IMPORTANCEFamily caregivers of patients with chronic critical illness experience significant psychological distress.OBJECTIVETo determine whether family informational and emotional support meetings led by palliative care clinicians improve family anxiety and depression.DESIGN, SETTING, AND PARTICIPANTSA multicenter randomized clinical trial conducted from October 2010 through November 2014 in 4 medical intensive care units (ICUs). Adult patients (aged ≥21 years) requiring 7 days of mechanical ventilation were randomized and their family surrogate decision makers were enrolled in the study. Observers were blinded to group allocation for the measurement of the primary outcomes.INTERVENTIONSAt least 2 structured family meetings led by palliative care specialists and provision of an informational brochure (intervention) compared with provision of an informational brochure and routine family meetings conducted by ICU teams (control). There were 130 patients with 184 family surrogate decision makers in the intervention group and 126 patients with 181 family surrogate decision makers in the control group.MAIN OUTCOMES AND MEASURESThe primary outcome was Hospital Anxiety and Depression Scale symptom score (HADS; score range, 0 [best] to 42 [worst]; minimal clinically important difference, 1.5) obtained during 3-month follow-up interviews with the surrogate decision makers. Secondary outcomes included posttraumatic stress disorder experienced by the family and measured by the Impact of Events Scale-Revised (IES-R; total score range, 0 [best] to 88 [worst]), discussion of patient preferences, hospital length of stay, and 90-day survival.RESULTSAmong 365 family surrogate decision makers (mean age, 51 years; 71% female), 312 completed the study. At 3 months, there was no significant difference in anxiety and depression symptoms between surrogate decision makers in the intervention group and the control group (adjusted mean HADS score, 12.2 vs 11.4, respectively; between-group difference, 0.8 [95% CI, -0.9 to 2.6]; P = .34). Posttraumatic stress disorder symptoms were higher in the intervention group (adjusted mean IES-R score, 25.9) compared with the control group (adjusted mean IES-R score, 21.3) (between-group difference, 4.60 [95% CI, 0.01 to 9.10]; P = .0495). There was no difference between groups regarding the discussion of patient preferences (intervention, 75%; control, 83%; odds ratio, 0.63 [95% CI, 0.34 to 1.16; P = .14]). The median number of hospital days for patients in the intervention vs the control group (19 days vs 23 days, respectively; between-group difference, -4 days [95% CI, -6 to 3 days]; P = .51) and 90-day survival (hazard ratio, 0.95 [95% CI, 0.65 to 1.38], P = .96) were not significantly different.CONCLUSIONS AND RELEVANCEAmong families of patients with chronic critical illness, the use of palliative care-led informational and emotional support meetings compared with usual care did not reduce anxiety or depression symptoms and may have increased posttraumatic stress disorder symptoms. These findings do not support routine or mandatory palliative care-led discussion of goals of care for all families of patients with chronic critical illness.TRIAL REGISTRATIONclinicaltrials.gov Identifier: NCT01230099.

RATIONALE:Minority patients with lung cancer are less likely to receive stage-appropriate treatment. Along with access to care and provider-related factors, cultural factors such as patients' lung cancer beliefs, fatalism, and medical mistrust may help explain this disparity.OBJECTIVES:To determine cultural factors associated with disparities in lung cancer treatment.METHODS:Patients with newly diagnosed lung cancer were recruited from four medical centers in New York City from 2008 to 2011. Using validated tools, we surveyed participants about their beliefs regarding lung cancer, fatalism, and medical mistrust. We compared rates of stage-appropriate treatment among blacks, Hispanics, and nonminority patients. Multiple regression analyses and structural equation modeling were used to assess whether cultural factors are associated with and/or mediate disparities in care.MEASUREMENTS AND MAIN RESULTS:Of the 352 patients with lung cancer in the study, 21% were black and 20% were Hispanic. Blacks were less likely to receive stage-appropriate treatment (odds ratio [OR], 0.50; 95% confidence interval [CI], 0.27-0.93) compared with whites, even after adjusting for age, sex, marital status, insurance, income, comorbidities, and performance status. No differences in treatment rates were observed among Hispanics (OR, 1.05; 95% CI, 0.53-2.07). Structural equation modeling showed that cultural factors (negative surgical beliefs, fatalism, and medical mistrust) partially mediated the relationship between black race and lower rates of stage-appropriate treatment (total effect: -0.43, indirect effect: -0.13; 30% of total effect explained by cultural factors).CONCLUSIONS:Negative surgical beliefs, fatalism, and mistrust are more prevalent among minorities and appear to explain almost one-third of the observed disparities in lung cancer treatment among black patients. Interventions targeting cultural factors may help reduce undertreatment of minorities.

