For critically ill patients and their loved ones, high-quality health care includes the provision of excellent palliative care. To achieve this goal, the healthcare system needs to identify, measure, and report specific targets for quality palliative care for critically ill or injured patients. Our objective was to use a consensus process to develop a preliminary set of quality measures to assess palliative care in the critically ill.
We built on earlier and ongoing efforts of the Robert Wood Johnson Foundation Critical Care End-of-Life Peer Workgroup to propose specific measures of the structure and process of palliative care. We used an informal iterative consensus process to identify and refine a set of candidate quality measures. These candidate measures were developed by reviewing previous literature reviews, supplementing the evidence base with recently published systematic reviews and consensus statements, identifying existing indicators and measures, and adapting indicators from related fields for our objective. Among our primary sources, we identified existing measures from the Voluntary Hospital Association's Transformation of the ICU program and a government-sponsored systematic review performed by RAND Health to identify palliative care quality measures for cancer care.
Our consensus group proposes 18 quality measures to assess the quality of palliative care for the critically ill and injured. A total of 14 of the proposed measures assess processes of care at the patient level, and four measures explore structural aspects of critical care delivery. Future research is needed to assess the relationship of these measures to desired health outcomes. Subsequent measure sets should also attempt to include outcome measures, such as patient or surrogate satisfaction, as the field develops the means to rigorously measure such outcomes. The proposed measures are intended to stimulate further discussion, testing, and refinement for quality of care measurement and enhancement.
From the Center for Health Research, Kaiser Permanente Northwest, Portland, OR (RAM); Department of Medicine, Oregon Health and Science University, Portland, OR (RAM); Division of Pulmonary and Critical Care Medicine, Department of Medicine, School of Medicine, University of Washington, Harborview Medical Center, Seattle, WA (JRC); Palliative Care Service, Massachusetts General Hospital, Boston, MA (JAB); Harvard Medical School Center for Palliative Care, Harvard Medical School, Boston, MA (JAB); Yale Law School, Yale University, New Haven, CT (RB); Palliative Care Program, Dartmouth Hitchcock Medical Center, Lebanon, NH (IB); Departments of Anesthesiology and Community and Family Medicine, Dartmouth Medical School, Lebanon, NH (IB); Medical Critical Care Program, Department of Medicine, Lehigh Valley Hospital, Allentown, PA (CF); Division of Trauma and Critical Care, Department of Surgery, New Jersey Medical School, University of Medicine and Dentistry of New Jersey, Newark, NJ (ACM); Professional Practice and Programs, American Association of Critical-Care Nurses (JM); Department of Medicine, Lehigh Valley Hospital, Allentown, PA (DER); Pulmonary Associates, Allentown, PA (DER); Division of Pulmonary and Critical Care Medicine, Department of Medicine, Harborview Medical Center, Seattle, WA (GDR); Department of Family and Preventive Medicine and the Department of Medicine, University of California at San Diego, San Diego, CA (LJS); Division of Pulmonary and Critical Care Medicine, Department of Medicine, Harborview Medical Center, Seattle, WA (PDT); Medical Ethics and Anesthesia (Pediatrics), Division of Critical Care Medicine, Department of Anesthesia, Children's Hospital Boston, Boston, MA (RDT); Division of Medical Ethics, Department of Social Medicine, Harvard Medical School, Boston, MA (RDT); and the Medical Intensive Care Unit, Department of Medicine, Brown University School of Medicine, Rhode Island Hospital, Providence, RI (MML).