Promoting Excellence : Promoting Palliative Care Excellence in Intensive Care : University of Washington Schools of Medicine and Nursing

Updated September 2005

Grantee:
University of Washington (U of W) Schools of Medicine and Nursing, Seattle, Washington

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., are 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 400-bed county hospital within the University of Washington system in Seattle. The facility is a Level 1 Trauma Center serving four states with 58 ICU beds in six distinct units - Medical, Trauma, Neurosurgical, Surgical, Coronary and Burns- Pediatric ICUs). Patients in the ICUs represent a diverse group from the standpoint of critical illness, chronic illness and ethnicity. Clinicians involved in this project include nurses, physicians, social workers, respiratory therapists and chaplains.

Objectives of the program are:

• Evaluate effectiveness the multi-faceted, interdisciplinary intervention to improve palliative care for all ICU patients and their families;
• Examine the variability and predictors of quality of ICU palliative care; and
• Identify successful components of the intervention and describe institutional and clinician facilitators and barriers.

The five-component intervention includes:

• Clinician education about the principles and practice of palliative care;
• Local clinician champions (nurse, physician, respiratory therapy and social work champions) to provide and 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 of 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" to improve care and enhance sustainability of the program.

Clinician education component includes:

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

System supports include:

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

In their proposal for funding, Dr. Curtis describes the U of W 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:

Related Resources:

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

Critical Care Workgroup

Lessons Learned:

Education alone does not work, other components must be added in to create a successful model.

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, MDiv., 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.
Assoc. Prof.; Assoc. Medical Dir.
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: 206.731.2106
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
Ph: 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 is 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. Visit PromotingExcellence.org for more resources.