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University of Washington Schools of Medicine and Nursing

Project Overview

Title: Promoting Palliative Care Excellence in the ICU

J. Randall Curtis, M.D., M.P.H. and Patsy D. Treece, R.N., M.N., were Co-Principal Investigators for this project, a multi-faceted, interdisciplinary quality improvement intervention to improve palliative care for all patients and their families in seven ICUs located at Harborview Medical Center, a 350-bed county hospital within the University of Washington system in Seattle. The facility is a Level 1 Trauma Center serving four states with 65 ICU beds in seven distinct units - Medical, Trauma, Neurosurgical, Surgical, Coronary, Burns and Pediatric ICUs. Patients in the ICUs represented a diverse group from the standpoint of critical illness, chronic illness and ethnicity. Clinicians involved in this project included nurses, physicians, social workers, respiratory therapists and chaplains.
The goal of the intervention was to improve care for all patients in the ICU and their families. Objectives of the program were:

  • Evaluate effectiveness of the multi-faceted, interdisciplinary intervention to improve palliative care for all ICU patients and their families;
  • Examine the variability and predictors of quality ICU palliative care; and
  • Evaluate the successful components of the intervention and describe institutional and clinician facilitators and barriers to its implementation, in order to inform interventions at other hospitals.

The five-component intervention included:

  • Clinician education about the principles and practice of palliative care;
  • Local clinician champions (nurse, physician, respiratory therapy and social work champions) to provide, role modeling and promote attitudinal changes concerning palliative care;
  • Academic detailing of ICU directors (in-depth interviews) to identify ICU-specific barriers to palliative care and develop and implement solutions;
  • Feedback to clinicians on quality improvement data on pain ratings, family satisfaction, nursing satisfaction and quality of dying and death scores (compared to other units) to clinicians; and
  • Implementation of "systems supports" (order protocols and pathways, and staff support) to improve care and enhance sustainability of the program.

The clinician education component included:

  • Decision making about ICU palliative care and goals of care;
  • Communication skills with family and within team;
  • Symptom assessment and management;
  • Withdrawal of life support;
  • Spiritual care and family bereavement support; and
  • Cross-cultural awareness/accommodation.

System supports included:

  • Standardized order forms:
    • Pain and sedation protocols; and
    • Withdrawal of life support protocol;
  • Staff support programs:
    • "Death rounds"; and
    • Debriefing with Palliative Care Specialist;
  • Integrating cultural mediators; and
  • Development of a bereavement program.

In their proposal for funding, Dr. Curtis described the University of Washington model and team, "We are excited about the prospect of combining the many and diverse talents at our institution in a coordinated effort to produce a state-of-the art program that could be generalized to other institutions."

Tools

Resources

" Managing Death in the Intensive Care Unit, The Transition from Cure to Comfort" edited by J. Randall Curtis and Gordon D. Rubenfeld.
This book can be ordered from Oxford University Press by calling 1-800-451-7556.

Lessons Learned

  • Identify "local champions" for the intervention from a variety of disciplines (for example, social work, chaplains, nursing and respiratory therapy). Make sure people understand what it means to be a local champion, and clearly spell out expectations. Give local champions the necessary tools to be successful.
  • Get early support from hospital leadership, including the Medical Director and the Nursing Director.
  • Conduct palliative care rounds for medical residents on MICU service and implement resident rotations with the palliative care consult service. These educational opportunities yield increased awareness of palliative care, and with this project increased requests for palliative care consults.
  • Show unit staff their data during the project evaluation process to motivate them to improve on measurements where they received low scores.
  • Use the " Getting to Know Me " poster as a communication tool.
  • Education alone does not work in introducing a palliative care program in the ICU. Other intervention components must be added in to create a successful model.
  • The prevailing perception that palliative care is delivered after withdrawal of life support can be a barrier to a program's implementation. Palliative care can be started on admission; the perception that it is delivered after withdrawal of life support can be changed with education and practice ("tell and show").

Team Members

J. Randall Curtis, M.D., M.P.H., Principal Investigator
Associate Professor of Medicine
University of Washington
Dept. of Medicine, Division of Pulmonary and Critical Care Medicine
Harborview Medical Center

Patsy Treece, R.N., M.N. Principal Investigator
Research Nurse
University of Washington
Dept. of Medicine, Division of Pulmonary and Critical Care Medicine
Harborview Medical Center

Theresa Braungardt, R.N.
Nurse Manager, MICU/NICU
University of Washington
Harborview Medical Center

Nancy Chambers, M.Div., C.T.
Clinical Director, Spiritual Care
University of Washington
Harborview Medical Center

Ruth Engelberg, Ph.D.
Associate Director, End-of-Life Care Team
Research Program
Acting Assistant Professor
Division of Pulmonary and Critical Care
University of Washington
Harborview Medical Center

Stephanie Gundel, R.D., C.D.
Research Assistant
Dept. of Medicine, Division of Pulmonary and Critical Care
University of Washington
Harborview Medical Center

Darrell Owens, Ph.D., R.N.
Palliative Care Specialist
University of Washington
Harborview Medical Center

Kenneth P. Steinberg, M.D.
Associate Professor; Associate Medical Director
Critical Care Services
University of Washington
Harborview Medical Center

Ellen Wilhelm, M.Ed.
Research Coordinator
Pulmonary and Critical Care
University of Washington
Harborview Medical Center

Contact Information

J. Randall Curtis, M.D., M.P.H., Principal Investigator
Associate Professor of Medicine
University of Washington
Dept. of Medicine, Division of
Pulmonary and Critical Care Medicine
Harborview Medical Center
325 Ninth Avenue, Box 359762
Seattle, WA 98104
Phone: 206.731.3356
Fax: 206.731.8584
jrc@u.washington.edu

Patsy Treece, R.N., M.N., Principal Investigator
Research Nurse
University of Washington
Dept. of Medicine, Division of Pulmonary and Critical Care Medicine
Harborview Medical Center
325 9th Ave., Box 359762
Seattle, WA 98104
Phone: 206.744.9517
Fax: 206.744.9982
ptreece@u.washington.edu

Web sites:
http://depts.washington.edu/eolcare/
http://depts.washington.edu/pulmcc/

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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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