Palliative Care Integration in the ICU

1. Palliative Care Integration in the ICU • Colleen Tallen M.D. • tallencc@mercyhealth.com • September 26, 2013

2. Learning Objectives • Discuss challenges in the ICU setting • Understand key ingredients when initiating Palliative Care into the ICU • Know how to assess the ICU’s model of care • Evaluate how to address the ICU’s concerns about Palliative Care’s involvement • Discuss Mercy Health’s experience in joining the ICU team

3. Challenges in the ICU • Patients living longer with chronic illness present to ICU with significant complexity • Conflicts between families and staff usually boil down to broken communication • Ethics consults and futility policies historically are not practical • Reimbursement changes to discourage futile care

4. Key Ingredients when Initiating Palliative Care in the ICU • Shared vision - administration, ICU staff, Palliative care team, ethics • Unique Palliative Care team components are in place • Understanding of ICU culture and practices

5. Shared Vision • Open mind to embrace change • Healthcare champions in influential positions • Empower staff to participate in real solutions for patient/family/staff conflict • Model change from reactive to proactive • Financial commitment

6. Palliative Care Team Components • Honest evaluation of Palliative Care’s expertise and skill set • Honest assessment of care bias • Evaluate Palliative Care resources • Understand expectations related to Palliative Care’s role in the ICU

7. ICU Model of Care • “Closed” vs. “Open” admitting privileges can be defined several ways • Intensivist only vs generalist model • Physicians from one group practice vs several groups • Physicians hospital employees vs contracted

8. ICU Model of Care • Who writes the orders? • Who meets with patients/families? • Is there variation in care? • Who has accountability for patient outcomes? • How is the care coordinated before and after ICU stay?

9. ICU’s Concerns about Palliative Care Involvement • Palliative care=hospice (and if it really does, when does the Palliative Care team get involved) • Agenda to stop or limit treatments/interventions • Confusing role regarding who discusses what with patients/families • More healthcare persons involved can be worse • Duplication of services ie social worker, spiritual care

10. Mercy Health Saint Mary’s (MHSM) ICU Experience

11. MHSM’s Palliative Care Team’s Philosophy • No agenda to stop treatment/intervention. No agenda to help ICU staff “get it” • Goal to shift from a reactive to anticipatory model of care related to complex decision making • Joins ICU staff NOT replaces or displaces • Value healthcare provider and patient/family diversity of opinions and goals

12. MHSM’s Palliative Care’s ICU Journey • ICU Medical Director desired Palliative Care involvement though no other ICU doctor wanted palliative care in the ICU • ICU docs and staff started noticing cases went smoothly with PC involvement so consults increased • Ethics consults and involvement dropped significantly • Palliative care was getting involved after crisis identified

13. MHSM’s Palliative Care’s ICU Journey • Started meeting with head nurse, SW, spiritual care, ethics everyday to identify patients proactively • Identified triggers for patients at risk for crisis. Became available 24 hours by phone and 7 days a week in person • Established a weekly meeting with ethics, ICU staff, PC staff, administration to discuss all ICU patients and to review past weeks ICU patients • Daily ICU rounds with ICU team with patients identified for PC most times on Day 1 of ICU stay

14. Triggers for PC Involvement • High risk mortality • High chance sustained morbidity (change in functional status or quality of life) • Complicated or long hospital stay expected • Future decision-making likely • Complicated family dynamic

15. MHSM’s Palliative Care’s Philosophy of Care • Acclimating patient/family to ICU culture • Understand family dynamic - culture, religion, life experience, expectations • Help patient/family’s understanding of disease process and prepare for decision making • Understand differing viewpoints from medical specialist • Continuity of care • Symptom management

16. Lessons Learned • We’re not known as the hospice people • Didn’t force the process but let each case speak for itself • Palliative Care kept data that helped show ICU value • Stayed neutral. Did not join into opinion-driven conversations