October 2013 • Volume 41 • Number 10 royalties from McGraw Hill and Wiley. Dr. Lustbader served as a board member of ABIM, provided expert testimony for MLMIC, and received grant support from the Department of Health ECRIP. Dr. Puntillo received grant support from NIHNINR (RO1 Dr. Puntillo’s institution receives indirects from this grant), royalties from Oxford University Press ( co-editor of "End of Life Care in ICU") and Elsevier (co-editor of "Critical Care Nursing Secret E2") , and support for travel for the 2012 European Society of Intensive Care Medicine meeting in Lisbon, Portugal (served as speaker). Dr. Bassett consulted for the VHA Critical Care Innovation Network. Dr. Weissman consulted for the Center for Advanced Palliative Care. The remaining authors have disclosed that they do not have any potential conflicts of interest. Address requests for reprints to: Judith E. Nelson, MD, JD, Division of Pulmonary, Critical Care and Sleep Medicine, Mount Sinai School of Medicine, 1 Gustave L. Levy Place, Box 1232, New York, NY 10029. E-mail: judith.nelson@mssm.edu

Objective: Although successful models for palliative care delivery and quality improvement in the intensive care unit have been described, their applicability in surgical intensive care unit settings has not been fully addressed. We undertook to define specific challenges, strategies, and solutions for integration of palliative care in the surgical intensive care unit. Data Sources: We searched the MEDLINE database from inception to May 2011 for all English language articles using the term “surgical palliative care” or the terms “surgical critical care,” “surgical ICU,” “surgeon,” “trauma” or “transplant,” and “palliative care” or “end-of- life care” and hand-searched our personal files for additional articles. Based on review of these articles and the experiences of our interdisciplinary expert Advisory Board, we prepared this report. Data Extraction and Synthesis: We critically reviewed the existing literature on delivery of palliative care in the surgical intensive care unit setting focusing on challenges, strategies, models, and interventions to promote effective integration of palliative care for patients receiving surgical critical care and their families. Conclusions: Characteristics of patients with surgical disease and practices, attitudes, and interactions of different disciplines on the surgical critical care team present distinctive issues for intensive care unit palliative care integration and improvement. Physicians, nurses, and other team members in surgery, critical care and palliative care (if available) should be engaged collaboratively to identify challenges and develop strategies. “Consultative,” “integrative,” and combined models can be used to improve intensive care unit palliative care, although optimal use of trigger criteria for palliative care consultation has not yet been demonstrated. Important components of an improvement effort include attention to efficient work systems and practical tools and to attitudinal factors and “culture” in the unit and institution. Approaches that emphasize delivery of palliative care together with surgical critical care hold promise to better integrate palliative care into the surgical intensive care unit. (Crit Care Med 2012; 40:–1206)

