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

Wysham, Nicholas G. MD1,2; Hua, May MD3; Hough, Catherine L. MD, MSc4; Gundel, Stephanie MD4; Docherty, Sharron L. RN, PhD5; Jones, Derek M. MDiv1; Reagan, Owen PhD1; Goucher, Haley MD1; Mcfarlin, Jessica MD6,7; Cox, Christopher E. MD, MPH1,8

doi: 10.1097/CCM.0000000000002099
Online Clinical Investigations

Objective: Addressing the quality gap in 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: Three hundred three nurses, intensivists, and advanced practice providers.

Measurements 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 of them (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.

1Division of Pulmonary and Critical Care Medicine, Department of Medicine, Duke University, Durham, NC.

2Duke Clinical Research Institute, Durham, NC.

3Department of Anesthesia, Columbia University, New York, NY.

4Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Washington, Seattle, WA.

5School of Nursing, Duke University, Durham, NC.

6Division of Neurointensive Care, Department of Neurology, Duke University, Durham, NC.

7Palliative Care Medicine Program, Duke University, Durham, NC.

8Program to Support People and Enhance Recovery, Duke University, Durham, NC.

Drs. Wysham, Hua, Hough, Gundel, Docherty, Jones, Reagan, Goucher, Mcfarlin, and Cox contributed in writing and reviewing the article. Drs. Wysham and Cox contributed in analyses. Drs. Hua, Gundel, Jones, Reagan, and Goucher contributed in obtaining data. All authors approved the article. Dr. Cox is accountable for all aspects of work.

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Dr. Hua received support for article research from the National Institutes of Health (NIH). Her institution received funding from the National Institute on Aging, NIH. She was supported by a Paul B. Beeson Career Development Award K08AG051184 from the National Institute on Aging, NIH, and the American Federation for Aging Research. Dr. Cox received support for article research from the NIH award HL109823 and Duke Institute for Healthcare Innovation. The remaining authors have disclosed that they do not have any potential conflicts of interest.

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