Palliative Care in the Intensive Care Unit: The Standard of Care.

Intensive care unit-based palliative care has evolved over the past 30 years due to the efforts of clinicians, researchers, and advocates for patient-centered care. Although all critically ill patients inherently have palliative care needs, the path was not linear but rather filled with the challenges of blending the intensive care unit goals of aggressive treatment and cure with the palliative care goals of symptom management and quality of life. Today, palliative care is considered an essential component of high-quality critical care and a core competency of all critical care nurses, advanced practice nurses, and other intensive care unit clinicians. This article provides an overview of the current state of intensive care unit-based palliative care, examines how the barriers to such care have shifted, reviews primary and specialist palliative care, addresses the impact of COVID-19, and presents resources to help nurses and intensive care unit teams achieve optimal outcomes.

Innovative Strategies for Palliative Care in the Intensive Care Unit.

Palliative care is interdisciplinary care that addresses suffering and improves the quality of care for patients and families when patients are facing a life-threatening illness. Palliative care needs in the intensive care unit include communication regarding diagnosis and prognosis, goals-of-care conversations, multidimensional pain and symptom management, and end-of-life care that may include withdrawal of mechanical ventilation and life support. Registered nurses spend the greatest amount of time with patients and families who are facing death and serious illness, so nurses must be armed with adequate training, knowledge, and necessary tools to address patient and caregiver needs and deliver high-quality, patient-centered palliative care. Innovative approaches to integrating palliative care are important components of care for intensive care nurses. This article reviews 2 evidence-based practice projects, a serious illness support tool and the 3 Wishes Project, to add to the palliative care toolkit for registered nurses and other team members.

Utilizing a Tailored Approach to Standardized Screening of Health-Related Social Needs.

BACKGROUND: Despite the increased awareness of social determinants of health (SDoH), integrating social needs screening into health care practice has not consistently occurred. LOCAL PROBLEM: No social needs screening using recommended standardized questions was available at an outpatient hemodialysis clinic. METHODS: Plan-Do-Study-Act cycles, based on the Model for Improvement, were used to implement the Core 5 SDoH screening tool, a staff referral process, and an evaluation of the implementation process. INTERVENTION: A standardized social needs screening tool and a staff referral process were implemented. An evaluation of the implementation process also occurred. RESULTS: Of 73 patients screened, 21 reported 32 unmet social needs; all received referrals to community resources. Nurses demonstrated high acceptance and usability of the tool and the referral process. CONCLUSIONS: Implementing a standardized screening and referral process customized to clinical workflow enhanced the identification of social needs in patients undergoing hemodialysis.

Use of the 3 Wishes Project to Help Individualize End-of-Life Care in a Medical Intensive Care Unit.

BACKGROUND: Multiple organizations recommend that individualized end-of-life (EOL) care should be standard practice. However, a standardized approach does not exist because EOL care should be individually tailored. The 3 Wishes Project is an EOL intervention that provides direction for individualized care with 3 goals: dignify death, celebrate the patient's life, and support family members and the intensive care unit clinicians caring for the patient. Patients and families are given the opportunity to choose 3 wishes during the dying process. OBJECTIVE: To ascertain if the implementation of the 3 Wishes Project allowed the medical team to provide individualized EOL care. METHODS: The Iowa Model was used for this evidence-based project. The project was implemented in the medical intensive care unit at an academic medical center. Outcomes were evaluated by the collection and analysis of qualitative and quantitative data. RESULTS: From the 57 patients who died during the 2-month implementation period, 32 wish forms were collected; 31 patients participated and 1 declined. Overall participation among patients was 56%. The top 5 wishes were cloth hearts, blankets, heartbeat printouts, fingerprints and handprints, and music. The total cost was $992, and the average cost per wish was $6.98. Eighty-five percent (33 of 39) of the respondents to the medical team survey indicated that they either agreed or strongly agreed that the project allowed the medical team to consistently provide individualized EOL care. CONCLUSIONS: The survey data support the 3 Wishes Project as a method that allowed the medical team to individualize EOL care and as a valuable tool for incorporation at the bedside.

Effect of Simulation-Based Training on the Self-Confidence of New Nurses in the Care of Patients With Acute Deterioration and Activation of the Rapid Response Team.

