Clinician attitudes and beliefs about ICU- based ... · Hua M, et al. 2015; Zalenski R, et al....

Clinician attitudes and

beliefs about ICU-

based palliative care

Christopher Cox // Duke University // DukeProSPER.org

Disclosures

No commercial interests; NIH, PCORI, DIHI, DTRI

Advice to Canada: build a wall to keep U.S. out, ASAP!

Palliative care: patient- & family-

centered care that aims to optimize QOL

by addressing physical, emotional,

intellectual, and spiritual needs.

Wysham NG, Hua M, Hough CL, Gundel S, Docherty SL, Jones

DM, Reagan O, Goucher H, McFarlin J, Cox CE. Improving ICU-

based palliative care delivery: a multicenter, multidisciplinary

survey of critical care clinician attitudes and beliefs.

Crit Care Med. 2016 in pressNot addressing needs consistently given

the high variability in ICU-based palliative

care quality.

What we need: ‘Interventions and

care models that match existing

availability of personnel and are

broadly scalable.’ Block S. Lancet 2014But to get to scalable,

you have to

understand the users.

Methods: aims & goals

Aim

Explore attitudes, beliefs, and preferences about

integration of palliative care specialists into ICU care

Goal

Inform development of a sensible collaborative care

delivery model (i.e., ICU team + pall care team)

Methods: design, measures, analyses

Design

• Cross-sectional study

Measures

• Survey of our own design

• Responses were multiple-selection and 5-item Likert scales

• 23 potential trigger criteria in published literature

• Open-ended items

Analyses

–Descriptive, comparative, exploratory

–Thematic content analysis

Results: 4 sites & 303 participants

Sites: 3 academic & 1 community

– Private, urban, NE

– Public, urban, NW

– Private non-profit, midsize SE

– Community, urban, SE

– None with trigger systems for pall care

– ICUs: medical, surgical, cardiac, trauma,

neuro

Participants: diverse clinical roles

– Nurses (49%)

– Attendings, fellows (37%)

– APPs (13%)

– 88% response rate

75% - palliative care consultation is underutilized*

63% - palliative care consultation is effective.

73% - ‘highly interested’ in developing new models.

*Nurses slightly more likely to agree than physicians (p=0.001) and medical more likely

to agree than surgical (p=0.008).

Do you think palliative care specialist consultation

is appropriately utilized in the ICU…or effective?

By what process would you prefer to integrate

palliative care specialists into the ICU setting?

less autonomymore autonomy

6732

16 33

13 4

27 25

5 8

nursephysician

8043

16 55

12 2

37 292 22

palliative care underusedpalliative care overused

23 99

10 61

15 2

25 40

1 22

palliative care effectivepalliative care ineffective

9323

32 32

10 7

28 38

12 10

Formal

palliative care -

ICU team

interaction

Informal

palliative care -

ICU team

interaction

No change

needed

n = 17 (6%)

n = 66 (22%)

n = 123 (40%)

n = 24 (8%)

n = 71 (24%)

EHR-

based

triggers

Multiple

acceptable

types



less autonomymore autonomy

6732

16 33

13 4

27 25

5 8

nursephysician

8043

16 55

12 2

37 292 22

palliative care underusedpalliative care overused

23 99

10 61

15 2

25 40

1 22

palliative care effectivepalliative care ineffective

9323

32 32

10 7

28 38

12 10

Formal

palliative care -

ICU team

interaction

Informal

palliative care -

ICU team

interaction

No change

needed

n = 17 (6%)

n = 66 (22%)

n = 123 (40%)

n = 24 (8%)

n = 71 (24%)

EHR-

based

triggers

Multiple

acceptable

types

No differences were seen by ICU, site, job type, or seniority.



How would you prefer to operationalize specialist

palliative care integration?





ICU MD orders n=16 (5%)

ICU nurse screens*

n=76 (25%)

ICU physician and nurse screen

n=73 (24%)

Multiple strategiesn=45 (15%)

Palliative care team screens

n=92 (31%)29%

31%

21%

16%

4%

Nursesn=191 (63%)




ICU nurse screens*

n=76 (25%)


n=73 (24%)



n=92 (31%)

16%

30%

13%

8%

33%

Physiciansn=114 (37%)




ICU nurse screens*

n=76 (25%)


n=73 (24%)



n=92 (31%)29%

31%

21%

16%

4%

Nursesn=191 (63%)

16%

30%

13%

8%

33%

Physiciansn=114 (37%)

p=0.51

p=0.004

p=0.63

p=0.54

p=0.11



What factors would enhance your interest in

developing new palliative care systems?

