Improving ICU-Based Palliative Care Delivery: A Multicenter, Multidisciplinary Survey of Critical Care Clinician Attitudes and Beliefs

Abstract

Objective-Addressing the quality gap in intensive care unit (ICU)-based palliative care is limited by uncertainty about acceptable models of collaborative specialist and generalist care. Therefore, we characterized the attitudes of physicians and nurses about palliative care delivery in an ICU environment. Design-Mixed-methods study.Setting-Medical and surgical ICUs at three large academic hospitals.Participants-303 nurses, intensivists, and advanced practice providers. Author Manuscript Author ManuscriptAuthor Manuscript Author ManuscriptMeasurements and main results-Clinicians completed written surveys that assessed attitudes about specialist palliative care presence and integration into the ICU setting, as well as acceptability of 23 published palliative care prompts ('triggers') for specialist consultation. Most (n=225, 75%) reported that palliative care consultation was underutilized. Prompting consideration of eligibility for specialist consultation by electronic health record searches for triggers was most preferred (n=123, 41%); only 17 (6%) felt current processes were adequate. The most acceptable specialist triggers were metastatic malignancy, unrealistic goals of care, end of life decision making, and persistent organ failure. Advanced age, length of stay, and duration of life support were the least acceptable. Screening led by either specialists or ICU teams was equally preferred. Central themes derived from qualitative analysis of 65 written responses to open-ended items included concerns about the roles of physicians and nurses, implementation, and impact on ICU team-family relationships.Conclusions-Integration of palliative care specialists in the ICU is broadly acceptable and desired. However, the most commonly used current triggers for prompting specialist consultation were among the least well accepted, while more favorable triggers are difficult to abstract from electronic health record systems. There is also disagreement about the role of ICU nurses in palliative care delivery. These findings provide important guidance to the development of collaborative care models for the ICU setting.

A Quality Project to Optimize Palliative Care Consultations in the Medical Intensive Care Unit

“…Patient records were reviewed to identify triggers for palliative care, as defined in the literature ( Table 1). (Nelson et al, 2013, Wysham et al, 2017 Events such as goals of care discussions by the MICU team, placement of advance directive and palliative care consultation were identified. Patients were followed for a 2-week period or until transfer out of ICU.…”

A Review of the Integrated Model of Care: An Opportunity to Respond to Extensive Palliative Care Needs in Pediatric Intensive Care Units in Under-Resourced Settings

“…According to the consultative model, ICU staff are positioned as gatekeepers to PC access; if they lack training, have negative attitudes or false beliefs about PC, do not understand its applications and potential benefits, or cannot recognize the “triggers” that signal a patient’s PC needs, external PC resources may not be used when indicated and, consequently, PC may not be normalized in a given ICU ( 6 , 7 ). Lynn explains, “The course of care is much more strongly associated with the service supply and habit patterns of the local care system than with the particular preferences or prognoses of the individual patient” ( 8 ).…”

“…Lynn explains, “The course of care is much more strongly associated with the service supply and habit patterns of the local care system than with the particular preferences or prognoses of the individual patient” ( 8 ). If consultative models do not involve the intentional training of ICU staff in holistic care, the personnel’s attitudes, knowledge, and practices may impede the treatment of patients’ PC needs ( 6 , 7 ).…”

“…These findings suggest that education is key to creating an environment receptive to PC. Another study of nurses, intensivists, and advanced practice providers at three large academic hospitals found the “triggers” for initiating PC consultation to be an important barrier: the staff most frequently relied on triggers that resulted in late-stage PC application ( 6 ), which is inconsistent with best-practice recommendations that PC should be applied early and concurrently with disease-directed treatment ( 2 , 22 , 28 ). Again, education is key to implementing evidence-based practices; if ICU staff are expected to bridge the gaps in PC in their units, they must be properly trained to do so.…”

A brief intervention for preparing ICU families to be proxies: A phase I study

“…ICU clinicians commonly report that family members’ incorrectly optimistic expectations for patient recovery is a major challenge to effective communication [ 22 – 25 ]. Effective communication with families is also time-consuming, not consistently taught during critical care training programs[ 26 ], and requires advanced communication skills [ 27 , 28 ].…”