1 Integrating Palliative Care Principles into Critical Care Nursing It s the Caring, Compassionate, Holistic, Patient and Family Centered, Better Communication, Keeping my patient comfortable amidst the tubes, lines, machines Nursing Practice Maria Fox DNP, APRN-CNS, ACHPN, CCRN University of Kansas Hospital, Clinical Nurse Specialist Center for Practical Bioethics, KCMO, Clinical Ethics Associate 2 Objectives Describe the role of palliative care in patients who are critically ill: CONTEXTUALIZE Discuss the unique role of critical care nurses in patient/family communication: INDIVIDUALIZE Describe EBP strategies that integrate palliative care into critical care: STRATEGIZE 3
4 What is 30-second Elevator Pitch Palliative Care? Expert Pain and Symptom Management Communication or counseling around difficult issues - patient/family centered Assist with dispositions/transitions out of hospital For patients at high-risk of death Or At end-of-life The Old Paradigm Life Prolonging Care Disease Progression Palliative/ Hospice Care D E A T H Chris Duncan, c. 2010 5 What s the Problem with That? Going Palliative! Withdraw (or stop) care Why aren t they a DNAR? Death Panel 6
7 The New Paradigm Source: University of Michigan Geriatric Program The New Paradigm Establish relationship with patient/family early Assist to improve QOL while patient is going through active treatment The feel better so you can enjoy life team Embedded in heart failure clinic, OP cancer clinics, liver clinic at KU Hospital 8 Go Palliative Team!! 9
10 What does this have to do with Critical Care Nursing? 2002-2004 in Michigan MHA Keystone estimates that more than 1,578 lives were saved, reducing hospital days by 81,000 and saving $165 million during the 15-month span. Newsweek, Oct 16 2005 As a profession, nursing has an obligation to respond to the demands of an aging population, increasing chronic illness and a seriously burdened health care system quality of life matters, even at end of life Betty Ferrell, 2001, forward 11 12
13 What does this have to do with Critical Care Nursing? 1 out of 5 Americans will die in and around an ICU stay (Angus, et al, 2004, CCM) Over 55% of Americans will die in a facility (Hospital, LTACH, NH) (Kaufmann, 2005) Aggressive medical and surgical interventions are offered to a growing population of older adults with multiple comorbid conditions 14 What s a Critical Care Nurse to do? 15
16 Palliative Care Based on Need Patients: Decreased mortality Increased ICU survivors ARDS: symptoms the first year after ICU Debilitating insomnia, fatigue, pain, emotional lability (Cox, et al, 2009, CCM) Depression Chronic pain Chronically critically ill: vent dependent Palliative Care Based on Need Families: Anxiety and depression are common Complicated grief Post Intensive Care Syndrome recognized in families and patients 17 Case Study Elderly man, trached, PEG d, in the ICU Palliative Care consulted for goals of care Had family meeting with wife, ICU team and PC team Plan for transfer to LTACH, continue attempts at wean from mechanical vent 18
19 With patient With family With other providers Communication Family Meeting A Palliative Care Procedure Physician-led is best studied Proactive versus reactive Multidisciplinary Primary Palliative Care Intervention 20 EBP Nurse Communication in ICU Nurse-led family interaction in waiting room Nurse initiated daily phone call 21
22 EBP Nurse Communication in ICU SUPPORT Study Specially trained nurse liaison Failed to demonstrate improved communication about CPR, preferences EBP Nurse Communication in ICU APRNs in OP settings: reduce LOS, reduce readmissions (Project ENABLE) APRNs In Critical Care (ICS) (Daly, et al, 2010, Chest) Nurse liaisons (Family Support Specialist) (White, et al., 2012, AJCC) Nurses commonly feel constrained (Slatore, et al., 2012, AJCC. 23 Exploring Perceptions of the Nurse s Role in the ICU Family Meeting Case Study Nurse did not participate in the family meeting Nurse had crucial information 24
