End-of-Life Care in the ICU

1. End-of-Life Care in the ICU OU Tulsa College of Nursing Natalie Banker Julia Furr Nichole Jones Kelley Wing 2010 *Guidelines (National Guidelines Clearing House) Comparisons for all articles (what have in common?)*Guidelines (National Guidelines Clearing House) Comparisons for all articles (what have in common?)

2. PICO Population Adult dying patients in the ICU Intervention Establish end-of-life policies & palliative care team Comparison No end-of-life policies & palliative care team Outcome Enhance quality of life

3. PICO question In adult dying patients in the intensive care unit, do having end of life policies and palliative care in place enhance the quality of life?

4. Identifying the Problem Evidence of unmet needs and concerns of patients, family members and medical personnel regarding end of life issues in the adult intensive care unit. Medical staff perspective Family perspective Medical Staff: In a national survey, physician and nurse ICU directors expressed concern over ability to give �idea end-of-life care� and they strongly recommended having palliative care in place Family: �Right up until the last time that the doctor called me, I always thought my brother was going to get better and come home�I never thought (he wouldn�t come home) and then the doctor called us� and said, your brother is not doing well�he is not responding to anything�I wasn�t aware until the last day�Discussing the prognosis sooner might have helped me prepare mentally.� Medical Staff: In a national survey, physician and nurse ICU directors expressed concern over ability to give �idea end-of-life care� and they strongly recommended having palliative care in place Family: �Right up until the last time that the doctor called me, I always thought my brother was going to get better and come home�I never thought (he wouldn�t come home) and then the doctor called us� and said, your brother is not doing well�he is not responding to anything�I wasn�t aware until the last day�Discussing the prognosis sooner might have helped me prepare mentally.�

5. Important Statistics 20% of all deaths in the United States occur in the ICU ICU beds have increased by 26% since 1985

6. Current Practice in Intensive Care Units Current Guidelines Communication skills ICU family conference early Interdisciplinary team rounds Availability of palliative care and/or ethics consultation Supportive ICU culture for ethical practice and communication http://www.guideline.gov/summary/summary.aspx?doc_id=12655&nbr=006550&string=end+AND+life+AND+care+AND+ICU Tulsa Hospital Guidelines This is what was found in all articles that supports our PICO question Of 4 major hospitals in Tulsa surveyed, only one had protocols for palliative care in ICUs: comfort measures only and withdrawal of life support and compassionate extubation protocolThis is what was found in all articles that supports our PICO question Of 4 major hospitals in Tulsa surveyed, only one had protocols for palliative care in ICUs: comfort measures only and withdrawal of life support and compassionate extubation protocol

7. Review of Literature Population: 35 patients, their care providers, and 18 healthcare teams Results 8 interrelated themes were found Unmet patient needs Insecure caregivers Difficult clinician communication Recommendation: Earlier implementation of palliative care Fitzsimons, Et al. (2007) 8 themes: Findings were that deteriorating health status led to decreased independence, social isolation and family burden, these were increased by lack of public resources and available support from hospital and community resources. Outcomes: caregivers feeling ill-equipped to provide for the individuals holistic needs. Clinicians stated they felt difficulty talking with patients and their families concerning the palliative nature of their treatment. Rec: �An earlier and more effective implementation of the palliative care approach is necessary if the needs of patients in the final stages of chronic illness are to be adequately addressed.� 8 themes: Findings were that deteriorating health status led to decreased independence, social isolation and family burden, these were increased by lack of public resources and available support from hospital and community resources. Outcomes: caregivers feeling ill-equipped to provide for the individuals holistic needs. Clinicians stated they felt difficulty talking with patients and their families concerning the palliative nature of their treatment. Rec: �An earlier and more effective implementation of the palliative care approach is necessary if the needs of patients in the final stages of chronic illness are to be adequately addressed.�

8. Review of Literature Assessment of Pain and Agitation Population: Control Group 100 patients Intervention Group 130 patients Findings: Chanques et al., (2006) Physicians and residents were educated and given �written support that encouraged them to vigorously assess and treat pain and agitation� Nurses were also trained by the same individual on assessing pain and agitation assessments occurred at rest, 30 min after any procedure, between the hours of 0800-1000, 1400-1600, and 2000-2200 hours. Dr notified promptly of pain or agitation regardless of hour Behavior Pain scale >5, Numerical Rating Scale (pt states pain level) >3, Richmond Agitation Sedation Scale >1 Physicians and residents were educated and given �written support that encouraged them to vigorously assess and treat pain and agitation� Nurses were also trained by the same individual on assessing pain and agitation assessments occurred at rest, 30 min after any procedure, between the hours of 0800-1000, 1400-1600, and 2000-2200 hours. Dr notified promptly of pain or agitation regardless of hour Behavior Pain scale >5, Numerical Rating Scale (pt states pain level) >3, Richmond Agitation Sedation Scale >1

