New Jersey Medical School

Grantee:
University of Medicine and Dentistry of New Jersey, New Jersey Medical School, Newark, New Jersey

Project Overview

Title: Interdisciplinary Model for Palliative Care in the Trauma/Surgical ICU

The University of Medicine and Dentistry of New Jersey, New Jersey Medical School (UMDNJ) project developed an exportable model of palliative care in trauma/surgical intensive care, a new arena for palliative care services. The project developed and implemented the model at University Hospital, a 446-bed academic medical center on the Newark campus of the University of Medicine and Dentistry of New Jersey. The hospital is a Level 1 Trauma Center with an ethnically diverse patient population; only 17 percent of its patients receive Medicare benefits.

Project activities centered in the hospital's Surgical Intensive Care Unit and extended into the Emergency Department and step-down unit. The UMDNJ project patient populations include those experiencing trauma, liver transplants and general and other surgery, although the families of these patients were also direct recipients of the palliative care interventions.

The project's Co-Principal Investigators, Anne Mosenthal, M.D. and Pat Murphy, Ph.D., A.P.N., believe that the collaboration between University Hospital and the New Jersey Medical School is distinctive because "patients in the Surgical Intensive Care Unit are often young and critically ill without warning, and this causes an enormous amount of stress on patients, families and staff." There is great uncertainty in the Surgical ICU about who will die, and familiar palliative care models do not fit the clinical realities of a Trauma/Surgical ICU (SICU).

Mosenthal and Murphy, along with their colleagues, built their project on shared decision making, pain and symptom management and ongoing family bereavement support. Staff education was a key component of the project. It was based on both the EPERC (End-of-Life/Palliative Education Resource Center) for physicians and ELNEC (End-of-Life Nursing Education Consortium) for nurses curriculums. A core team, in place and well-accepted, introduced palliative care tools and practices into existing clinical structures and trained selected nurses and physicians' assistants as 24-hour onsite resource palliative care "experts." The project was integrated into the structures and processes of the SICU, and did not function as an external consult service.

Project Goals were:

  • Integrate palliative care into total critical care of the surgical or injured patient;
  • Achieve institutional culture change so that surgical critical care providers perceive palliative care as part of their clinical practice;
  • Based on the intervention, develop an exportable model, standards or pathway for critical care that incorporate the principles and domains of palliative care for all critically ill surgical patients regardless of diagnosis; and
  • Increase patient and family satisfaction and physician and nurse satisfaction with the compassion dimensions of care in the SICU.

The following interventions supported these goals:

  • Every patient admitted to the SICU had:
    • Bereavement/psychosocial support for patients/families within 24 hours of admission to the SICU;
    • Interdisciplinary palliative care assessment within 24 hours of admission;
    • Family meeting with physician and nurse within 72 hours of admission to the SICU;
    • Comprehensive interdisciplinary palliative care plan on the medical record within 72 hours;
    • Update of palliative care plan for each patient every 72 hours or as condition necessitates; and
    • Implementation of structured palliative/end-of-life care pathway and standing orders for patients who are identified from the above processes to be imminently dying.
  • Palliative care performance were integrated into morbidity-and-mortality conferences (M & Ms) and peer reviews:
    • SICU mortality reviews;
    • Surgery M & Ms; and
    • Liver transplant morbidity reviews.

Interdisciplinary Intervention Team that included the project team (see below), palliative resource nurses and a pastoral care provider.


Tools

Resources

  • Bibliography (PDF 12 KB / 1 page)
    Download Acrobat Reader
  • Articles:
    Mosenthal A. "Palliative Care in the Surgical ICU." In Surgical Clinics of North America, 85 (2005): 303-313.

    Mosenthal A. & Murphy P. "Trauma care and palliative care: time to integrate the two?" In Journal of the American College of Surgeons. 197, 3, 509-516, September, 2003.

Related Resources:

Book Chapter:
Mosenthal A., Price D. & Murphy P. "Interdisciplinary care." In Surgical Palliative Care, Dunn G.P. & Johnson A. (ed). Oxford, Oxford University Press, 2004

Critical Care Workgroup

Lessons Learned

  • Implement a Family Support Team. This project's team facilitated family meetings, taught communication skills to physicians and nurses and contributed to the project's success.
  • Use existing personnel, rather than new hires, to increase trust. Grow people from within and use existing processes.
  • Avoid adding more work for the ICU staff; try to add value without adding an extra burden.
  • When implementing a new program, ascertain clinician needs and respond to them.
  • Communicate early with the patient and family. Early prognostication will also help guide palliative goals of care. This project intervened within 24 hours of admission.
  • Make palliative care the standard of care with order sheets, Morbidity and Mortality (M and M) discussions and family meetings.
  • Do physician peer reviews of end-of-life care on all deaths. This project used the process as an educational tool.
  • Develop a strong chaplainry program. This project involved community clergy, and included 24/7 pastoral personnel coverage.
  • Conduct spiritual assessments early after admission.
  • Introduce all patients in the ICU to palliative care. Palliative care isn't just for dying patients.
  • Train medical students in palliative care to influence future physician practice and attitudes.
  • Communicate your successes within your institution. In this project, the enthusiasm of the palliative care staff was contagious and led to support from departmental and administrative leadership.

Team Members

Anne C. Mosenthal, M.D., FACS, Principal Investigator
Chief of Surgical Critical Care
University of Medicine & Dentistry of New Jersey

Patricia Murphy, Ph.D., A.P.N., FAAN, Principal Investigator
Advanced Practice Nurse, Ethics and Bereavement
University of Medicine & Dentistry of New Jersey

Kris Barker, M.A.
Research Tech Specialist
University of Medicine & Dentistry of New Jersey

Janet Harris Smith, M.S.
Bereavement/Family Support Counselor
University of Medicine & Dentistry of New Jersey

Susan McVicker, M.S.
Bereavement/Family Support Counselor
University of Medicine & Dentistry of New Jersey

Robin Preisler
Executive Director, Marketing and Media Relations
University of Medicine & Dentistry of New Jersey

Contact Information

Anne Mosenthal, M.D., FACS, Principal Investigator
Chief of Surgical Critical Care
University of Medicine and Dentistry of New Jersey School
150 Bergen Street
Newark, NJ 07103
Phone: 973.972.6398
Fax: 973.972.7441
mosentac@umdnj.edu

Patricia Murphy, Ph.D., A.P.N., FAAN, Principal Investigator
Advanced Practice Nurse, Ethics and Bereavement
University of Medicine and Dentistry of New Jersey
University Hospital G-345
150 Bergen Street
Newark, NJ 07103
Phone: 973.972.7251
Fax: 973.972.7154
murphypa@umdnj.edu

Web sites:
www.umdnj.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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