive care unit settings has not been fully addressed. We undertook to define specific challenges, strategies, and solutions for integration of palliative care in the surgical intensive care unit. Data Sources:We searched the MEDLINE database from inception to May 2011 for all English language articles using the term “surgical palliative care” or the terms “surgical critical care,” “surgical ICU,” “surgeon,” “trauma” or “transplant,” and “palliative care” or “end-of- life care” and hand-searched our personal files for additional articles. Based on review of these articles and the experiences of our interdisciplinary expert Advisory Board, we prepared this report. Data Extraction and Synthesis:We critically reviewed the existing literature on delivery of palliative care in the surgical intensive care unit setting focusing on challenges, strategies, models, and interventions to promote effective integration of palliative care for patients receiving surgical critical care and their families. Conclusions:Characteristics of patients with surgical disease and practices, attitudes, and interactions of different disciplines on the surgical critical care team present distinctive issues for intensive care unit palliative care integration and improvement. Physicians, nurses, and other team members in surgery, critical care and palliative care (if available) should be engaged collaboratively to identify challenges and develop strategies. “Consultative,” “integrative,” and combined models can be used to improve intensive care unit palliative care, although optimal use of trigger criteria for palliative care consultation has not yet been demonstrated. Important components of an improvement effort include attention to efficient work systems and practical tools and to attitudinal factors and “culture” in the unit and institution. Approaches that emphasize delivery of palliative care together with surgical critical care hold promise to better integrate palliative care into the surgical intensive care unit. (Crit Care Med 2012; 40:–1206)

Palliative care in the ICU: relief of pain, dyspnea, and thirst—A report from the IPAL-ICU Advisory Board

AbstractPurposePain, dyspnea, and thirst are three of the most prevalent, intense, and distressing symptoms of intensive care unit (ICU) patients. In this report, the interdisciplinary Advisory Board of the Improving Palliative Care in the ICU (IPAL-ICU) Project brings together expertise in both critical care and palliative care along with current information to address challenges in assessment and management.MethodsWe conducted a comprehensive review of literature focusing on intensive care and palliative care research related to palliation of pain, dyspnea, and thirst.ResultsEvidence-based methods to assess pain are the enlarged 0–10 Numeric Rating Scale (NRS) for ICU patients able to self-report and the Critical Care Pain Observation Tool or Behavior Pain Scale for patients who cannot report symptoms verbally or non-verbally. The Respiratory Distress Observation Scale is the only known behavioral scale for assessment of dyspnea, and thirst is evaluated by patient self-report using an 0–10 NRS. Opioids remain the mainstay for pain management, and all available intravenous opioids, when titrated to similar pain intensity end points, are equally effective. Dyspnea is treated (with or without invasive or noninvasive mechanical ventilation) by optimizing the underlying etiological condition, patient positioning and, sometimes, supplemental oxygen. Several oral interventions are recommended to alleviate thirst. Systematized improvement efforts addressing symptom management and assessment can be implemented in ICUs.ConclusionsRelief of symptom distress is a key component of critical care for all ICU patients, regardless of condition or prognosis. Evidence-based approaches for assessment and treatment together with well-designed work systems can help ensure comfort and related favorable outcomes for the critically ill.

The OHRP and SUPPORT

A group of medical ethicists and pediatricians asks for reconsideration of the recent Office for Human Research Protections decision about informed consent in SUPPORT.

Teaching antenatal counseling skills to neonatal providers

Counseling a family confronted with the birth of a periviable neonate is one of the most difficult tasks that a neonatologist must perform. The neonatologists goal is to facilitate an informed, collaborative decision about whether life-sustaining therapies are in the best interest of this baby. Neonatologists are trained to provide families with a detailed account of the morbidity and mortality data they believe are necessary to facilitate a truly informed decision. Yet these complicated and intensely emotional conversations require advanced communication and counseling skills that our current fellowship-training strategies are not adequately providing. We review educational models for training neonatology fellows to provide antenatal counseling at the threshold of viability. We believe that training aimed at teaching these skills should be incorporated into the neonatal-perinatal medicine fellowship. The optimal approaches for teaching these skills remain uncertain, and there is a need for continued innovation and outcomes-based research.

Neonatal Critical Care Communication (NC3): training NICU physicians and nurse practitioners.