9. Review of Literature Does Palliative Care Improve Quality? Population Families of 149 deceased patients: 54 palliative care patients and 95 usual care patients Results Palliative care family members Religious and spiritual needs were addressed Support for feelings Referral for psychosocial support Usual care family members No emotional or spiritual needs met Gelfman, et al., (2008) The purpose of this study was to assess the impact of palliative care programs on the quality of care received by hospitalized patients and their family members. The study was conducted by interviewing families of individuals who has died in the ICU during a nine month span in 2005 at Mount Sinai Medical Center. 149 interviews were completed with next of kin participants who met the inclusion criteria. The family members of palliative care patients were more likely to report that their religious and spiritual beliefs were addressed, they received support in dealing with their own feelings, and they had received a referral for follow-up psychosocial support. 65% of the family members interviewed with patients who had received usual care reported that no emotional or spiritual needs were met. The purpose of this study was to assess the impact of palliative care programs on the quality of care received by hospitalized patients and their family members. The study was conducted by interviewing families of individuals who has died in the ICU during a nine month span in 2005 at Mount Sinai Medical Center. 149 interviews were completed with next of kin participants who met the inclusion criteria. The family members of palliative care patients were more likely to report that their religious and spiritual beliefs were addressed, they received support in dealing with their own feelings, and they had received a referral for follow-up psychosocial support. 65% of the family members interviewed with patients who had received usual care reported that no emotional or spiritual needs were met.

10. Review of Literature Aspects of palliative care that are most important to patients and families Population- 48 people including patients, family members of patients who survived and died in ICU Finding Communication Patient focused decision making Clinical care of patient: comfort, dignity and personhood Care of the family: access to patient and bereavement care Nelson et al. (2010) Population- 15 pts, 14 family members survivors, 19 family members died Interviewed patients and family members who had ICU stays greater than 5 days from 3 different hospitals one on the East Coast, one on the West coast and one in the center of the United States. (they were trying to get an aspect across the entire United States.) Communication Quote �ICU clinicians are used to abbreviating long words with letters. So you get alphabet soup and go, what�s that? Patient Focused Decision Making Ex: know Advance directive in place immediately when pt arrives in ICU Clinical Care of Patient: Comfort- pain Dignity- cover when performing skills Personhood- pt more than just a number, they are a living human being Care of the family: Access to patient- pts emphasized their awareness of family presence and the comfort and strength they derieved from it Bereavement care- ex: pt�s child decided to withdraw the ventilator and no one approached them to talk about it, they felt like they were in a war zone. 3. �After he died, they just came in there and pronounced him dead, and started covering him up and moving him, and pulling out all these things� So, I just left. I would have appreciated some follow-up or grief support or social work or anything. Because I did not cry over my father. . . . I did not cry at all, until 2 months ago, I finally had myself a good little fit. I did not know that I was so messed up. I wished that I had spoken with someone. Or someone had reached out to me. In some way.� Population- 15 pts, 14 family members survivors, 19 family members died Interviewed patients and family members who had ICU stays greater than 5 days from 3 different hospitals one on the East Coast, one on the West coast and one in the center of the United States. (they were trying to get an aspect across the entire United States.) Communication Quote �ICU clinicians are used to abbreviating long words with letters. So you get alphabet soup and go, what�s that? Patient Focused Decision Making Ex: know Advance directive in place immediately when pt arrives in ICU Clinical Care of Patient: Comfort- pain Dignity- cover when performing skills Personhood- pt more than just a number, they are a living human being Care of the family: Access to patient- pts emphasized their awareness of family presence and the comfort and strength they derieved from it Bereavement care- ex: pt�s child decided to withdraw the ventilator and no one approached them to talk about it, they felt like they were in a war zone. 3. �After he died, they just came in there and pronounced him dead, and started covering him up and moving him, and pulling out all these things� So, I just left. I would have appreciated some follow-up or grief support or social work or anything. Because I did not cry over my father. . . . I did not cry at all, until 2 months ago, I finally had myself a good little fit. I did not know that I was so messed up. I wished that I had spoken with someone. Or someone had reached out to me. In some way.�

