Domain 3 - Continuity of Care

  • Maximize Continuity of care across clinicians, consultant and settings:
    • Consider a policy of compassionate non-discharge/non-transfer of the patient from the ICU if the patient's death is a reasonable expectation within the ensuing 12-48 hours, and if the patient and/or family desire it.
    • Identify primary care team to maintain/facilitate continuity of care across nurses, physicians, therapists etc.
  • Orient new clinicians regarding the patient and family status:
    • If the patient transferred from the ICU, ensure orders are consistent with the plan of care in the ICU and that a comprehensive report is given to new clinicians.
    • Ensure that needed equipment is available on the unit to which the patient is transferred.
    • Ensure that the patient's code status is included in reports, during transfers to procedure areas and transfers to other services.
  • Prepare the patient and/or family for a change of clinician(s) and introduce new clinicians:
    • Include new clinicians in family meetings to provide a "bridge" and enhance continuity of care.
    • Include questions on the family's Clinician Communication Evaluation survey about the effectiveness of the team during the transition of clinicians, and the perceived continuity or disruption of care.

Promoting Excellence in End-of-Life Care was a national program of the Robert Wood Johnson Foundation dedicated to long-term changes in health care institutions to substantially improve care for dying people and their families.