Journal of Palliative MedicineVol. 15, No. 2 RoundtablePalliative Care in the ICUModerator: Judith E. Nelson, Participants: Elie Azoulay, J. Randall Curtis, Anne C. Mosenthal, Colleen M. Mulkerin, Kathleen Puntillo, and Mark D. SiegelModerator: Judith E. NelsonDivision of Pulmonary, Critical Care and Sleep Medicine, The IPAL-ICU Project, Mount Sinai School of Medicine, New York, New York.Search for more papers by this author, Participants: Elie AzoulayService de Réanimation Médicale Groupe de Recherche Respiratoire en Réanimation Onco-Hématologique Groupe de Recherche Famiréa Hôpital Saint-Louis, Université Paris VII Paris, France.Search for more papers by this author, J. Randall CurtisDepartments of Medicine and Pulmonary and Critical Care Medicine, Harborview Medical Center, University of Washington, Seattle, Washington.Search for more papers by this author, Anne C. MosenthalDepartment of Surgery and Division of Surgical Critical Care, UMDNJ-NJMS, Newark, New Jersey.Search for more papers by this author, Colleen M. MulkerinDepartment of Palliative Medicine, Hartford Hospital, Hartford, Connecticut.Search for more papers by this author, Kathleen PuntilloDepartment of Physiological Nursing University of California, San Francisco, San Francisco, California.Search for more papers by this author, and Mark D. SiegelPulmonary and Critical Care Section, Department of Internal Medicine, Yale School of Medicine, Yale-New Haven Hospital, New Haven, Connecticut.Search for more papers by this authorPublished Online:17 Feb 2012https://doi.org/10.1089/jpm.2011.9599AboutSectionsView articleView Full TextPDF/EPUB Permissions & CitationsPermissionsDownload CitationsTrack CitationsAdd to favorites Back To Publication ShareShare onFacebookTwitterLinked InRedditEmail View articleFiguresReferencesRelatedDetailsCited byLessons Learned from an Embedded Palliative Care Model in the Medical Intensive Care UnitJournal of Pain and Symptom Management, Vol. 65, No. 4A three-step support strategy for relatives of patients dying in the intensive care unit: a cluster randomised trialThe Lancet, Vol. 399, No. 10325Post–Intensive Care Syndrome in Covid-19 Patients Discharged From the Intensive Care Unit17 September 2021 | Journal of Hospice & Palliative Nursing, Vol. 23, No. 6End-of-Life Issues in Intensive Care Units9 August 2020 | Seminars in Respiratory and Critical Care Medicine, Vol. 42, No. 01Kommunikation13 February 2021Factors Associated With DNR Status After Nontraumatic Intracranial Hemorrhage22 September 2019 | The Neurohospitalist, Vol. 10, No. 3Rationale and Resources to Accelerate Advanced Practice Palliative Care CompetencyAACN Advanced Critical Care, Vol. 31, No. 2Palliative care interventions in intensive care unit patients – a systematic review protocol22 June 2019 | Systematic Reviews, Vol. 8, No. 1Guiding intensive care physicians' communication and behavior towards bereaved relatives: study protocol for a cluster randomized controlled trial (COSMIC-EOL)22 December 2018 | Trials, Vol. 19, No. 1Family Members' Experiences With Bereavement in the Intensive Care UnitAmerican Journal of Critical Care, Vol. 27, No. 4Dying in intensive care units of India: Commentaries on policies and position papers on palliative and end-of-life careJournal of Critical Care, Vol. 39YOĞUN BAKIMDA PALYATİF BAKIMIN GEREKLİLİĞİ17 April 2017 | Kocatepe Tıp DergisiProfissionais Paliativistas e suas Contribuições na Prevenção de Luto ComplicadoPsicologia: Ciência e Profissão, Vol. 37, No. 1End-of-life care in the ICU: semper ad meliora (always strive for improvement)4 August 2016 | Intensive Care Medicine, Vol. 42, No. 10CAESAR: a new tool to assess relatives' experience of dying and death in the ICU7 March 2016 | Intensive Care Medicine, Vol. 42, No. 6Examination of a Palliative Care Screening Tool in Intensive Care Unit PatientsJournal of Hospice & Palliative Nursing, Vol. 17, No. 6Overcoming Barriers to Palliative Care ConsultationCritical Care Nurse, Vol. 35, No. 5Ethical Challenges in Caring for Cancer Patients in the Intensive Care Unit: Advanced Care Pathways and Avoidance of Futility1 September 2015 | Current Anesthesiology Reports, Vol. 5, No. 3Palliative Care Needs in the Neuro-ICUCritical Care Medicine, Vol. 43, No. 8Is a good death possible in Australian critical and acute settings?: physician experiences with end-of-life care18 August 2014 | BMC Palliative Care, Vol. 13, No. 1Critically ill cancer patient in intensive care unit: Issues that ariseJournal of Critical Care, Vol. 29, No. 5Feasibility and Economic Impact of Dedicated Hospice Inpatient Units for Terminally Ill ICU Patients*Critical Care Medicine, Vol. 42, No. 5Critical Care Medicine in the United StatesCritical Care Medicine, Vol. 41, No. 12Ethical Issues and Palliative Care in the Cardiovascular Intensive Care UnitCardiology Clinics, Vol. 31, No. 4Top 10 Things Palliative Care Clinicians Wished Everyone Knew About Palliative CareMayo Clinic Proceedings, Vol. 88, No. 8Integrating Palliative Care in the Intensive Care UnitThe Journal of Supportive Oncology, Vol. 10, No. 5 Volume 15Issue 2Feb 2012 InformationCopyright 2012, Mary Ann Liebert, Inc.To cite this article:Moderator: Judith E. Nelson, Participants: Elie Azoulay, J. Randall Curtis, Anne C. Mosenthal, Colleen M. Mulkerin, Kathleen Puntillo, and Mark D. Siegel.Palliative Care in the ICU.Journal of Palliative Medicine.Feb 2012.168-174.http://doi.org/10.1089/jpm.2011.9599Published in Volume: 15 Issue 2: February 17, 2012Online Ahead of Print:January 26, 2012PDF download