11. Review of Literature The �Big Picture� Population: 27 critical care nurses Data Collection: focus groups and interviews. Findings: nurses base communication on bringing attention to the �big picture� for families. Recommendations: nurses can be advocates by implementing 3 communication strategies. Liaschenko et al. (2009) Pop: Nurses were interviewed on communicating with patient and family regarding palliative care and end-of-life issues. Focus groups and interview. Findings: The central finding of this study was that nurses base communication on bringing attention to the �big picture� for families. Unlike physicians who usually just tell of whole body systems, �Intensive care unit nurses understand a large portion of their work as integrating large amounts of often disparate information into the big picture, thus making a meaningful whole of the patient's clinical situation while supporting the family.� Liaschenko (2009) Pop: Nurses were interviewed on communicating with patient and family regarding palliative care and end-of-life issues. Focus groups and interview. Findings: The central finding of this study was that nurses base communication on bringing attention to the �big picture� for families. Unlike physicians who usually just tell of whole body systems, �Intensive care unit nurses understand a large portion of their work as integrating large amounts of often disparate information into the big picture, thus making a meaningful whole of the patient's clinical situation while supporting the family.� Liaschenko (2009)

12. Review of Literature Multidisciplinary Family Meetings Population Families of 29 patients who had been on mechanical ventilation for more than 5 days Results Increased family satisfaction with end-of-life decision making was associated with the multidisciplinary family meetings Delgado, et al. (2009) The purpose of this study was to determine and assess the feasibility of routine proactive multidisciplinary family meetings for those patients at high risk of death and to assess the impact of these meetings on end-of-life decision making. The meetings were convened on all patients who required mechanical ventilation for five or more days, between the months of April and May 2008 in the medical ICU at Thomas Jefferson University Hospital in Philadelphia. All meetings began with an inquiry addressed to the patient�s family to determine if they understood the patient�s diagnosis, prognosis, and goals of care. The meetings were held in the ICU conference room and potential participants included the critical care attending physician, fellow and residents, the ICU nurse, clinical nurse specialist, members of the palliative care team, other consulting physicians, social worker, and pastoral care provider. A structured multidisciplinary team and family conference form, derived from palliative care literature, was completed during each meetings. Meetings were held every 3 days thereafter or earlier if requested by the family until a consensus was achieved and a definitive treatment plan was formulated. Upon completion of this pilot study there were never any negative feedback from either the patient�s family or members of the care team. The families indicated that the meetings helped them better understand their relatives medical condition and allowed them to arrive at a meaningful treatment plan with little family conflict. **Stated a little more eloquently: The meetings actually saved the hospital and the families money: 52% of the patients had life support withdrew and died after the first meeting because the families were able to speak with the medical team and understand their loved ones diagnosis and prognosis. The purpose of this study was to determine and assess the feasibility of routine proactive multidisciplinary family meetings for those patients at high risk of death and to assess the impact of these meetings on end-of-life decision making. The meetings were convened on all patients who required mechanical ventilation for five or more days, between the months of April and May 2008 in the medical ICU at Thomas Jefferson University Hospital in Philadelphia. All meetings began with an inquiry addressed to the patient�s family to determine if they understood the patient�s diagnosis, prognosis, and goals of care. The meetings were held in the ICU conference room and potential participants included the critical care attending physician, fellow and residents, the ICU nurse, clinical nurse specialist, members of the palliative care team, other consulting physicians, social worker, and pastoral care provider. A structured multidisciplinary team and family conference form, derived from palliative care literature, was completed during each meetings. Meetings were held every 3 days thereafter or earlier if requested by the family until a consensus was achieved and a definitive treatment plan was formulated. Upon completion of this pilot study there were never any negative feedback from either the patient�s family or members of the care team. The families indicated that the meetings helped them better understand their relatives medical condition and allowed them to arrive at a meaningful treatment plan with little family conflict. **Stated a little more eloquently: The meetings actually saved the hospital and the families money: 52% of the patients had life support withdrew and died after the first meeting because the families were able to speak with the medical team and understand their loved ones diagnosis and prognosis.

