Therese B. Cortez

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.

Hospital-Based Palliative Care Consultation: Effects on Hospital Cost

CONTEXT Palliative care consultation teams in hospitals are becoming increasingly more common. Palliative care improves the quality of hospital care for patients with advanced disease. Less is known about its effects on hospital costs. OBJECTIVE To evaluate the relationship between palliative care consultation and hospital costs in patients with advanced disease. DESIGN, SETTING, AND PATIENTS An observational study of 3321 veterans hospitalized with advanced disease between October 1, 2004 and September 30, 2006. The sample includes 606 (18%) veterans who received palliative care and 2715 (82%) who received usual hospital care. October 1, 2004 and September 30, 2006. MAIN OUTCOME MEASURES We studied the costs and intensive care unit (ICU) use of palliative versus usual care for patients in five Veterans Affairs hospitals over a 2-year period. We used an instrumental variable approach to control for unmeasured characteristics that affect both treatment and outcome. RESULTS The average daily total direct hospital costs were

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

464 a day lower for the 606 patients receiving palliative compared to the 2715 receiving usual care (p < 0.001). Palliative care patients were 43.7 percentage points less likely to be admitted to ICU during the hospitalization than usual care patients (p < 0.001). COMMENTS Palliative care for patients hospitalized with advanced disease results in lower costs of care and less utilization of intensive care compared to similar patients receiving usual care. Selection on unobserved characteristics plays an important role in the determination of costs of care.

Family meetings made simpler: a toolkit for the intensive care unit.

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.

Physician reimbursement for critical care services integrating palliative care for patients who are critically ill.

Although a growing body of evidence has associated the intensive care unit (ICU) family meeting with important, favorable outcomes for critically ill patients, their families, and health care systems, these meetings often fail to occur in a timely, effective, and reliable way. In this article, we describe 3 specific tools that we have developed as prototypes to promote more successful implementation of family meetings in the ICU: (1) a family meeting planner, (2) a meeting guide for families, and (3) a family meeting documentation template. We describe the essential features of these tools and ways that they might be adapted to meet the local needs of individual ICUs and to maximize acceptability and use. We also discuss the role of such tools in structuring a performance improvement initiative. Just as simple tools have helped reduce bloodstream infections, our hope is that the toolkit presented here will help critical care teams to meet the important communication needs of ICU families.

The Use of Toolkits for Palliative Care Quality Improvement: The VA's “Strive for 65 Implementation Package” (SA500)

Patients with advanced illness often spend time in an ICU, while nearly one-third of patients with advanced cancer who receive Medicare die in hospitals, often with failed ICU care. For most, death occurs following the withdrawal or withholding of life-sustaining treatments. The integration of palliative care is essential for high-quality critical care. Although palliative care specialists are becoming increasingly available, intensivists and other physicians are also expected to provide basic palliative care, including symptom treatment and communication about goals of care. Patients who are critically ill are often unable to make decisions about their care. In these situations, physicians must meet with family members or other surrogates to determine appropriate medical treatments. These meetings require clinical expertise to ensure that patient values are explored for medical decision making about therapeutic options, including palliative care. Meetings with families take time. Issues related to the disease process, prognosis, and treatment plan are complex, and decisions about the use or limitation of intensive care therapies have life-or-death implications. Inadequate reimbursement for physician services may be a barrier to the optimal delivery of high-quality palliative care, including effective communication. Appropriate documentation of time spent integrating palliative and critical care for patients who are critically ill can be consistent with the Current Procedural Terminology codes (99291 and 99292) for critical care services. The purpose of this article is to help intensivists and other providers understand the circumstances in which integration of palliative and critical care meets the definition of critical care services for billing purposes.

Patient Rated Weight Loss, Karnofsky Performance Status, and Prognosis: A Recursive Partitioning Algorithm (410-B)

with the highest potential for impact upon the field of hospice and palliative medicine. A hand search of leading journals highly relevant to the practice of hospice and palliative care was supplemented with a search of evidencebased reviews, a targeted keyword search, and conversations with experts in the disciplines of medicine, nursing, and social work. Journal articles were reviewed for both study quality and potential for immediate impact on the field of hospice and palliative care. There was a selection bias against descriptive studies, pilot studies, pre-clinical studies, retrospective studies, open-label trials, case-series, instrument validation studies, and confirmatory analyses.

Training nurses for interdisciplinary communication with families in the intensive care unit: an intervention.

Objectives 1. Recognize that wounds have significant negative impact on a person’s quality of life and wound pain is reported as the most distressing symptom. 2. Discuss the medications that have been studied in clinical trials as topical agents aimed at reducing pain in the wound. 3. Recognize Dermafill Cellulose Wound Care Dressing as a cost-effective treatment option for the management of wound pain in the hospice and palliative care setting. Background. There is growing evidence that wounds have significant negative impact on a person’s quality of life and wound pain is reported as the most distressing symptom. When reviewing evidence-based literature, the focus of the majority of studies is relief of pain during dressing changes as patients report the pain at time of dressing removal as the greatest pain related to the wound. The few studies that focused on overall wound pain reduction in the wound had limited success of pain reduction. Case description. A 67-year-old male admitted to hospice with end-stage cardiac disease presents with a painful leg wound as a result of ‘‘bumping into the coffee table.’’ Patient lives at home with his caregiver-wife. The patient has no known allergies. Patient’s chief complaint is pain and inability to ‘‘do anything because of this darn leg!’’ Patient rates pain at an 8 on the 0-10 scale with the pain escalating to a 10 when manipulated or touched. Patient currently takes oral pain medication without relief from pain. During this presentation, we will review past treatments, potential future treatment options, and conclude by presenting the treatment option we chosedDermafill, which reduced patient’s pain to a 0 on the 0e10 scale without any oral pain medications. Patient was able to walk without pain and reported a significant increase in his quality of life because of this product. Conclusion. The presenter recognizes Dermafill Cellulose Wound Care Dressing as a cost-effective treatment option for the management of wound pain in the hospice and palliative care setting. It is a valuable dressing in the treatment of wound pain. Physicians and nurses can perform weekly assessments without removing the dressing: eliminating the need for frequent and painful dressing changes in our patients.