Feasibility and Acceptability of a Palliative Approach Screening Tool in the Intensive Care Unit

Jane Venis, MSN, RN; Peter Dodek, MD, MHSc

Disclosures

Am J Crit Care. 2020;29(3):214-220. 

In This Article

Abstract and Introduction

Abstract

Background: Identifying critically ill patients who have unmet needs for palliative care is the first step in integrating the palliative approach for patients and their families into intensive care units.

Objective: To explore how palliative care is addressed in an intensive care unit and to develop and test a screening tool for unmet needs that may be met through the palliative approach.

Methods: A mixed-methods study was conducted in the intensive care unit of a tertiary care hospital to explore the palliative approach. Focus groups and a survey were used to identify items for the screening tool. After pilot testing of the tool, interviews were conducted to refine the content.

Results: The first focus group (14 participants) revealed participants' frustration with unclear communication and a desire for better collaboration among health care team members regarding patients with serious life-limiting illnesses and their families. The survey (response rate: 20%; 30 of 150) showed clinicians' preference for items that identify specific needs rather than diagnoses. The second focus group (8 participants) yielded strategies to operationalize the tool for all patients in the intensive care unit. After 2 separate pilot testing cycles, bedside nurses noted that use of the screening tool prompted earlier discussions and broader assessments of what is meaningful to patients and their families.

Conclusion: Development of a screening tool for unmet palliative care needs among intensive care unit patients is feasible and acceptable and may help to systematically integrate the palliative approach into routine care for critically ill patients.

Introduction

Enhancing palliative care has become a health care priority. According to the former US Institute of Medicine (now the National Academy of Medicine), improvement in the palliative approach is necessary to meet present and future health care challenges.[1] A continued focus on "saving" or curing patients with serious illness (defined as a health condition with high associated mortality that adversely affects quality of life and daily functioning or a condition resulting in caregiver strain)[2] in critical care makes it difficult to integrate the palliative approach because of competing priorities related to resuscitation, organ support, and other treatments.[3]

According to the Canadian Nurses Association, the palliative approach involves palliative care principles such as promoting hope, dignity, and relief of suffering throughout the trajectory of a life-limiting disease, rather than just at the end of life.[4] Communication with the patient and the patient's family is central to the decision-making process and involves sensitive and ongoing elicitation of their values, needs, and wishes with a reduced focus on prognosis.[4]

The palliative approach is a philosophy of care that does not require specialty palliative care services and can be systematically integrated into a care setting early in the disease course by generalist clinicians.[5–8] The integration of palliative principles into the intensive care unit (ICU) setting requires improvement.[9] Seriously ill patients and their families often have specific unaddressed physical, psychological, emotional, and spiritual needs.[10] Various tools and models have been developed to help identify patients who have unmet palliative needs through screening criteria or "triggers."[5,10–17] To our knowledge, however, no validated or standardized palliative screening tools have been expressly designed for the ICU. Many palliative screening tools for the outpatient and primary care settings contain general and specific criteria for health decline not well suited for the ICU.[15–17] Tools for the ICU include mostly disease-oriented triggers that have been developed for specialty palliative care consultation and focus less on psychosocial and spiritual support needs.[11] We incorporated existing tools into the development of a screening tool used by nurses in our ICU, referring to recommendations and guidance from the Improving Palliative Care in the ICU Advisory Group.[18] Engaging bedside nurses in such efforts is important and can promote high-quality palliative care in the ICU.[19–21]

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