Palliative care is increasingly recognized as an integral component of comprehensive intensive care for all critically ill patients, regardless of prognosis, and for their families. Here we discuss the key role that nurses can and must continue to play in making this evidence-based paradigm a clinical reality across a broad range of ICUs. We review the contributions of nurses to implementation of ICU safety initiatives as a model that can be applied to ICU palliative care integration. We focus on the importance of nursing involvement in design and application of work processes that facilitate this integration in a systematic way, including processes that ensure the participation of nurses in discussions and decision making with families about care goals. We suggest ways that nurses can help to operationalize an integrated approach to palliative care in the ICU and to define their own essential role in a successful, sustainable ICU palliative care improvement effort. Finally, we identify resources including The IPAL-ICU ProjectTM, a new initiative by the Center to Advance Palliative Care that can assist nurses and other healthcare professionals to move such efforts forward in diverse critical care settings.

BACKGROUND Integration of palliative care with standard oncologic care improves quality of life and survival of lung cancer patients. We surveyed physicians to identify factors influencing their decisions for referral to palliative care. METHODS We provided a self-administered questionnaire to physicians caring for lung cancer patients at five medical centers. The questionnaire asked about practices and views with respect to palliative care referral. We used multiple regression analysis to identify predictors of low referral rates (<25%). RESULTS Of 155 physicians who returned survey responses, 75 (48%) reported referring <25% of patients for palliative care consultation. Multivariate analysis, controlling for provider characteristics, found that low referral rates were associated with physicians' concerns that palliative care referral would alarm patients and families [odds ratio (OR) 0.45, 95% confidence interval (CI) 0.21-0.98], while the belief that palliative care specialists have more time to discuss complex issues (OR 3.07, 95% CI 1.56-6.02) was associated with higher rates of referral. CONCLUSIONS Although palliative care consultation is increasingly available and recommended throughout the trajectory of lung cancer, our data indicate it is underutilized. Understanding factors influencing decisions to refer can be used to improve integration of palliative care as part of lung cancer management.

High‐quality lung cancer care includes physician‐patient communication about the disease and treatment, patient needs/preferences, and care goals. In this study, the authors evaluated communication with patients at all stages across multiple topics.

1.Identify barriers to optimal end-of-life care in intensive care units, specifically surgical intensive care units.2.Identify barriers to communication regarding prognosis between intensive care unit patients and healthcare providers and also between healthcare providers. Background. Twenty percent of deaths in the United States occur after admission to an intensive care unit (ICU). To provide quality palliative care, ICU healthcare providers must communicate effectively and administer compassionate end-of-life care to dying patients. In a surgical ICU, nursing, surgery, and ICU intensivist teams must work together to provide care. Multiple care teams, combined with surgical ICU culture, pose unique barriers to provision of quality palliative care. Research objectives. Our goal was to identify barriers to both optimal communication regarding prognosis and optimal end-of-life care for surgical ICU patients. Methods. We used a semi-structured interview tool to conduct focus groups of surgical ICU nurses at a tertiary care, academic, inner city hospital. Responses were summarized into domains and further validated by independent observers and a subset of nurses who participated in the focus groups. Results. In total, 32 surgical ICU nurses, with a median of 8 years and range of 0.5 to 30 years of ICU experience, participated in four focus groups. The focus groups identified 34 barriers to optimal communication regarding prognosis, which were summarized into four domains: logistics, discomfort with discussing prognosis, perceived lack of skill and training, and fear of conflict. The groups identified 24 barriers to optimal end-of-life care, which were summarized into four domains: logistics, inability to acknowledge an end-of-life situation, perceived lack of skill and training, and cultural barriers. Conclusion. Some of the identified barriers are unique to surgical ICUs, while others are likely universal. In total, this study illuminates the complicated relationships present in ICUs, particularly surgical ICUs, where nurses, surgeons, ICU physicians, and advanced practice nurses must work together to provide the care for any single patient. Implications for research, policy, or practice. This study highlights multiple potential targets for both research and performance improvement initiatives to optimize delivery of palliative care to all ICU patients. Structure and Processes of Care