13. Review of Literature End-of-life care for the critically ill: A national intensive care unit survey. Mailed survey: 600 ICUs; 10% of U.S. ICUs Participation: 468 ICUs (78%), 590 ICU directors Issues identified: - Barriers to end-of-life care - Perceived benefit of strategies to improve care - Availability of strategies Nelson et al. (2006) The objective of this study was to elicit views and experiences of ICU directors (both nurse and physician directors) regarding barriers to optimal end-of-life care. This study is unique in that it is the first survey of ICU directors in the United States about end-of-life care, and the first study of both nurses� and physicians perceptions of barriers to, and solutions for, best practice. The authors mailed surveys to 600 ICUs in the United States, which is approximately 10% of all U.S. ICUs. Of the 600 ICUs that were mailed surveys, 468 ICUs participated, which included 590 ICU directors. Important barriers to better end-of-life care identified by those surveyed included: patient/family factors, clinician factors, and institution factors 1) Patient/Family factors identified were: - unrealistic patient/family expectations - inability of patients to participate in discussions - (and) lack of advance directives 2) Clinician factors identified were: - insufficient physician training in communication - competing demands on physician�s time 3) Institution factors identified were: - suboptimal space for family meetings - lack of a palliative care service Potential solutions to these problems identified were: - implementing a family bereavement program - regular pastoral care visits - role modeling and close supervision of trainees by clinicians experienced in end-of-life care - training of ICU clinicians in relevant communication skills - training in symptom management - use of formal scales for symptom assessment and documentation - accommodating cultural diversity of clients - (and) promoting continuity of care by care provider Despite the fact that 80% of respondents endorsed the suggested strategies, there was limited availability in the ICUs of these beneficial solutions�. Indicating the need for change!The objective of this study was to elicit views and experiences of ICU directors (both nurse and physician directors) regarding barriers to optimal end-of-life care. This study is unique in that it is the first survey of ICU directors in the United States about end-of-life care, and the first study of both nurses� and physicians perceptions of barriers to, and solutions for, best practice. The authors mailed surveys to 600 ICUs in the United States, which is approximately 10% of all U.S. ICUs. Of the 600 ICUs that were mailed surveys, 468 ICUs participated, which included 590 ICU directors. Important barriers to better end-of-life care identified by those surveyed included: patient/family factors, clinician factors, and institution factors 1) Patient/Family factors identified were: - unrealistic patient/family expectations - inability of patients to participate in discussions - (and) lack of advance directives 2) Clinician factors identified were: - insufficient physician training in communication - competing demands on physician�s time 3) Institution factors identified were: - suboptimal space for family meetings - lack of a palliative care service Potential solutions to these problems identified were: - implementing a family bereavement program - regular pastoral care visits - role modeling and close supervision of trainees by clinicians experienced in end-of-life care - training of ICU clinicians in relevant communication skills - training in symptom management - use of formal scales for symptom assessment and documentation - accommodating cultural diversity of clients - (and) promoting continuity of care by care provider Despite the fact that 80% of respondents endorsed the suggested strategies, there was limited availability in the ICUs of these beneficial solutions�. Indicating the need for change!