BACKGROUND: New nurses report feeling unprepared and having low levels of self-confidence. High-fidelity simulation (HFS) is frequently used to increase confidence and improve patient safety. This study assessed whether HFS training increased new nurses' self-confidence and activation of the rapid response team (RRT) when caring for patients with clinical deterioration. METHOD: A quality improvement design was used. New nurses on two units at a Level I trauma center completed a 70-minute HFS. The change in self-confidence was measured by Grundy's C-Scale, and the change in percentage of staff-initiated RRT calls versus auto-triggered calls was calculated 3 months after HFS. RESULTS: All 12 nurses who participated in the HFS showed improved self-confidence immediately after simulation. A Wilcox-on signed-rank paired data test showed statistically significantly improved confidence scores for all five items of the C-Scale from preintervention to immediately postintervention as well as 5 months later. One unit showed an increase in percentage of staff-initiated RRT calls 3 months postsimulation, and the other unit showed a decline in staff-initiated versus auto-triggered RRT calls. DISCUSSION: The HFS increased self-confidence scores from preintervention to immediately postintervention, with the increase sustained 5 months later. However, how this increase translated into practice when activating RRT calls cannot be determined because many factors can influence RRT call patterns. CONCLUSION: The literature review and study results suggest that HFS training embedded into an existing nurse residency program can build self-confidence in caring for patients with clinical deterioration. [J Contin Educ Nurs. 2023;54(8):367-376.].

Palliative Sedation Therapy: A Case Report.

INTRODUCTION: Despite repeated exposure to dying patients, critical care providers and nurses may not be familiar with palliative sedation. This case report describes a scenario in which palliative sedation therapy was considered for a patient dying in the intensive care unit. CLINICAL FINDINGS: A 72-year-old woman was transferred from an outside hospital for management of severe acute respiratory distress syndrome. After her transfer, she experienced cardiac arrest and was resuscitated. DIAGNOSIS: The patient was diagnosed with pneumonia related to COVID-19. Arterial blood gas values showed her ratio of partial pressure of oxygen to fraction of inspired oxygen to be less than 200, consistent with acute respiratory distress syndrome. INTERVENTIONS: The patient was intubated and started on a ventilator protocol for acute respiratory distress syndrome. After her cardiac arrest, she required a continuous epinephrine infusion. OUTCOMES: The patient's family was notified of the severity of her clinical status, and the critical care team began to plan the transition from aggressive to comfort care. A provider suggested that the patient should receive continuous intravenous propofol after extubation to manage dyspnea during the dying process. CONCLUSION: Palliative sedation therapy may be needed for dying patients, such as those with severe acute respiratory distress syndrome. The transition from curative to palliative measures often occurs in intensive care units but the ethical principles behind palliative sedation are not well understood by those providing care in these settings. It is vital that critical care nurses and providers be informed about available treatments for symptoms of dying patients, including palliative sedation.

Targeted Temperature Management: A Program Evaluation.

In the United States, more than 350 000 cardiac arrests occur annually. The survival rate after an out-of-hospital cardiac arrest remains low. The majority of patients who have return of spontaneous circulation will die of complications of hypoxic-ischemic brain injury. Targeted temperature management is the only recommended neuroprotective measure for those who do not regain consciousness after return of spontaneous circulation. Despite current practices, a review of the literature revealed that evidence on the ideal time to achieve target temperature after return of spontaneous circulation remains equivocal. A program evaluation of a targeted temperature management program at an academic center was performed; the focus was on timing components of targeted temperature management. The program evaluation revealed that nurse-driven, evidence-based protocols can lead to optimal patient outcomes in this low-frequency, high-impact therapy.

Increasing Critical Care Nurse Engagement of Palliative Care During the COVID-19 Pandemic.

BACKGROUND: The coronavirus disease 2019 pandemic has led to escalating infection rates and associated deaths worldwide. Amid this public health emergency, the urgent need for palliative care integration throughout critical care settings has never been more crucial. OBJECTIVE: To promote palliative care engagement in critical care; share palliative care resources to support critical care nurses in alleviating suffering during the coronavirus disease 2019 pandemic; and make recommendations to strengthen nursing capacity to deliver high-quality, person-centered critical care. METHODS: Palliative and critical care literature and practice guidelines were reviewed, synthesized, and translated into recommendations for critical care nursing practice. RESULTS: Nurses are ideally positioned to drive full integration of palliative care into the critical care delivery for all patients, including those with coronavirus disease 2019, given their relationship-based approach to care, as well as their leadership and advocacy roles. Recommendations include the promotion of healthy work environments and prioritizing nurse self-care in alignment with critical care nursing standards. CONCLUSIONS: Nurses should focus on a strategic integration of palliative care, critical care, and ethically based care during times of normalcy and of crisis. Primary palliative care should be provided for each patient and family, and specialist services sought, as appropriate. Nurse educators are encouraged to use these recommendations and resources in their curricula and training. Palliative care is critical care. Critical care nurses are the frontline responders capable of translating this holistic, person-centered approach into pragmatic services and relationships throughout the critical care continuum.