25 Methods Setting: single medical ICU Population: ICU nurses Procedure: mixed method approach Instruments: Experience with Family Meeting Questionnaire Self-Rating Communication Skills Questionnaire Demographic Questionnaire Guided Interview of Perception of Nurse Role Data Analysis Quantitative data collection REDCap Surveys Frequency of responses to survey questions Self-rating scores of Excellent and Very Good Qualitative data collection Guided interviews Open-ended questions to explore the ICU nurse role in family meetings 26 Characteristic Quantitative Results Nurses Surveyed Nurses Interviewed N= 20 a N=5 b Female: Num. (%) 16 (80) 5 (100) Age: mean (SD) 31.7 (7.6) na Race - White: Num. (%) 17 (85) 5 (100) Years in Practice: mean (SD) 7.6 (6.6) 6.4 (2.9) Years in ICU practice: mean (SD) 6.4 (6.3) 4.8 (2.2) Role - Direct caregiver RN: Num. (%) 16 (80) 5 (100) Professional Certification: Num. (%) 14 (70) 5 (100) Participate in Shared Governance: Num, (%) 10 (50) 4 (80) Day Shift: Num. (%) 16 (80) 3 (60) 27
28 Reasons to have family meetings Reasons for not attending family meetings 29 Quantitative Results Self-rating skills in family communication: Excellent or Very Good Most nurses confident about: Communicating patient needs to ICU physician Ensuring that family has opportunity to meet IDT Responding to questions about condition, treatment and goals of care Most nurses not confident about: Addressing the emotional needs of the family Responding to questions about prognosis 30
31 Spearman s Rank Correlation Between Self-rated Communication Skills and Nurse Characteristics of age and years in practice b Comm with doctors Consistent comm Family Meet IDT Active Participant Investigate GOC Emotional needs Age.120.297 -.028.373.583**.415 Years c.246.414.219.640*.667**.660* *significant at 0.05 level **significant at 0.01 level Spearman s Rank Correlation Between Self-rated Communication Skills and Nurse Characteristics of age and years in practice b Comm with doctors Consistent comm Family Meet IDT Active Participant Investigate GOC Emotional needs Age.120.297 -.028.373.583**.415 Years c.246.414.219.640*.667**.660* *significant at 0.05 level **significant at 0.01 level 32 Qualitative Results Three types of family meetings Formal family meeting Informal family meeting Emergent/Urgent family meeting ICU Nurse Role Information reconciliation Balanced Advocacy Skills needed: know the patient, educate patient/family, honest communication 33
34 Conclusions Nurses perceive a limited role, little influence in formal family meetings ICU nurses frequently participate in informal, impromptu family meetings Older, more experienced ICU nurses self-rate higher in discussing difficult topics Targeted education of EBP strategies about family meetings is needed ICU nurses can take lead in improving communication with patients and families Unique role of critical care nurse Case Study: Elderly man, chronic vent, trached, PEG d, planning to discharge to LTACH? Nurse facilitated repeat family meeting at bedside and advocated for patient to tell wife his wishes Patient went home that evening, with hospice, died the next morning at home 35 What next? Better integration of palliative care principles into critical care Emphasis on primary palliative care for the bedside provider Education Provider education: Physician, Nurse, Allied Health 36
37 Barriers to Better Integration Unrealistic expectations of therapies Misperceptions that palliative care and critical care are mutually exclusive Palliative care equals hospice care Palliative care means no care Will hasten death Aslakson, Curtis & Nelson, CCM, 2014 Barriers to Better Integration Insufficient training in communication and other skills Competing demands without adequate compensation Failure of effective approaches for system or culture change Aslakson, Curtis & Nelson, CCM, 2014 38 Consultative vs. Integrative Model Palliative Care Team Palliative Care Consultation Usual ICU care by Critical Care Team Palliative Care Principles embedded in typical ICU care Nelson, et al., CCM, 2010 39
