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Massachusetts General Hospital and Harvard Medical School

Project Overview:

Title: Merging Palliative and Critical Care Cultures in the Medical Intensive Care Unit

The Massachusetts General Hospital and Harvard Medical School project utilized program grant funds to merge a well-established palliative care program with a Medical Intensive Care Unit (ICU) at Massachusetts General Hospital (MGH). MGH is an 875-bed (with 122 ICU beds) urban, tertiary care teaching hospital with Magnet hospital status affiliated with Harvard Medical School. MGH is a Level 1 Trauma Center.

The MGH Palliative Care Service (PCS) is one of the most experienced palliative care teams in the country. Members of the PCS team joined with other clinicians at the hospital to form an interdisciplinary leadership team that introduced patient and family-centered palliative care practices into the Medical ICU and merged palliative care and critical care cultures.

Co-Principal Investigators for the project were J. Andrew Billings, M.D., and Adele Keeley, R.N. Dr. Billings describes their model, "We identified, piloted and evaluated a series of practical, transferable and measurable interventions that assured greater attention to the physical, psychosocial and spiritual suffering of all patients admitted to the Medical Intensive Care Unit and their families." All health professionals, as well as health profession students, were exposed to palliative care practice, with the existing PCS serving as trainers and consultants. Cross training between the Palliative Care Service staff and ICU staff assured training for the palliative care staff in the culture and practice of critical care medicine. Billings explains that the training included, "role modeling about palliative care and relevant communications skills."
Project Goals were:

  • Improve and standardize physical and psychosocial/spiritual end-of-life care in the institution;
  • Strengthen staff education and support programs so that staff have access to state-of-the-art palliative care; and
  • Generate, publish and otherwise disseminate useful evaluation data about transferable improvements.

Project Intervention Components were:

  • Recruitment and training of Palliative Care Nurse Champions;
  • Development of Palliative Care Curriculum and Tools;
  • Palliative Care Grand Rounds;
  • Study Procedures and Evaluation:
    • Chart abstractions;
    • Questionnaires for families;
    • Clinical education surveys for nurses and physicians;
    • Quality of death survey for nurses; and
    • Quality of death survey for families.

Tools

Resources

Related Resources:

Critical Care Workgroup

Lessons Learned

  • Look for moral distress and address it when necessary.
  • Have palliative care clinicians (both physician and nurse) round in the ICU to improve communication.
  • Pay attention to the uniqueness of individual cultures when introducing palliative care into the ICU environment. Culture change takes a long time.
  • Avoid adding more work to an already busy staff.
  • Use the " Getting to Know Me " poster to deliver patients from anonymity.
  • Use ethics rounds as part of the project.
  • Get buy-in from the ICU staff when introducing a palliative care consult service into the ICU.
  • Partner with the patients' families.
  • It is difficult to quantitatively measure many palliative care interventions (such as family meetings).
  • Projects with nurse-physician Co-Principal Investigators work well. It was important to this project's success to have the ICU Nurse Manager as a Co-Principal Investigator.

Team Members

J. Andrew Billings, M.D., Principal Investigator
Director, Palliative Care Services
Massachusetts General Hospital

Adele Keeley, R.N., Principal Investigator
Nurse Manager, Medical ICU
Massachusetts General Hospital

Joel Bauman, M.D.
Staff Physician, Palliative Care Service
Massachusetts General Hospital

Alexandra Cist, M.D.
Pulmonary/Critical Care & Clinical Ethics
Massachusetts General Hospital

Edward E. Coakley, R.N.
Project Advisor
Director Emeritus
Massachusetts General Hospital

Connie Dahlin, M.S.N., A.N.P.
Palliative Care Nurse Practitioner
Massachusetts General Hospital

Paul Montgomery, Ph.D.
Bereavement Coordinator
Massachusetts General Hospital

B. Taylor Thompson, M.D.
Director, Medical ICU
Associate Professor of Medicine
Pulmonary and Critical Care
Massachusetts General Hospital

Marilyn G. Wise, M.S.W., LICSW
Social Worker, Medical ICU
Massachusetts General Hospital
Palliative Care Nurse Champions

Contact Information:

J. Andrew Billings, M.D., Principal Investigator
Director, Palliative Care Services
Massachusetts General Hospital
55 Fruit Street, Founders 600
Boston, MA 02114
Ph: 617.724.9197
Fax: 617.724.8693
jbillings@partners.org

Adele Keeley, R.N., Principal Investigator
Nurse Manager, Medical ICU
Massachusetts General Hospital
Blake 7 MICU
Boston, MA 02114
Ph: 617.726.2594
Fax: 617.724.8410
akeeley@partners.org

Web sites:
www.massgeneral.org/palliativecare/
www.hms.harvard.edu/cdi/pallcare/
www.mgh.harvard.edu/

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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.

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