Communication and Palliation in Trauma Critical Care: Impact of Trainee Education and Mentorship.

BACKGROUND: Surgical residency training requires Advance Care Planning (ACP) and Palliative Care (PC) education. To meet education needs and align with American College of Surgeons guidelines, our Surgical Intensivists and PC faculty developed courses on communication and palliation for residents (2017-18) and fellows (2018-19). We hypothesized that education in ACP would increase ACP communication and documentation. METHODS: The trauma registry of an academic, level 1trauma center was queried for ICU admissions from 2016-2019, excluding incarcerated and pregnant patients. A retrospective chart review was performed, obtaining frequency of ACP documentation, ACP meetings, time from admission to documentation, and PC consultation. We collected ICU quality measures as secondary outcomes: ICU Length Of Stay (LOS), hospital LOS, ventilator days, invasive procedures, discharge disposition, and mortality. Comparisons were made between years prior to (Y 1) and following implementation (Y 2: residents, Y 3: fellows). RESULTS: For 1732 patients meeting inclusion criteria, patient demographics, injuries, and injury severity score were comparable. ACP documentation increased from 19.5% in Y 1 to 57.2% in Y 3 (P < 0.001). Time to ACP documentation was reduced from 47.6 to 13.1 h (P < 0.001) from time of admission. ICU LOS decreased from 6 to 4.8 d (P = 0.004). Patients in Y 3 had fewer tracheostomies and percutaneous endoscopic gastrostomies. PC consultations decreased. Mortality was unchanged. CONCLUSION: Following trainee education, we observed increases in ACP documentation, earlier communication and improvements in ICU quality measures. Our findings suggest that trainee education positively impacts ACP documentation, reduces LOS, and improves trauma critical care outcomes.

Palliative Care Professional Development for Critical Care Nurses: A Multicenter Program.

BACKGROUND: Integrating palliative care into intensive care units (ICUs) requires involvement of bedside nurses, who report inadequate education in palliative care. OBJECTIVE: To implement and evaluate a palliative care professional development program for ICU bedside nurses. METHODS: From May 2013 to January 2015, palliative care advanced practice nurses and nurse educators in 5 academic medical centers completed a 3-day train-the-trainer program followed by 2 years of mentoring to implement the initiative. The program consisted of 8-hour communication workshops for bedside nurses and structured rounds in ICUs, where nurse leaders coached bedside nurses in identifying and addressing palliative care needs. Primary outcomes were nurses' ratings of their palliative care communication skills in surveys, and nurses' identification of palliative care needs during coaching rounds. RESULTS: Each center held at least 6 workshops, training 428 bedside nurses. Nurses rated their skill level higher after the workshop for 15 tasks (eg, responding to family distress, ensuring families understand information in family meetings, all P < .01 vs preworkshop). Coaching rounds in each ICU took a mean of 3 hours per month. For 82% of 1110 patients discussed in rounds, bedside nurses identified palliative care needs and created plans to address them. CONCLUSIONS: Communication skills training workshops increased nurses' ratings of their palliative care communication skills. Coaching rounds supported nurses in identifying and addressing palliative care needs.

ICU Bedside Nurses' Involvement in Palliative Care Communication: A Multicenter Survey.

CONTEXT: Successful and sustained integration of palliative care into the intensive care unit (ICU) requires the active engagement of bedside nurses. OBJECTIVES: To describe the perspectives of ICU bedside nurses on their involvement in palliative care communication. METHODS: A survey was designed, based on prior work, to assess nurses' perspectives on palliative care communication, including the importance and frequency of their involvement, confidence, and barriers. The 46-item survey was distributed via e-mail in 2013 to bedside nurses working in ICUs across the five academic medical centers of the University of California, U.S. RESULTS: The survey was sent to 1791 nurses; 598 (33%) responded. Most participants (88%) reported that their engagement in discussions of prognosis, goals of care, and palliative care was very important to the quality of patient care. A minority reported often discussing palliative care consultations with physicians (31%) or families (33%); 45% reported rarely or never participating in family meeting discussions. Participating nurses most frequently cited the following barriers to their involvement in palliative care communication: need for more training (66%), physicians not asking their perspective (60%), and the emotional toll of discussions (43%). CONCLUSION: ICU bedside nurses see their involvement in discussions of prognosis, goals of care, and palliative care as a key element of overall quality of patient care. Based on the barriers participants identified regarding their engagement, interventions are needed to ensure that nurses have the education, opportunities, and support to actively participate in these discussions.

When open-ended questions don't work: the role of palliative paternalism in difficult medical decisions.

Abstract The balance between patient autonomy and medical paternalism must be reexamined. The tension between autonomy and paternalism is both an ethical and practical issue. Autonomy is the current gold standard approach to patient communication and has grown to the point that patient preference dictates care, even when their choices are not possible or are medically nonbeneficial. Furthermore, we have observed a trend among physicians to avoid making difficult medical decisions by hiding behind a shield of patient autonomy. Paternalism, characterized as the antithesis of autonomy, is widely dismissed as having any role in medicine. We disagree and believe that paternalism still has an important role in medical decision making.

Symptom control in stem cell transplantation: a multidisciplinary palliative care team approach. Part 2: psychosocial concerns.

Stem cell transplantation (SCT) offers a potential cure for patients with otherwise incurable benign and malignant disorders. However, the treatment will cause considerable physical, social, psychological, and spiritual suffering. In part 1 of this review, the management of the physical symptoms was reviewed. In part 2, we discuss the approaches to managing the other aspects of distress that are primarily psychological, social, and spiritual in nature. In practice, these dimensions are not so easily distinguished; the division between physical and psychological symptoms is blurred, and physical symptoms are often interrelated with the patient's emotional status and social support.

Symptom control in stem cell transplantation: a multidisciplinary palliative care team approach. Part 1: Physical symptoms.

Stem cell transplantation (SCT) offers a potential cure for patients with otherwise incurable benign and malignant disorders, but the arduous SCT process may cause considerable physical, social, psychological, and spiritual suffering. Relief of suffering associated with SCT begins by understanding the patient experience and the SCT culture. Symptom burden is the combined impact of all disease- or therapy-related symptoms on the patient's ability to function. In approaching symptom management, the division between physical and psychological symptoms is blurred; physical symptoms are often interrelated with the patient's emotional status and social support. Physical symptoms that frequently occur in SCT include pain, nausea, mucositis, diarrhea, and delirium. At the same time, SCT is recognized as one of the most stressful treatments in modern cancer care, resulting in psychological distress, social isolation, and role changes. Psychological symptoms include depression/ anxiety, grief/loss, demoralization, and anger. Based on our experience on an academic SCT ward for adults, we review physical, psychological, social, and spiritual symptoms during the course of SCT in a two-part series and offer an approach to their management. This month, in part I, we focus on physical symptoms linked to SCT. In a future issue, part II will highlight psychosocial concerns in SCT.