Enhancing End of Life Care in the ICU
CCCF ePoster library. Houston G. Oct 26, 2015; 117310; P19 Disclosure(s): Health Force Ontario Late Career Initiative
Grace Houston
Grace Houston
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Abstract
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P19


Topic: Quality Assurance/Quality Improvement Project


Enhancing End of Life Care in the ICU



Grace Houston, E. Hajdini, L. Kinsella, J. Barthel, K. Cosby, A. Shelley, P. Durepos, D. Anstee, S. DiSabatino

Critical Care, Hamilton Health Sciences, Hamilton, Canada | Critical Care, Hamilton Health Sciences, Hamilton, Canada | Critical Care, Hamilton Health Sciences, Hamilton, Canada | Critical Care, Hamilton Health Sciences, Hamilton, Canada | Critical Care, Hamilton Health Sciences, Hamilton, Canada | Critical Care, Hamilton Health Sciences, Hamilton, Canada | Critical Care, Hamilton Health Sciences, Hamilton, Canada | Critical Care, Hamilton Health Sciences, Hamilton, Canada | Hamilton, Hamilton Health Sciences, Hamilton, Canada

Introduction:

Patient care delivery in the Intensive Care Unit (ICU) consists of life sustaining care in a holistic manner (1). However due to the focus on curative approaches in this setting, practitioners often engage in the initiation of End-of-Life (EOL) care too late in the course of treatment (2, 4). This deferred EOL plan often fails to account for the patient’s advance care planning goals (3). The variation of EOL clinical practice amongst ICU physicians and the rapid transition in care focus toward palliation often increases emotional strain for both families and staff (3).



Objectives:

The ICU team embarked on an improvement initiative aimed at applying best practices for EOL care of critically ill patients in a Level 1 regional trauma centre. The goal was to improve the quality of patient care by delivering an integrative EOL care approach.



Methods:

The ICU Palliative Care Committee consists of front line staff, allied health personnel, managers, educators, and physicians who reviewed literature and best practice EOL care standards in other centers. A qualitative study was designed to explore the perspectives of the interdisciplinary ICU staff related to communication, continuity of care, decision making, symptom management, resources and emotional support.

A questionnaire was developed and used to anonymously survey participants using 26 questions. The survey was distributed to the ICU team and achieved a response from 110 people. This response rate was approximately 50%. The data was analyzed and several key themes emerged.



Results:

Four major themes emerged: 1) improve EOL care for ICU patients and families by initiating early discussion towards palliation using communication tools; 2) enhance the quality of patient care by implementing standardized EOL protocols and orders; 3) strengthen staff education and provision of available resources; 4) provide added support to patients and families.



Conclusion:

The ICU Palliative Care Committee questionnaire provided a framework to transform EOL care in the trauma ICU. Recommendations for improvement were based on the themes from the responses, several which have been initiated. Early EOL discussion during patient rounding amongst the interdisciplinary staff has been adopted through a developed communication tool. The tool provides a structure which guides EOL best practice concerns. Another key communication strategy was the implementation of a visible mounted sign set outside of a patient room, which alerts staff to regard the environment as an EOL situation. This alert enhances dignity of the patient and their family in a discreet manner. A standardized EOL order set has been developed, which addresses symptom management and de-escalation of invasive procedures. Staff support and provision of resources have improved through education initiatives and a family care cart. Plans for a dedicated EOL room in the ICU are underway.



References:

1) Cook D, Rocker G. Dying with Dignity in the Intensive Care Unit. N Eng J Med. 2014; 370(26) 2) Daly D, Chavez Matel S. Building a Transdisciplinary Approach to Palliative Care in an Acute Care Setting. Omega. 2013;67(1-2): 43-51 3) Hartjes TM, Meece L, Horgas A. Implementing palliative care in the ICU. Nurs Crit Care. 2014;9(4) 4) Ho AL, Engelberg RA, Curtis JR, et al. Comparing clinician ratings of the quality of palliative care in the intensive care unit. Crit Care Med. 2011;39(5):1-9 5) Mosenthal AC, Weissman DE, Curtis JR, et al. Integrating palliative care In the surgical and trauma intensive care unit: A report from the Improving Palliative Care in the Intensive Care Unit (IPAL-ICU) Project Advisory Board and the Center to Advance Palliative Care. Crit Care Med. 2012;40(4):1199-1206 6) Nelson JE, Bassett R, Boss RD, et al. Models for structuring a clinical initiative to enhance palliative care in the intensive care unit: A report from the IPAL-ICU Project. Crit Care Med. 2010;38(9): 1761-1771 7) Nevidjon BM, Mayer, DK. Death Is Not an Option, How You Die Is: Reflections From a Career in Oncology Nursing. Nurs Econ. 2012.30(3): 148-152 8) Norton SA, Hogan LA, Holloway RG, et al. Proactive palliative care in the medical intensive care unit: Effects on length of stay for selected high-risk patients. Crit Care Med. 2007;35(6):1530-1535 9) Penrod JD, Pronovost PJ, Livote EE, et al. Meeting standards of high-quality intensive care unit palliative care: Clinical Performance and Predictors. Crit Care Med. 2012; 40(4):1105-1111 10) Popejoy LL, Brandt LC, Beck M et al. Intensive Care Unit Nurse Perceptions of Caring for the Dying: Every Voice Matters. J Hosp Palliat Nurs. 2009;11( 3): 179-185 11) Puntillo, KA, Nelson JA, Cortez TB, et al. Integrating Palliative Care in the ICU: The Nurse in a Leading Role. J Hosp Palliat Nurs. 2011;13(2): 89-94. 12) Weissman DE, Meier DE. Identifying Patients in Need of a Palliative Care Assessment in the Hospital Setting: A Consensus Report from the Center to Advance Palliative Care. J Pal Med. 2011;14(1):1-4.

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