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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)*

Nelson, Judith E. MD, JD; Bassett, Rick MSN, RN, ACNS-BC, CC, RN; Boss, Renee D. MD; Brasel, Karen J. MD, MPH; Campbell, Margaret L. PhD, RN, FAAN; Cortez, Therese B. MSN, NP, ACHPN; Curtis, J. Randall MD, MPH; Lustbader, Dana R. MD, FACCM, FCCP; Mulkerin, Colleen MSW, LCSW; Puntillo, Kathleen A. RN, DNSc, FAAN; Ray, Daniel E. MD, MS, FCCP; Weissman, David E. MD

doi: 10.1097/CCM.0b013e3181e8ad23
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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.

From the Department of Medicine (JEN), Division of Pulmonary, Critical Care and Sleep Medicine and Hertzberg Palliative Care Institute, Mount Sinai School of Medicine, New York, NY; Boise, Meridian, & Mountain States Tumor Institute (RB), St Luke's Hospital, Boise, ID; the Division of Neonatology (RDB), Department of Pediatrics, Johns Hopkins Hospital, Baltimore, MD; the Departments of Surgery and Health Policy (KB), Medical College of Wisconsin, Milwaukee, WI; the Center for Health Research (MLC), College of Nursing, Wayne State University, Detroit, MI; the Palliative Care Program (TBC), Department of Veterans Affairs Veterans' Integrated Service Network 3, New York, NY; the Department of Medicine (JRC), Division of Pulmonary and Critical Care Medicine, University of Washington School of Medicine, Seattle, WA; the Section of Palliative Care (DL), North Shore University Hospital, Manhasset, NY; Hartford Hospital (CM), Hartford, CT; the Department of Physiological Nursing (KAP), University of California, San Francisco, San Francisco, CA; Lehigh Valley Health Network (DER), Allentown, PA; and the Center to Advance Palliative Care (DEW), Mount Sinai School of Medicine, New York, NY.

The IPAL-ICU Project is based at Mount Sinai School of Medicine with support from the National Institute on Aging (K07 Academic Career Leadership Award AG034234 to Dr. Nelson) and the Center to Advance Palliative Care.

The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs.

The authors have not disclosed any potential conflicts of interest.

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© 2010 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins