Improving Palliative Care in the ICU

Abstract & Commentary

By Ruth Kleinpell, PhD, RN, Director, Center for Clinical Research and Scholarship, Rush University Medical Center; Professor, Rush University College of Nursing, Chicago, IL, is Associate Editor for Critical Care Alert.

Synopsis: A quality improvement intervention aimed at improving palliative care in the ICU resulted in improvements of nurse-assessed quality of dying and a reduction in ICU length of stay, but no changes in family perceptions of quality of dying or satisfaction with care.

Source: Curtis JR, et al. Integrating palliative and critical care: Evaluation of a quality-improvement intervention. Am J Respir Crit Care Med 2008;178:269-275.

This study reports on the results of a single-hospital study of a quality improvement intervention to improve palliative care in the ICU. An interdisciplinary intervention designed to improve the ability of ICU clinicians to provide palliative care focused on providing clinician education through the use of a teaching video, poster boards, and pamphlets; training of ICU champions on palliative care concepts in a half- or full-day training session; and the use of family satisfaction data to provide feedback to the ICU team. The intervention occurred over a 10-month period. Family members of patients who died in the ICU after a minimum stay of 6 hours before death or within 24 hours of transfer to another hospital location from the ICU were surveyed 4-6 weeks after the patient's death. ICU nurses who cared for the patients were surveyed within 48 hours of the patient's death. Responses from 275 family members revealed no significant improvement in family-assessed quality of dying or satisfaction with care, but responses from 523 nurses demonstrated significant improvements in nurse-assessed quality of dying and a reduction in ICU length of stay through the integration of palliative care in the ICU.

Commentary

Palliative care focuses on symptom management, promoting treatment based on patient and family preferences, and facilitating care for patients with life-threatening illness and their families with a focus on comfort and quality of life.1 Palliative care is increasingly being integrated into the care of patients in the ICU. There is growing recognition that integrating palliative care in the ICU is beneficial for patients with complex symptom management issues or with end-of-life care, as well as for their family members.

A number of national initiatives have focused on improving palliative care in the ICU, including the Center to Advance Palliative Care (www.capc.org), the Robert Wood Johnson Foundation program for promoting palliative care excellence in the ICU (www.promotingexcellence.org), and the American College of Critical Care Medicine,2 among others.

Interventions and strategies for improving palliative care in the ICU have specifically focused on improving communication, promoting family involvement, utilizing interdisciplinary team rounds, creating a supportive ICU culture for end-of-life care, and integrating palliative care consultations in the ICU.2-4

The results of this study show that focused efforts to integrate palliative care through the use of an interdisciplinary intervention designed to improve ICU clinicians' ability to provide palliative and end-of-life care in the ICU were beneficial in decreasing length of stay and in quality of dying ratings by nurses. This study contributes to the body of literature on integrating palliative care in the ICU and indicates that additional focus on providing direct interventions to family members may be needed to improve family perceptions of quality of care. The study did not demonstrate improvements in family perceptions of the quality of dying or in family satisfaction ratings, and it is evident that additional research is indicated to further explore the impact of interventions addressing palliative care on family members.

References

  1. Institute of Medicine, National Research Council Improving Palliative Care. We Can Take Better Care of People with Cancer. Washington, DC: National Academy Press; 2003.
  2. Truog RD, et al. Recommendations for end-of-life care in the intensive care unit: A consensus statement by the American College of Critical Care Medicine. Crit Care Med 2008;36:953-963.
  3. Curtis JR, Rubenfeld GD. Improving palliative care for patients in the intensive care unit. J Palliat Care Med 2005;8:840-854.
  4. Treece PD, et al. Integrating palliative and critical care: Description of an intervention. Crit Care Med 2006;34(11 Suppl):S380-S387.