Palliative Care Integration in the ICU Colleen Tallen M.D. [email protected] September 26,...
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Transcript of Palliative Care Integration in the ICU Colleen Tallen M.D. [email protected] September 26,...
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