14. Review of Literature Using the medical record to evaluate the quality of end-of-life care in the ICU Multicenter study of 10 ICUs in northwest U.S. Chart abstraction & family surveys Objective: Identify chart based markers that could be used as measures for improving the quality of end-of-life care in the ICU. Glavan, et al. (2008) This study of 10 northwest ICUs addresses the difficult issue of measuring quality of care in dying patients in the ICU. It states that the lack of measurable, reproducible quality markers within the medical record remains a major barrier to quality improvement. The objective was to identify chart-based markers that could be used as measures for improving the quality of end-of-life care. This multicenter study utilized chart abstraction and surveyed family members of 356 patients who died in an ICU or within 24 hours within being transferred from the ICU using a 22-item assessment survey (Quality of Dying and Death) and a single item QODD question. In all, 442 family members of 1,186 eligible family members participated which is a 41.2% participation rate. This study identified chart-based variables associated with higher QODD scores. Higher scores indicated a positive correlation with enhanced end-of-life care according to patient families surveyed. Variables abstracted from the medical record that were associated with end-of-life care domains included the following topics: - patient & family, communication (within the team & with patients and families), emotional & practical support for patients/families, symptom management & comfort care, and spiritual support for patient/ families Variables found to be associated with higher family assessments of QODD scores included: - emphasis on discussing end-of-life care preferences with patients before critical illness and documenting their wishes - increased access of family members to patients at the time of death, an important aspect of improving end-of-life care - pain assessment in the last 24 hours of life - the presence of a living will - documentation of discussions of a patient�s wish to withdraw life support during a family conference - presence of a family member at the time of death - withdrawal of a tube feeding for the purpose of withdrawing life support Variables found to be associated with lower family assessments of QODD scores included: - CPR in the last hour of life - patient death in the setting of full support From this study, we can clearly see that these chart-based variables may serve as potential targets for measuring and improving the quality of end-of-life care in the ICU and may have potential as chart-based �quality markers for end-of-life care in the ICU.�This study of 10 northwest ICUs addresses the difficult issue of measuring quality of care in dying patients in the ICU. It states that the lack of measurable, reproducible quality markers within the medical record remains a major barrier to quality improvement. The objective was to identify chart-based markers that could be used as measures for improving the quality of end-of-life care. This multicenter study utilized chart abstraction and surveyed family members of 356 patients who died in an ICU or within 24 hours within being transferred from the ICU using a 22-item assessment survey (Quality of Dying and Death) and a single item QODD question. In all, 442 family members of 1,186 eligible family members participated which is a 41.2% participation rate. This study identified chart-based variables associated with higher QODD scores. Higher scores indicated a positive correlation with enhanced end-of-life care according to patient families surveyed. Variables abstracted from the medical record that were associated with end-of-life care domains included the following topics: - patient & family, communication (within the team & with patients and families), emotional & practical support for patients/families, symptom management & comfort care, and spiritual support for patient/ families Variables found to be associated with higher family assessments of QODD scores included: - emphasis on discussing end-of-life care preferences with patients before critical illness and documenting their wishes - increased access of family members to patients at the time of death, an important aspect of improving end-of-life care - pain assessment in the last 24 hours of life - the presence of a living will - documentation of discussions of a patient�s wish to withdraw life support during a family conference - presence of a family member at the time of death - withdrawal of a tube feeding for the purpose of withdrawing life support Variables found to be associated with lower family assessments of QODD scores included: - CPR in the last hour of life - patient death in the setting of full support From this study, we can clearly see that these chart-based variables may serve as potential targets for measuring and improving the quality of end-of-life care in the ICU and may have potential as chart-based �quality markers for end-of-life care in the ICU.�

15. Summary of Findings Palliative Care and End-of-life care policies enhances the quality of life by: Improving communication Meet patient and family needs Symptom management Families making informed decisions Providing support for families and patients

16. What Are The PROs To Solving This Problem? Low cost to implement training program Enhanced quality of life Patient and family satisfaction Improved communication Decrease negative symptoms Reduce costs of medical treatment Increased holistic care Reduce costs of medical txt: Family understands illness and understands pulling the plug Low cost: $10,000 to train nurses and clinicians. ELNEC (End of life nursing education consortium) and EPERC (End of life/palliative education resource center) for doctors. Even though sounds like lots of money, this is less than the cost they will loose if not have palliative care in place Increased Holistic Care: Looks at person and family as a whole. reflects positively on the institution itselfReduce costs of medical txt: Family understands illness and understands pulling the plug Low cost: $10,000 to train nurses and clinicians. ELNEC (End of life nursing education consortium) and EPERC (End of life/palliative education resource center) for doctors. Even though sounds like lots of money, this is less than the cost they will loose if not have palliative care in place Increased Holistic Care: Looks at person and family as a whole. reflects positively on the institution itself

17. What Are The CONs To Solving This Problem? Costs for end-of-life training program Scheduling conflict Costs money to implement palliative care teams Resistance to change

18. Recommended Interventions Orchestrating, interpreting and acting on information for families Building trusting relationships with families Cultural influence on end-of-life care (Liaschenko et al., 2009) Implement systematic evaluation of pain and agitation levels with training done by one individual or a designated training team. (Chanques et al., 2006) (1) Orchestrating, interpreting, and acting on information for families�* Assess the family's understanding of what is happening with their family member.�* Provide an honest view of patient's status and prognosis.�* Orchestrate end-of-life care that honors the patient and family's desires.�* Interpret and explain medical information in understandable language.�* Provide information in increments to facilitate comprehension.�* Act as an advocate for the patient and family in a manner that is consistent with the needs and values of the family.�(2) Building trusting relationships with families�* Take time to learn the patient and family story through active listening.�* Engage in open discussion with the family to discover the patient and family's values, preferences, and goals of care.�(3) Cultural influence on end-of-life care�* Take into consideration the unit culture when providing end-of-life care.�* Advocate for privacy and space for the patient and family.�* Manipulate the environment in a way that is in line with federal and hospital healthcare regulations yet is sensitive to the patient and family's needs at end of life.�* Create a culture of knowledgeable nurses in palliative and end-of-life care through participation in educational activities and certification.(1) Orchestrating, interpreting, and acting on information for families�* Assess the family's understanding of what is happening with their family member.�* Provide an honest view of patient's status and prognosis.�* Orchestrate end-of-life care that honors the patient and family's desires.�* Interpret and explain medical information in understandable language.�* Provide information in increments to facilitate comprehension.�* Act as an advocate for the patient and family in a manner that is consistent with the needs and values of the family.�(2) Building trusting relationships with families�* Take time to learn the patient and family story through active listening.�* Engage in open discussion with the family to discover the patient and family's values, preferences, and goals of care.�(3) Cultural influence on end-of-life care�* Take into consideration the unit culture when providing end-of-life care.�* Advocate for privacy and space for the patient and family.�* Manipulate the environment in a way that is in line with federal and hospital healthcare regulations yet is sensitive to the patient and family's needs at end of life.�* Create a culture of knowledgeable nurses in palliative and end-of-life care through participation in educational activities and certification.