40 Creating a Screening Tool Who are the stakeholders? What is your process? How do you evaluate? Outcomes? Primary palliative care vs. Palliative Care consult? Nelson, et al., 2013, CCM Screening Tool Examples 41 Structured Approaches to Communication Usually pre-post design Associated with significant reductions in resource utilization Family Meetings ICU team Palliative Care Team Ethics Consultants/Committee Brochure 42
43 Surgical ICU Interventions Before and after interventions: multi-faceted, multidisciplinary intervention to integrate palliative care principles into usual or standard care in an open ICU Earlier consensus around goals of care Earlier more frequent use of DNAR and withdrawal of artificial life sustaining treatments Shorter SICU LOS, unchanged mortality Support for Families and Surrogates Involvement in daily rounds Designated staff to support families SW, Nurse Chaplains Advance Practice Nurses Require further evaluation RCT eval of SW or Nurse as liaison White, et al., 2012. Journal of Critical Care 44 Decision Support Tools Video about CPR, DNAR (McCannon, 2012, Journal of Palliative Med) Admission assessment tool to identify surrogate decision-makers and clarify decision-making A decision-aid for surrogates for patients on prolonged mechanical ventilation 45
46 ICU Protocols Diaries Standardized order sets Clinician debriefing Nurse-led Interventions Implement nurse-initiated communication bundle that culminates in family meeting, 1. identify health proxy or surrogate 2. determine presence of AD 3. clarify the code status Day 1 4. assess pain regularly 5. manage pain optimally 6. offer SW support Day 3 7. offer spiritual support 8. conduct multidisciplinary family meeting Day 5 47 Nurse-led Interventions Involve others: SW, Case Managers, Chaplains Come to the table! 48
49 Web-based Resources IPAL: The Improving Palliative Care in the ICU Project: https://www.capc.org/ipal/ipal-icu/ Education: ELNEC Web-based Resources Central Plain Geriatric Center 50 Professional Practice Recommendations American Association of Critical Care Nurses 51
52 Professional Practice Recommendations Society of Critical Care Medicine Professional Practice Recommendations American Heart Association and American College of Cardiology Foundation 53 Where do we go from here? 54
55 Thank-you for your attention! Questions? References Billings, J. A. (2011). The End-of-life family meeting in Intensive Care Part I: Indication, Outcomes, and family needs. Journal of Palliative Medicine, 14 (9), 1042-1050. Daly, B. J., et al. (2010). Effectiveness trial of an intensive communication structure for families of long-stay ICU patients. Chest, 138(6), 1240-1348. Fox, M. Y. Improving communication with patients and families in the intensive care unit. Palliative care strategies for the Intensive Care Unit Nurse. Journal of Hospice and Palliative Nursing, 16 (2), 93-98. Mosenthal, A. C., et al. (2012). 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. Critical Care Medicine, 40 (4), 1199-1206. Munro, C. L. & Savel, R.H. (2013). Communicating and commecting with patients and their families. American Journal of Critical Care, 22(1), 4-6. 56 References Nelson, J. E. et al, (2010). Models for structuring a clinical initiative to enhance palliative care in the Intensive care unit: A report from the IPAL-ICU Project (Improving Palliative Care in the ICU). Critical Care Medicine, 38 (9), 1765-1772). Nelson, J. E., et al. (2013). Choosing and Using Screening Criteria for Palliative Care Consultation in the ICU: A report from the Improving Palliative Care in the ICU (IPAL-ICU) Advisory Board. Critical Care Medicine, 41(10), 2318-2327. Penrod, J. D. et al. (2011). Implementation and evaluation of a network-based pilot program to improve palliative care in the Intensive Care Unit. Journal of Pain and Symptom Management, 42 (5) 668-671. Slatore, C., et al. (2012). Communication by nurses in the intensive care unit: Qualitative analysis of domains of patient-centered care. American Journal of Critical Care, 21 (6), 410-418. White,D., et al. (2012). Nurse-led intervention to improve surrogate decision making for patients with advanced critical illness. American Journal of Critical Care, 21 (6), 396-407). 57