Networking Lunch: Integrating Palliative and Critical Care

1. Networking Lunch: Integrating Palliative and Critical Care Kenneth P. Steinberg, MD Associate Professor of Medicine Medical Director, Medical Intensive Care Unit Associate Medical Director, Critical Care Services Harborview Medical Center University of Washington Seattle, WA

2. Networking Lunch: Agenda • Time allotted: 90 minutes • Background talk: 10 minutes • Introductions: 15 minutes • Table discussions: 40 minutes • Group presentations: 20 minutes

3. HMC VAMC UWMC FHCRC Integrating Palliative andCritical Care (IPACC) J. Randall Curtis, MD, MPH Patsy D. Treece, RN, MN Theresa Braungardt, RN Darrell Owens, RN, PhD Kenneth P. Steinberg, MD Harborview Medical Center University of Washington Seattle, WA

4. Critical Care • Critical care is the sophisticated, state-of-the-art and technologically-oriented medical and nursing care provided to patients facing life-threatening illness or injury with the goal of reversing illness or injury and restoring health

5. Palliative Care • Interdisciplinary care for persons with life-threatening illness or injury which addresses physical, emotional, social and spiritual needs and seeks to improve quality of life for the ill person and his or her family

6. Dichotomous Care: Curative versus Palliative Curative / life-prolonging therapy Presentation Death Palliative care

7. Why is Palliative Care an Important Part of ICU Care? • 20% of all Americans die in an ICU • 10-20% of ICU patients will die • 70 - 90% of ICU deaths occur in the context of withholding or withdrawing life support • Most ICU patients are at risk of dying • Many ICU patients - • Live with significant reduction in quality of life after the ICU • Return to the ICU Angus, Crit Care Med, 2004; 32:638; SUPPORT, JAMA 1996;274:1591

8. What is ICU Palliative Care? • Palliative care in the ICU is NOT just - • Withdrawing life support • Comfort care • Palliative care in the ICU also includes • Decision-making about the goals of care • Communication with families • Pain and symptom control • Cultural competency

9. Integrated Therapies: Curative AND Palliative Curative / life-prolonging therapy Presentation Death Palliative care

10. Objectives of IPACC • Evaluate effectiveness of a multi-faceted, inter-disciplinary, nurse-focused intervention to improve palliative care for all ICU patients and their families • Examine the variability and predictors of quality of ICU palliative care • Identify successful components of the intervention and describe institutional and clinician facilitators and barriers

11. The “Real” Intervention • Teach basic palliative care skills and the language of palliative care • Encourage ICU clinicians to prioritize palliative care • Empower ICU clinicians to act on behalf of patients and families • Shift the culture of the ICU • “Make the right thing to do the easy thing to do”

12. The 5-Component Intervention • Clinician education in palliative care • Local clinician champions to provide role modeling and promote attitudinal change • Academic detailing of ICU directors to address local barriers • Feedback of quality improvement data • “Systems supports” • Computer physician order entry protocols • Staff support programs • Patient care coordinators

13. Challenges Encountered • Intervention described a structure • Depended on having material to teach • ELNEC of limited value to our ICU nurses • Need to develop educational materials for ICU clinicians and local champions • Lecture and small group exercises • Clinician pamphlets & posters • Training of local champions

14. Successes Achieved • ICU liaison program • Withdrawal of life sustaining therapy order form • Local champion training sessions • Weekly palliative care rounds for housestaff in the MICU • Get-To-Know-Me posters (MGH, Boston) • Baseline data completed • New Palliative Care Consult service

15. Challenges Remaining • Where do I start? • Engaging the local champions • DNAR order form revision • Post-intervention data capture • Will we actually succeed • Will we be able to show it if we do? • Sustainability • Changing the culture • Generalizability

16. Networking Lunch: Questions • What priorities of or conditions within your hospital, institution, or community create an opportunity for expanding palliative care into the ICU now? • Please identify 1-2 ideas that were most unusual or intriguing to report out to the full group • What specific strategies for program design have your used or might you use to overcome local barriers or challenges? • Please develop a list of 2 ideas to report out to the full group

17. Be the change you hope to see in the world. Gandhi

19. 1. Clinician Education: Content • Decision-making about ICU palliative care • Communication skills • Symptom management • Withdrawal of life support • Spiritual care and bereavement support • Cross-cultural awareness/accommodation

20. 1. Clinician Education: Setting • Interdisciplinary • Lectures: Grand rounds, Ethics forum • Weekly Palliative Care Rounds • “Death Rounds” • Nurse-focused • Unit-based education by RN Educator • Palliative Care Core

21. 2. Local Champions • Nurse, physician, respiratory therapy, social work champions in each ICU • Training in palliative care • Palliative care retreat • Ongoing meetings • Implement intervention and facilitate evaluation • Role model and resource person

22. 3. Academic Detailing • In-depth interviews with RN, MD, RT, SW managers • Identify ICU-specific barriers to quality palliative care • Develop and implement solutions to barriers

23. 4. Feedback of QI Data • ICU-specific data compared to other units • Pain ratings • Family satisfaction • Nursing satisfaction • Quality of dying and death scores

24. 5. System Supports • Computer physician order entry • Pain and sedation protocols • Withdrawal of life support protocol • Physician flags for pain ratings • Staff support programs • “Death Rounds” • Integrate cultural mediators • Family focus groups • Bereavement program • Patient care coordinators