19. Recommended Interventions Implement chart based markers within the assessment (Glavan et al., 2008) Provide broader availability of bereavement services Schedule staff to promote continuity of care Offer mechanisms for providing emotional support to staff (Nelson et al.,2006) Patients of family members who are dying to meet with all members of the interdisciplinary team, preferably no fewer than every three days during hospitalization or sooner if requested by family. (Delgado et al., 2009)

20. Student Recommendations Multidisciplinary family meetings Knowledge of professionals in palliative care Bereavement follow-up Family centered care

21. Evaluation Family satisfaction surveys - Six week follow-up Physician & nurse surveys Chart reviews using predetermined chart-based markers� Chart based markers: using predetermined chart based markers Family Satisfaction Surveys: Six Week Follow Up Interview after patient has passed away Retrospective studies: to evaluate the change implemented Physician and nurse survey: ask if feel well prepared to give EOL care since implemented Palliative Care TeamChart based markers: using predetermined chart based markers Family Satisfaction Surveys: Six Week Follow Up Interview after patient has passed away Retrospective studies: to evaluate the change implemented Physician and nurse survey: ask if feel well prepared to give EOL care since implemented Palliative Care Team

22. Suggestions for Further Study Conduct nationwide research to cover more and varying populations of adults in ICUs Identify components of palliative care that most enhance patient quality of life. Determine patient�s points of view on how palliative care is helping them Gaining perspective on patient preferences when first admitted 3. Most information is gained from families and not directly from the patient�s 4. Involve patients more in their care while they are still living 3. Most information is gained from families and not directly from the patient�s 4. Involve patients more in their care while they are still living

23. �At the end of life, what often matters most to a person who is dying is simply being� taking time to hold a hand, give support and just be.� Angela Morrow, RN

24. References Chanques, G. et al. (2006). Impact of systematic evaluation of pain and agitation in an intensive care unit. Critical Care Medicine, 34(6), 1691-1699. Delgado, E.M., Callahan, A., Paganelli, G., Reville, B., Parks, S., & Marik, P. (2009). Multidisciplinary family meetings in the ICU facilitate end-of-life decision making. American Journal of Hospice & Palliative Medicine, 26(4), 295-302. Fitzsimons, D. (2007). The challenge of patients� unmet palliative care needs in the final stages of chronic illness. Palliative Medicine, 21, 313-322. Gelfman, L., Meier, D., & Morrison, R. (2008). Does palliative care improve quality? A survey of bereaved family members. Journal of Pain & Symptom Management, 36(1), 22-28.

25. References Glavan, B.J., Engelberg, R.A., Downey, L., Curtis, J.R. (2008). Using the medical record to evaluate the quality of end-of-life care in the intensive care unit. Critical Care Medicine 36 (4), 1138-1146. Liaschenko, J., O�Connor-Von, S., & Peden-McAlpine, C. (2009). The �big picture�: communicating with families about end-of-life care in intensive care unit. Dimensions of Critical Care Nursing, 28(5), 224-231. Matzo, M.L., & Sherman, D.W. (2006). Palliative care nursing. New York, NY: Springer Publishing Company. Nelson, J. et al. (2010). In their own words: patients and families define high-quality palliative care in the intensive care unit. Critical Care Medicine, 38(3), 1-11. Nelson, J.E., Angus, D.C., Weissfeld, L.A., Puntillo, K.A., Danis, M., Deal, D., Levy, M.M., & Cook, D.J. (2006). End-of-life care for the critically ill: a national intensive care unit survey. Critical Care Medicine 34 (10), 2547-2553.