RAMPED-UP: The Development and Testing of an Interprofessional Collaboration Model.

Interprofessional collaboration (IPC) is an essential component of care delivery needed to achieve optimal patient- and system-level outcomes. The purpose of this project was to measure the impact of a structured IPC model, RAMPED-UP, on hospital length of stay (LOS) in a surgical trauma population. The study design was a prospective cohort with a historical comparison group. The project was conducted at a Level 1 trauma center. The RAMPED-UP group constituted trauma patients admitted from October to December 2017 (n = 96). Trauma patients admitted from October to December 2016 constituted the pre-RAMPED-UP group (n = 98). The 2 groups were similar in demographics. Hospital LOS was not statistically significant between groups. Median RAMPED-UP LOS, defined as the number of days the patient received RAMPED-UP rounds, was 3 days. Patients in the RAMPED-UP group were more likely to be discharged home, with higher discharge-by-noon (DBN) rates of 18.2% (p = .005). A statistically significant correlation was found between incentive spirometry (I/S) values and hospital LOS and RAMPED-UP LOS in the RAMPED-UP group (95% CI: rs -0.301, p = .008; 95% CI: rs -0.270, p = .018, respectively). Although the RAMPED-UP model did not decrease hospital LOS, the model did significantly improve DBN and RAMPED-UP LOS. Further exploration of I/S values as a predictor of LOS is warranted. The use of a structured IPC model that includes essential members of the IPC team can aid in improving patient outcomes such as DBN.

Choosing Wisely in Critical Care: A National Survey of Critical Care Nurses.

BACKGROUND: To promote the use of appropriate testing, and decrease unnecessary treatments, the ABIM Foundation established the Choosing Wisely campaign in 2012. Initially targeting physicians, the campaign has evolved to encourage all providers to promote high-value care; however, information related to critical care nursing is limited. OBJECTIVES: To assess nurses' reports of the use of Choosing Wisely recommendations in critical care settings. METHODS: Responses from nurses were examined as part of a critical care survey of members of 4 societies in order to assess awareness and use of the Choosing Wisely recommendations. RESULTS: Of the 1651 acute and critical care nurses who were members of the American Association of Critical-Care Nurses and responded to the survey, 632 (38.3%) reported being familiar with the Choosing Wisely campaign. Of these respondents, 200 identified as advanced practice nurses. A total of 620 reported implementing the 5 Critical Care Society Collaborative recommendations, including reducing diagnostic testing (n = 311 [50.2%]), reducing the number of red blood cell transfusions (n = 530 [85.5%]), not using parenteral nutrition in adequately nourished patients (n = 293 [47.3%]), not using deep sedation in patients receiving mechanical ventilation (n = 499 [80.5%]), and offering comfort care for patients at high risk for death (n = 416 [67.1%]). Staff education, specific protocols, electronic medical record alerts, and order sets all raised nurses' awareness of the recommendations. CONCLUSIONS: Acute and critical care nurses are directly involved with measures to reduce unnecessary testing and treatments. Greater awareness and championing of the Choosing Wisely recommendations by acute and critical care nurses can help to promote high-value care for acute and critically ill patients.

Choosing Wisely in Critical Care: Results of a National Survey From the Critical Care Societies Collaborative.

OBJECTIVES: Over-utilization of tests, treatments, and procedures is common for hospitalized patients in ICU settings. American Board of Internal Medicine Foundation's Choosing Wisely campaign tasked professional societies to identify sources of overuse in specialty care practice. The purpose of this study was to assess how critical care clinicians were implementing the Critical Care Societies Collaborative Choosing Wisely recommendations in clinical practice. DESIGN: Descriptive survey methodology with use of Research Electronic Data Capture (https://projectredcap.org/) sent via email newsletter blast or to individual emails of the 150,000 total members of the organizations. SETTING: National survey. SUBJECTS: ICU physicians, nurses, advanced practice providers including nurse practitioners and physician assistants, and pharmacist members of four national critical care societies in the United States. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: A six-question survey assessed what Choosing Wisely recommendations had been implemented in ICU settings and if the impact was assessed. A total of 2,520 responses were received from clinicians: nurses (61%; n = 1538), physicians (25.9%; n = 647), advanced practice providers (10.5%; n = 263), and pharmacists (2.1%; n = 52), reflecting a 1.6% response rate of the total membership of 150,000 clinicians. Overall, 1,273 respondents (50.6%) reported they were familiar with the Choosing Wisely campaign. Respondents reported that Choosing Wisely recommendations had been integrated in a number of ways including being implemented in clinical care (n = 817; 72.9%), through development of a specific clinical protocol or institutional guideline (n = 736; 65.7%), through development of electronic medical record orders (n = 626; 55.8%), or with integration of longitudinal tracking using an electronic dashboard (n = 213; 19.0%). Some respondents identified that a specific quality improvement initiative was developed related to the Choosing Wisely recommendations (n = 468; 41.7%), or that a research initiative had been conducted (n = 156; 13.9%). CONCLUSIONS: The results provide information on the application of the Choosing Wisely recommendations to clinical practice from a small sample of critical care clinicians. However, as only half of the respondents report implementation, additional strategies are needed to promote the Choosing Wisely recommendations to make impactful change to improve care in ICU settings.

