Palliative Care Integration in the ICU

Colleen Tallen M.D.

tallencc@mercyhealth.com

September 26, 2013

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

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

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

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

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

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

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?

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

Mercy Health Saint Mary’s (MHSM) ICU Experience

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

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

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

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

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

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