1. Palliative Care Integration in the ICU Colleen Tallen M.D. tallencc@mercyhealth.com September 26, 2013

2. Learning Objectives Discuss challenges in the ICU setting Understand key ingredients when initiating Palliative Care into the ICU Know how to assess the ICU’s model of care Evaluate how to address the ICU’s concerns about Palliative Care’s involvement Discuss Mercy Health’s experience in joining the ICU team

3. Challenges in the ICU Patients living longer with chronic illness present to ICU with significant complexity Conflicts between families and staff usually boil down to broken communication Ethics consults and futility policies historically are not practical Reimbursement changes to discourage futile care

4. Key Ingredients when Initiating Palliative Care in the ICU Shared vision - administration, ICU staff, Palliative care team, ethics Unique Palliative Care team components are in place Understanding of ICU culture and practices

5. Shared Vision Open mind to embrace change Healthcare champions in influential positions Empower staff to participate in real solutions for patient/family/staff conflict Model change from reactive to proactive Financial commitment

6. Palliative Care Team Components Honest evaluation of Palliative Care’s expertise and skill set Honest assessment of care bias Evaluate Palliative Care resources Understand expectations related to Palliative Care’s role in the ICU

7. ICU Model of Care “Closed” vs. “Open” admitting privileges can be defined several ways Intensivist only vs generalist model Physicians from one group practice vs several groups Physicians hospital employees vs contracted

8. ICU Model of Care Who writes the orders? Who meets with patients/families? Is there variation in care? Who has accountability for patient outcomes? How is the care coordinated before and after ICU stay?

9. ICU’s Concerns about Palliative Care Involvement Palliative care=hospice (and if it really does, when does the Palliative Care team get involved) Agenda to stop or limit treatments/interventions Confusing role regarding who discusses what with patients/families More healthcare persons involved can be worse Duplication of services ie social worker, spiritual care

10. Mercy Health Saint Mary’s (MHSM) ICU Experience

11. MHSM’s Palliative Care Team’s Philosophy No agenda to stop treatment/intervention. No agenda to help ICU staff “get it” Goal to shift from a reactive to anticipatory model of care related to complex decision making Joins ICU staff NOT replaces or displaces Value healthcare provider and patient/family diversity of opinions and goals

12. MHSM’s Palliative Care’s ICU Journey ICU Medical Director desired Palliative Care involvement though no other ICU doctor wanted palliative care in the ICU ICU docs and staff started noticing cases went smoothly with PC involvement so consults increased Ethics consults and involvement dropped significantly Palliative care was getting involved after crisis identified

13. MHSM’s Palliative Care’s ICU Journey Started meeting with head nurse, SW, spiritual care, ethics everyday to identify patients proactively Identified triggers for patients at risk for crisis. Became available 24 hours by phone and 7 days a week in person Established a weekly meeting with ethics, ICU staff, PC staff, administration to discuss all ICU patients and to review past weeks ICU patients Daily ICU rounds with ICU team with patients identified for PC most times on Day 1 of ICU stay

14. Triggers for PC Involvement High risk mortality High chance sustained morbidity (change in functional status or quality of life) Complicated or long hospital stay expected Future decision-making likely Complicated family dynamic

15. MHSM’s Palliative Care’s Philosophy of Care Acclimating patient/family to ICU culture Understand family dynamic - culture, religion, life experience, expectations Help patient/family’s understanding of disease process and prepare for decision making Understand differing viewpoints from medical specialist Continuity of care Symptom management

16. Lessons Learned We’re not known as the hospice people Didn’t force the process but let each case speak for itself Palliative Care kept data that helped show ICU value Stayed neutral. Did not join into opinion-driven conversations