Palliative Nursing Summit: Nurses Leading Change and Transforming Care: The Nurse's Role in Communication and Advance Care Planning.

Advance care planning (ACP) is an essential component of quality palliative care that requires expert communication skills. Nurses are often the health care provider patients and families rely on when exploring their values and preferences and making treatment decisions. Therefore, communication and ACP was one of the 3 areas of practice addressed during the Palliative Nursing Summit. This article summarizes patient outcomes and nursing actions recommended by summit participants related to communication and ACP. Areas addressed included education, clinical care, research, and policy/regulation. Recommended patient outcomes included the honoring of patient/family preferences and the inclusion of ACP discussions during routine care and across the life span. Recommended nursing actions included the following: (1) nursing education (both undergraduates and practicing nurses) and competencies related to communication and ACP be developed and implemented; (2) primary palliative care, including communication and ACP, be included in the practice standards of all nursing specialties; (3) health care systems support conversations about ACP and related documentation; (4) research be conducted related to the implementation of patient/family preferences and related health care utilization; and (5) regulation and reimbursement be crafted to support nursing practice related to ACP and related conversations at the nurses' full level of expertise.

Physical Impairments Associated With Post-Intensive Care Syndrome: Systematic Review Based on the World Health Organization's International Classification of Functioning, Disability and Health Framework.

Background: Post-intensive care syndrome (PICS) is a constellation of new or worsening impairments in physical, mental, or cognitive abilities or a combination of these in individuals who have survived critical illness requiring intensive care. Purpose: The 2 purposes of this systematic review were to identify the scope and magnitude of physical problems associated with PICS during the first year after critical illness and to use the World Health Organization's International Classification of Functioning, Disability and Health (ICF) framework to elucidate impairments of body functions and structures, activity limitations, and participation restrictions associated with PICS. Data Sources: Ovid MEDLINE, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials (CENTRAL), PubMed, CINAHL Plus with Full Text (EBSCO), Web of Science, and Embase were searched from inception until March 7, 2017. Study Selection: Two reviewers screened titles, abstracts, and full text to independently determine study eligibility based on inclusion and exclusion criteria. Data Extraction: Study methodological quality was assessed using the Newcastle-Ottawa Scale. Data describing study methods, design, and participant outcomes were extracted. Data Synthesis: Fifteen studies were eligible for review. Within the first year following critical illness, people who had received intensive care experienced impairments in all 3 domains of the ICF (body functions and structures, activity limitations, and participation restrictions). These impairments included decreased pulmonary function, reduced strength of respiratory and limb muscles, reduced 6-minute walk test distance, reduced ability to perform activities of daily living and instrumental activities of daily living, and reduced ability to return to driving and paid employment. Limitations: The inclusion of only 15 observational studies in this review may limit the generalizability of the findings. Conclusions: During the first year following critical illness, individuals with PICS experienced physical impairments in all 3 domains of the ICF.

From the Team to the Table: Nursing Societies and Health Care Organizational Ethics.

Health care work is interprofessional work. Nurses and physicians, members of the professions whose close collaboration is foundational to health care delivery, continue to be educated separately in most academic institutions. Their work also is organized in ways that challenge interprofessional collaboration. Understanding workplace realities faced by nurses and physicians, separately and jointly, is a starting place for exploring how to support ethically sound interprofessional work. In this essay, we look most closely at the work of nurses and physicians who care for seriously ill hospitalized patients, a patient population closely associated with ethical challenges.

Palliative care delivery models.

