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Choosing and Using Screening Criteria for Palliative Care Consultation in the ICU: A Report From the Improving Palliative Care in the ICU (IPAL-ICU) Advisory Board*

Nelson, Judith E. MD, JD1; Curtis, J. Randall MD, MPH2; Mulkerin, Colleen MSW, LCSW3; Campbell, Margaret PhD, RN, FAAN4; Lustbader, Dana R. MD, FCCM, FCCP5; Mosenthal, Anne C. MD, FACS6; Puntillo, Kathleen RN, PhD, FAAN7; Ray, Daniel E. MD, MS, FCCP8; Bassett, Rick MSN, RN9; Boss, Renee D. MD10; Brasel, Karen J. MD, MPH11; Frontera, Jennifer A. MD12; Hays, Ross M. MD13; Weissman, David E. MD, FACP14

doi: 10.1097/CCM.0b013e31828cf12c
Clinical Investigations

Objective: To review the use of screening criteria (also known as “triggers”) as a mechanism for engaging palliative care consultants to assist with care of critically ill patients and their families in the ICU.

Data Sources: We searched the MEDLINE database from inception to December 2012 for all English-language articles using the terms “trigger,” “screen,” “referral,” “tool,” “triage,” “case-finding,” “assessment,” “checklist,” “proactive,” or “consultation,” together with “intensive care” or “critical care” and “palliative care,” “supportive care,” “end-of-life care,” or “ethics.” We also hand-searched reference lists and author files and relevant tools on the Center to Advance Palliative Care website.

Study Selection Two members (a physician and a nurse with expertise in clinical research, intensive care, and palliative care) of the interdisciplinary Improving Palliative Care in the ICU Project Advisory Board presented studies and tools to the full Board, which made final selections by consensus.

Data Extraction We critically reviewed the existing data and tools to identify screening criteria for palliative care consultation, to describe methods for selecting, implementing, and evaluating such criteria, and to consider alternative strategies for increasing access of ICU patients and families to high-quality palliative care.

Data Synthesis The Improving Palliative Care in the ICU Advisory Board used data and experience to address key questions relating to: existing screening criteria; optimal methods for selection, implementation, and evaluation of such criteria; and appropriateness of the screening approach for a particular ICU.

Conclusions: Use of specific criteria to prompt proactive referral for palliative care consultation seems to help reduce utilization of ICU resources without changing mortality, while increasing involvement of palliative care specialists for critically ill patients and families in need. Existing data and resources can be used in developing such criteria, which should be tailored for a specific ICU, implemented through an organized process involving key stakeholders, and evaluated by appropriate measures. In some settings, other strategies for increasing access to palliative care may be more appropriate.

1Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY.

2Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Washington School of Medicine, Seattle, WA.

3Hartford Hospital, Hartford, CT.

4Center for Health Research, College of Nursing, Wayne State University, Detroit, MI.

5Section of Palliative Care, North Shore-Long Island Jewish Health System, Manhasset, NY.

6Department of Surgery, New Jersey Medical School–University of Medicine and Dentistry of New Jersey, Newark, NJ.

7Department of Physiological Nursing, University of California, San Francisco, CA.

8Lehigh Valley Health Network, Allentown, PA.

9Boise, Meridian, & Mountain States Tumor Institute, St. Luke’s Hospital, Boise, ID.

10Division of Neonatology, Department of Pediatrics, Johns Hopkins Hospital, Baltimore, MD.

11Departments of Surgery and Health Policy, Medical College of Wisconsin, Milwaukee, WI.

12Cerebrovascular Center, Cleveland Clinic, Cleveland, OH.

13Departments of Rehabilitation Medicine, Pediatrics and Bioethics & Humanities, University of Washington School of Medicine, Seattle, WA.

14Center to Advance Palliative Care, Icahn School of Medicine at Mount Sinai, New York, NY.

* See also p. 2443.

The IPAL-ICU Project is based at Mount Sinai School of Medicine.

Supported, in part, by the Center to Advance Palliative Care.

Dr. Nelson received funding from the National Institutes of Health (NIH) and received grant support and the K07 Academic Career Leadership Award AG034234 from the National Institute of Aging. Dr. Curtis received grant support from the NIH and Patient-Centered Outcomes Research Institute. Dr. Campbell consulted for an NIH-funded research study (Banzett et al), received grant support from Blue Cross Blue Shield of MI foundation and the National Institute of Nursing Research, and received royalties from McGraw Hill and Wiley. Dr. Lustbader served as a board member of ABIM, provided expert testimony for MLMIC, and received grant support from the Department of Health ECRIP. Dr. Puntillo received grant support from NIH- NINR (RO1 - Dr. Puntillo’s institution receives indirects from this grant), royalties from Oxford University Press ( co-editor of "End of Life Care in ICU") and Elsevier (co-editor of "Critical Care Nursing Secret E2") , and support for travel for the 2012 European Society of Intensive Care Medicine meeting in Lisbon, Portugal (served as speaker). Dr. Bassett consulted for the VHA Critical Care Innovation Network. Dr. Weissman consulted for the Center for Advanced Palliative Care. The remaining authors have disclosed that they do not have any potential conflicts of interest.

Address requests for reprints to: Judith E. Nelson, MD, JD, Division of Pulmonary, Critical Care and Sleep Medicine, Mount Sinai School of Medicine, 1 Gustave L. Levy Place, Box 1232, New York, NY 10029. E-mail:

© 2013 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins