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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.
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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 persons and their families. Visit PromotingExcellence.org for more resources.