OBJECTIVES: To provide an overview of the four major palliative care delivery models: ambulatory clinics, home-based programs, inpatient palliative care units, and inpatient consultation services. The advantages and disadvantages of each model and the generalist and specialist roles in palliative care will be discussed. DATA SOURCES: Literature review. CONCLUSION: The discipline of palliative care continues to experience growth in the number of programs and in types of delivery models. Ambulatory- and home-based models are the newest on the scene. IMPLICATIONS FOR NURSING PRACTICE: Nurses caring for oncology patients with life-limiting disease should be informed about these models for optimal impact on patient care outcomes. Oncology nurses should demonstrate generalist skills in the care of the seriously ill and access specialist palliative care providers as warranted by the patient's condition.

Acute and critical care nurses' perceptions of palliative care competencies: a pilot study.

Competency development among acute and critical care nurses has focused primarily on the provision of life-sustaining care and less on the care of patients who fail to respond to life-prolonging treatments. Examining nurses' beliefs, perceptions, and experiences with patients' palliative care needs may improve continuing education programs, practice resources, educational curricula, and professional nursing practice. Survey methodology was used to conduct this pilot study. Forty-nine nurses completed a 33-item survey instrument in 2012. Respondents consisted of nurses attending a critical care continuing education event and graduate nursing students in an acute care nurse practitioner program. Statistical tests were used to examine differences in perceived importance of core competencies in palliative care. Findings from this study demonstrate variation in palliative care knowledge and perceived relative importance of core competencies needed in palliative care practice. This study provides preliminary data about knowledge differences among different nursing groups and a foundation for further study.

End-of-life care education in acute and critical care: the California ELNEC project.

Acute and critical care nurses care for an increasingly aging population in the last stages of life. Unfortunately, many of these nurses do not have adequate education to care for this population. The End-of-Life Nursing Education Consortium (ELNEC) developed a critical care course, and in 2007 the Archstone Foundation provided a grant to educate critical care nurses in California. From 2007 to 2010, 388 participants completed the course and rated it very effective at improving end-of-life care education in their institution. After completing the national ELNEC-Critical Care train-the-trainer course, these participants taught more than 2900 classes in the ELNEC modules to their colleagues. Participants also revised policies and made system changes in their workplaces to provide better care to dying critical care patients and their families. The ELNEC/Archstone program improved acute and critical care nurses' end-of-life care education and, ultimately, practice and serves as a model for future educational efforts.

Music therapy reduces pain in palliative care patients: a randomized controlled trial.

CONTEXT: Treatment of pain in palliative care patients is challenging. Adjunctive methods of pain management are desirable. Music therapy offers a nonpharmacologic and safe alternative. OBJECTIVES: To determine the efficacy of a single music therapy session to reduce pain in palliative care patients. METHODS: Two hundred inpatients at University Hospitals Case Medical Center were enrolled in the study from 2009 to 2011. Patients were randomly assigned to one of two groups: standard care alone (medical and nursing care that included scheduled analgesics) or standard care with music therapy. A clinical nurse specialist administered pre- and post-tests to assess the level of pain using a numeric rating scale as the primary outcome, and the Face, Legs, Activity, Cry, Consolability Scale and the Functional Pain Scale as secondary outcomes. The intervention incorporated music therapist-guided autogenic relaxation and live music. RESULTS: A significantly greater decrease in numeric rating scale pain scores was seen in the music therapy group (difference in means [95% CI] -1.4 [-2.0, -0.8]; P<0.0001). Mean changes in Face, Legs, Activity, Cry, Consolability scores did not differ between study groups (mean difference -0.3, [95% CI] -0.8, 0.1; P>0.05). Mean change in Functional Pain Scale scores was significantly greater in the music therapy group (difference in means -0.5 [95% CI] -0.8, 0.3; P<0.0001) [corrected]: A single music therapy intervention incorporating therapist-guided autogenic relaxation and live music was effective in lowering pain in palliative care patients.

Providing a "good death" for oncology patients during the final hours of life in the intensive care unit.

Cancer is a leading cause of death in the United States. Aggressiveness of cancer care continues to rise in parallel with scientific discoveries in the treatment of a variety of malignancies. As a result, patients with cancer often require care in intensive care units (ICUs). Although growth in hospice and palliative care programs has occurred nationwide, access to these programs varies by geographic region and hospital type. Thus, critical care nurses may be caring for patients with cancer during the final hours of life in the ICU without the support of palliative care experts. This article provides an overview of the meaning of the final hours of life for cancer patients and uses principles of a "good death" and the tenets of hospice care to organize recommendations for critical care nurses for providing high quality end-of-life care to patients with cancer in the ICU.