Improving ICU-Based Palliative Care Delivery: A Multicenter, Multidisciplinary Survey of Critical Care Clinician Attitudes and Beliefs

Abstract

Objective: Addressing the quality gap in ICU-based palliative care is limited by uncertainty about acceptable models of collaborative specialist and generalist care. Therefore, we characterized the attitudes of physicians and nurses about palliative care delivery in an ICU environment.

Design: Mixed-methods study.

Setting: Medical and surgical ICUs at three large academic hospitals.

Participants: Three hundred three nurses, intensivists, and advanced practice providers.

Measurements and main results: Clinicians completed written surveys that assessed attitudes about specialist palliative care presence and integration into the ICU setting, as well as acceptability of 23 published palliative care prompts (triggers) for specialist consultation. Most (n = 225; 75%) reported that palliative care consultation was underutilized. Prompting consideration of eligibility for specialist consultation by electronic health record searches for triggers was most preferred (n = 123; 41%); only 17 of them (6%) felt current processes were adequate. The most acceptable specialist triggers were metastatic malignancy, unrealistic goals of care, end of life decision making, and persistent organ failure. Advanced age, length of stay, and duration of life support were the least acceptable. Screening led by either specialists or ICU teams was equally preferred. Central themes derived from qualitative analysis of 65 written responses to open-ended items included concerns about the roles of physicians and nurses, implementation, and impact on ICU team-family relationships.

Conclusions: Integration of palliative care specialists in the ICU is broadly acceptable and desired. However, the most commonly used current triggers for prompting specialist consultation were among the least well accepted, while more favorable triggers are difficult to abstract from electronic health record systems. There is also disagreement about the role of ICU nurses in palliative care delivery. These findings provide important guidance to the development of collaborative care models for the ICU setting.

Figure 1. Clinician preferences for integrating palliative care specialists into the ICU setting

The height of each thick black bar is proportional to the number of clinicians who preferred one of five strategies for integrating palliative care specialists into the ICU setting. The width of colored boxes represents the number of clinicians within each preference categorized by four key characteristics shown in the key. Bolded red numbers represent statistically significant (p<0.05) comparisons using chi-square tests or Fisher's exact tests.

Figure 2. Clinician attitudes about five possible methods to operationalize an ICU-based palliative care trigger system

The height of bars represents clinician number for each method. The percentage of responses for each method is shown for nurses (blue) and physicians (red). P values represent comparisons between nurses and physicians within each preferred method.