Objective:Communicating with families is a core skill for neonatal clinicians, yet formal communication training rarely occurs. This study examined the impact of an intensive interprofessional communication training for neonatology fellows and nurse practitioners.Study Design:Evidence-based, interactive training for common communication challenges in neonatology incorporated didactic sessions, role-plays and reflective exercises. Participants completed surveys before, after, and one month following the training.Result:Five neonatology fellows and eight nurse practitioners participated (n=13). Before the training, participants overall felt somewhat prepared (2.6 on 5 point Likert-type scale) to engage in core communication challenges; afterwards, participants overall felt very well prepared (4.5 on Likert-type scale) (P<0.05). One month later, participants reported frequently practicing the taught skills and felt quite willing to engage in difficult conversations.Conclusion:An intensive communication training program increased neonatology clinicians’ self-perceived competence to face communication challenges which commonly occur, but for which training is rarely provided.

Integrating Palliative Care into the Care of Neurocritically Ill Patients: A Report from the Improving Palliative Care in the ICU Project Advisory Board and the Center to Advance Palliative Care∗

Objectives:To describe unique features of neurocritical illness that are relevant to provision of high-quality palliative care; to discuss key prognostic aids and their limitations for neurocritical illnesses; to review challenges and strategies for establishing realistic goals of care for patients in the neuro-ICU; and to describe elements of best practice concerning symptom management, limitation of life support, and organ donation for the neurocritically ill. Data Sources:A search of PubMed and MEDLINE was conducted from inception through January 2015 for all English-language articles using the term “palliative care,” “supportive care,” “end-of-life care,” “withdrawal of life-sustaining therapy,” “limitation of life support,” “prognosis,” or “goals of care” together with “neurocritical care,” “neurointensive care,” “neurological,” “stroke,” “subarachnoid hemorrhage,” “intracerebral hemorrhage,” or “brain injury.” Data Extraction and Synthesis:We reviewed the existing literature on delivery of palliative care in the neurointensive care unit setting, focusing on challenges and strategies for establishing realistic and appropriate goals of care, symptom management, organ donation, and other considerations related to use and limitation of life-sustaining therapies for neurocritically ill patients. Based on review of these articles and the experiences of our interdisciplinary/interprofessional expert advisory board, this report was prepared to guide critical care staff, palliative care specialists, and others who practice in this setting. Conclusions:Most neurocritically ill patients and their families face the sudden onset of devastating cognitive and functional changes that challenge clinicians to provide patient-centered palliative care within a complex and often uncertain prognostic environment. Application of palliative care principles concerning symptom relief, goal setting, and family emotional support will provide clinicians a framework to address decision making at a time of crisis that enhances patient/family autonomy and clinician professionalism.

This is a decision you have to make: using simulation to study prenatal counseling.

Introduction Prenatal decision making during extremely preterm labor is challenging for parents and physicians. Ethical and logistical concerns have limited empirical descriptions of physician counseling behaviors in this setting and constricted opportunities for communication training. This pilot study examines how simulation might be used to engage neonatologists in reflecting on their usual prenatal counseling behaviors. Methods Neonatology physicians counseled a couple (standardized patients) with the female patient having impending delivery at 23 3/7 weeks. Encounters were videotaped. Physicians completed postencounter surveys and debriefing interviews. Mixed-methods analysis explored the outcomes of clinical verisimilitude and counseling behaviors. Results All 10 neonatology physicians found that the simulation was highly realistic and that their behaviors paralleled neonatologist self-report in other studies. Physicians contributed more than 80% of encounter dialogue and mostly focused on biomedical information related to the acute perinatal period. Physicians spent nearly a quarter of each encounter in building relationships and expressing empathy. Most physicians initiated discussion about quality versus quantity of life but infrequently elicited the parents’ related goals and values. When medical factors and family preferences were held constant, physicians assumed variable responsibility for making decisions about resuscitation. Most physicians declined parent requests for treatment recommendations, although all of those physicians felt more than 75% certain about what should be done. Conclusions Simulation can reproduce the decisional context of prenatal counseling for extremely premature labor. These results have implications for communication training in any setting where physicians and patients without established relationships must discuss acute diagnoses and make high-stakes medical decisions.