Objective: There are numerous challenges to successfully integrating palliative care in the intensive care unit. Our primary goal was to describe and compare the quality of palliative care delivered in an intensive care unit as rated by physicians and nurses working in that intensive care unit. Design: Multisite study using self-report questionnaires. Setting: Thirteen hospitals throughout the United States. Participants: Convenience sample of 188 physicians working in critical care (attending physicians, critical care fellows, resident physicians) and 289 critical care nurses. Measurements and Main Results: Clinicians provided overall ratings of the care delivered by either nurses or physicians in their intensive care unit for each of seven domains of intensive care unit palliative care using a 0–10 scale (0 indicating the worst possible and 10 indicating the best possible care). Analyses included descriptive statistics to characterize measurement characteristics of the ten items, paired Wilcoxon tests comparing item ratings for the domain of symptom management with all other item ratings, and regression analyses assessing differences in ratings within and between clinical disciplines. We used p < .001 to denote statistical significance to address multiple comparisons. The ten items demonstrated good content validity with few missing responses or ceiling or floor effects. Items receiving the lowest ratings assessed spiritual support for families, emotional support for intensive care unit clinicians, and palliative-care education for intensive care unit clinicians. All but two items were rated significantly lower than the item assessing symptom management (p < .001). Nurses rated nursing care significantly higher (p < .001) than physicians rated physician care in five domains. In addition, although nurses and physicians gave comparable ratings to palliative care delivered by nurses, nurses' and physicians' ratings of physician care were significantly different with nurse ratings of this care lower than physician ratings on all but one domain. Conclusion: Our study supports the content validity of the ten overall rating items and supports the need for improvement in several aspects of palliative care, including spiritual support for families, emotional support for clinicians, and clinician education about palliative care in the intensive care unit. Furthermore, our findings provide some preliminary support for surveying intensive care unit clinicians as one way to assess the quality of palliative care in the intensive care unit.

Extract Palliative care in the ICU through a legal lens Scenarios These scenarios highlight the range of legal issues that can arise in the context of palliative care in the ICU. The following should help you to be able to identify the issues and know what to do and where to turn for help when confronted by any of them. Definitions* * Many of these definitions are based on those provided in: J Downie (2004). Dying justice: a case for decriminalizing euthanasia and assisted suicide in Canada. University of Toronto Press, Toronto. ** This framework is based on related frameworks for analysis developed by Jocelyn Downie, Françoise Baylis, and Richard Devlin. Sources of legal obligations Legal obligations come from a variety of sources. It is important to be aware of them all so that you can determine what your legal obligations are in any particular situation. Legislation Many jurisdictions have legislation dealing directly...

Objective: Chronic critical illness is a devastating syndrome for which treatment offers limited clinical benefit but imposes heavy burdens on patients, families, clinicians, and the health care system. We studied the availability of advance directives and appropriate surrogates to guide decisions about life-sustaining treatment for the chronically critically ill and the extent and timing of treatment limitation. Design: Prospective cohort study. Setting: Respiratory Care Unit (RCU) in a large, tertiary, urban, university-affiliated, hospital. Patients: Two hundred three chronically critically ill adults transferred to RCU after tracheotomy for failure to wean from mechanical ventilation in the intensive care unit. Interventions: None. Measurements and Main Results: We interviewed RCU caregivers and reviewed patient records to identify proxy appointments, living wills, or oral statements of treatment preferences, resuscitation directives, and withholding/withdrawal of mechanical ventilation, nutrition, hydration, renal replacement and vasopressors. Forty-three of 203 patients (21.2%) appointed a proxy and 33 (16.2%) expressed preferences in advance directives. Do not resuscitate directives were given for 71 patients (35.0%). Treatment was limited for 39 patients (19.2%). Variables significantly associated with treatment limitation were proxy appointment prior to study entry (time of tracheotomy/RCU transfer) (odds ratio = 6.7, 95% confidence interval [CI], 2.3–20.0, p = 0.0006) and palliative care consultation in the RCU (OR = 40.9, 95% CI, 13.1–127.4, p < 0.0001). Median (interquartile range) time to first treatment limitation was 39 (31.0–45.0) days after hospital admission and 13 (8.0–29.0) days after RCU admission. For patients dying after treatment limitation, median time from first limitation to death ranged from 3 days for mechanical ventilation and hydration to 7 days for renal replacement. Conclusions: Most chronically critically ill patients fail to designate a surrogate decision-maker or express preferences regarding life-sustaining treatments. Despite burdensome symptoms and poor outcomes, limitation of such treatments was rare and occurred late, when patients were near death. Opportunities exist to improve communication and decision-making in chronic critical illness.