Palliative Care in the ICU: Spotting and Surmounting the Obstacles. HERTZBERG PALLIATIVE CARE INSTITUTE. Judith Nelson, MD, JD Mount Sinai School of Medicine March 2006. Overview of Presentation. BARRIERS Empirical Evidence Commentary STRATEGIES Palliative Care Consultation
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HERTZBERG PALLIATIVE CARE INSTITUTE
Judith Nelson, MD, JD
Mount Sinai School of Medicine
Typically, more death in ICUs than anywhere else in the hospital
J Intens Care Med 1999; Crit Care Med 2001
www.promotingexcellence.org - Crit Care Peer Workgroup
Why, then, is change so slow and difficult?
Can we accelerate the process?
JE Nelson, DJ Cook, DC Angus, L Weissfeld, M Danis, KA Puntillo, D Deal, M Levy
For the Robert Wood Johnson Foundation Critical Care Peer Workgroup of Promoting Excellence in End-of-Life Care
National ICU Survey Random, National Sample:
% Rating Large/Huge
Barrier to EOL Care
N = 85 pairs of responses from MDs and RNs representing same ICUs:
→ Perspectives of patients and families are essential, though difficult to obtain
→ → Slow Change
“For most patients, two fundamental facts ensure that the transition to death will remain difficult. First is the
widespread and deeply held desire not to be dead.
Second is medicine’s inability to predict the future … to give patients a precise and reliable prognosis…
When death is the alternative, many patients who have only a small amount of hope will pay a high price to continue the struggle.”
Finucane TE. JAMA 1999; 282:1670.
Fewer than 10% of ICU patients can participate in treatment decisions.
Easy to drown in a sea of surrogates, whose levels of anxiety and depression impair their own capacity for decision-making.
-Pochard, CCM 2001; 29:1893
-Pochard, JCC 2005; 20:90
Four demonstration projects:
U Wash, MGH, Lehigh Valley Hosp, UMDNJ
“Each project suggests a cultural change in critical care settings that fuses palliative care into existing practice patterns, and includes educating ICU staff and embedding palliative care practice in daily hospital routines.”
Palliative Care Consultation in the ICU: Foundation
Crossing A Cultural Divide
Morrison et al. Foundation J Palliat Med (12/05).
Studies show improvements in
care quality and costs:
► Better control of pain and other symptoms
► Higher patient and family satisfaction
► Shorter ICU and hospital length of stay
► Savings in ancillary services and pharmacy costs
Campbell. Chest 2003; 123:266-71.
Higginson. J Pain Sympt Manage 2003; 25:150-68.
Finlay. Ann Oncol 2003; 13 Suppl:257-64.
Campbell, Chest 2003; 123:266.
Both diagnostic groups:
↓time from identification of diagnosis to comfort care goals (4-5 days)
↓ ICU and hospital LOS (3-4 days) vs. historical control group
Campbell, Chest 2003; 123:266.
For patients with PC consultation vs. DRG/age-matched controls without:
Morrison RS (unpublished data).
Clarke et al. Crit Care Med 2003; 31:2255-2262.
J Nelson, MD, JD, P Pronovost, MD, PhD,
C Mullerkin, MSW, LCSW, L Adams, MS
TICU Clinical Teams, Measurement Team, Faculty/Staff Colleagues
Interdisciplinary panel of national experts outside TICU:
Day 1 Foundation
(1) Identify decision-maker
(2) Address AD status
(3) Address CPR status
(4) Distribute info leaflet
(5) Assess pain regularly
(6) Manage pain optimally
(7) Offer social work support
(8) Offer spiritual support
(9) Family meetingVHA Palliative Care Bundle
(10) Organizational ICU Assessment: Family meeting room
Process vs outcome measures Foundation
E.g., whether SW offered, not whether accepted or effective; whether meeting occurred, not whether informative or satisfactory
Medical record review vs. direct observation
Practical, relevant, action trigger
Subset of indicators
Avoid undue measurement burden, while relying on strongest available evidence
16 ICUs: Med/Surg (5), Mixed (4), Med (4), Surg (3) 10 hospitals, N = 94
The fastest way to our objectives is to Foundation
observe the speed limits.