Models for structuring a clinical initiative to enhance palliative care in the intensive care unit: A report from the IPAL-ICU Project (Improving Palliative Care in the ICU)*

Abstract

Objective To describe models used in successful clinical initiatives to improve the quality of palliative care in critical care settings. Data Sources We searched the MEDLINE database from inception to April 2010 for all English language articles using the terms “intensive care,” “critical care,” or “ICU” and “palliative care”; we also hand-searched reference lists and author files. Based on review and synthesis of these data and the experiences of our interdisciplinary expert Advisory Board, we prepared this consensus report. Data Extraction and Synthesis We critically reviewed the existing data with a focus on models that have been used to structure clinical initiatives to enhance palliative care for critically ill patients in intensive care units and their families. Conclusions There are two main models for intensive care unit–palliative care integration: 1) the “consultative model,” which focuses on increasing the involvement and effectiveness of palliative care consultants in the care of intensive care unit patients and their families, particularly those patients identified as at highest risk for poor outcomes; and 2) the “integrative model,” which seeks to embed palliative care principles and interventions into daily practice by the intensive care unit team for all patients and families facing critical illness. These models are not mutually exclusive but rather represent the ends of a spectrum of approaches. Choosing an overall approach from among these models should be one of the earliest steps in planning an intensive care unit–palliative care initiative. This process entails a careful and realistic assessment of available resources, attitudes of key stakeholders, structural aspects of intensive care unit care, and patterns of local practice in the intensive care unit and hospital. A well-structured intensive care unit–palliative care initiative can provide important benefits for patients, families, and providers.

Intervention to Improve Care at Life’s End in Inpatient Settings: The BEACON Trial

“…This may be due to recent patientcentered practice changes in ICU settings, 22,58,59 including permitting longer and more frequent family presence. Transfer to other settings may be advisable in fewer cases, as it may move the patient away from providers who know them well.…”

A Prognostic Model for 6-Month Mortality in Elderly Survivors of Critical Illness

“…While our model requires further refi nement and validation, it ultimately could be used to identify and risk-stratify elderly ICU survivors just prior to hospital discharge for postacute interventions that are rehabilitative (diaphragmatic exercise training to improve ventilator weaning 37 and exercise tolerance 38 ), therapeutic (use of pharmaconutrients 39 and growth hormone secretagogues, such as ghrelin, 40 insulin-like growth factor-1, 41 and myostatin antagonists to decrease and prevent muscle loss 42 ), preventative (screening for colonization and subsequent infection with antimicrobial-resistant organisms 39 ), and palliative. 43 We also chose to study 6-month postdischarge mortality because Medicare defi nes hospice eligibility as characterize the longer-term effect of critical illness on mortality. Future studies should carefully measure frailty, disability, and comorbidity in this population to establish the relationships between these factors and outcomes after hospital discharge and to determine the mechanisms that contribute to these associations.…”

The Impact of Poor Prognostic Patients Admitted to the Intensive Care Unit on Family Member's Emotional Disorders

“…We know that the integration of Palliative Care with standard oncologic care may facility the optimal and appropriate administration of anticancer therapy, especially during the final months of life [11]. Nelson and colleagues show us various benefits of integrating Palliative Care in the ICU, including the increase of family satisfaction and comprehension and the decrease of symptoms of anxiety, depression and post-traumatic stress disorders [12].…”

“…In addition, the earlier integration of Palliative Care with standard cancer care may improve the survival and the quality of life (QOL), and lessen psychological conditions, ICU length of stay, duration of mechanical ventilation and the use of unbeneficial treatments [11][12][13]. In this study, our goals were to evaluate the impact of poor prognosis patients admitted to the ICU on their family members' emotional disorders during ICU and at 3 months follow up.…”