What factors would enhance your interest in

developing new palliative care systems?

* p < 0.05.

5.7

28.8

8

7

5.2

4.9

4.4

2.6

5

22

16.5

9.8

8.3

4.3

2.8

2.6

2

3.6

12.1

7.8

7.4

4.9

4.2

2.8

2.7

1.8

0 5 10 15 20 25 30

PRE-EXISTING CHARACTERISTICS

Active Stage 4 or metastatic malignancy

Dementia or chronic neuromuscular disease

Age >___ with ≥___ major comorbidities

Baseline O2-dependent and now on ventilator

Functional dependence at baseline

Admitted from nursing home or long-term care

Advanced age (>___ years old)

FAMILY NEEDS AND CONFLICT

Unrealistic goals of care or expectations for recovery

Need help with goals of care decision making

Conflict within family or between patient/family and staff

Non-physician staff believe patient/family could benefit

Decision making for acute dialysis with mortality >___%

Refractory physical symptoms

Decision making for tracheostomy or surgically-placed feeding tube

Refractory psychological symptoms

CURRENT CRITICAL ILLNESS/ ICU COURSE

Multiple organ system failure for ___ days

Cerebral ischemia __ days after arrest or stroke

Intracerebral hemorrhage + ≥___ days ventilation

Predicted mortality ≥__% by SOFA or APACHE

≥___ ICU admissions in past ___ months

Mechanical ventilation ≥____days

ICU length of stay ≥__ days

ICU admission after ≥__ hospital days

Clinician attitudes about 23 published triggers

(agree : disagree ratios)

5.7

28.8

8

7

5.2

4.9

4.4

2.6

5

22

16.5

9.8

8.3

4.3

2.8

2.6

2

3.6

12.1

7.8

7.4

4.9

4.2

2.8

2.7

1.8

0 5 10 15 20 25 30

























ICU length of stay ≥__ days

ICU admission after ≥__ hospital days

Clinician attitudes about 23 published triggers

(agree : disagree ratios)

Most preferred

Least preferred

What is the ideal concept

for a trigger?

Nurses

Nurses

Physicians

Nurses

Physicians

Themes from open-ended questions

• Conflict about provider roles‘…bedside RNs would provide a "constant" with the trigger system. Our residents cannot…add this to their load. Realistically, the residents, might not be as quick to assess for triggers as bedside RNs who have more face time with families’

• Implementation concerns

‘Any trigger system which is implemented needs to be simple to follow. Anything which is too busy will not be received in a positive manner.’

• Impact on ICU clinician - family relationship

‘Triggered consults could lead to conflicting information and confusing messages for families.’

Summary / discussion

1. Balancing triggers with actual needs at a time

when momentum is building for ‘more triggers’

Hua M, et al. 2015; Zalenski R, et al. 2014; Lupu et al. 2010; Kamal AH et al. 2016; Creutzfeld C 2016









5.7 million ICU patients & families

1.5 million are ‘trigger positive’

Unmet needsTrue positive

Needs metFalse positive








spiritual

needs

emotional

needs

physical

symptoms

commun-

ication

social

support

decision

support

cultural /

language

inform-

ational

1

How to identify actual unmet needs?1

Unmet palliative care needs








Are needs for trigger positive > trigger negative?2

2

spiritual

needs

emotional

needs

physical

symptoms

commun-

ication

social

support

decision

support

cultural /

language

inform-

ational

1










Are needs for trigger positive > trigger negative?2

2

10,000 intensivists

5,500 pall. care specialists

3

How to deliver collaborative care?3

Clinicians

spiritual

needs

emotional

needs

physical

symptoms

commun-

ication

social

support

decision

support

cultural /

language

inform-

ational

1







Process

Barriers

Structural

Barriers




2

10,000 intensivists


3

Clinicians

spiritual

needs

emotional

needs

physical

symptoms

commun-

ication

social

support

decision

support

cultural /

language

inform-

ational

1



5.2 million are ‘trigger negative’


Process

Barriers

Structural

Barriers




1

10,000 intensivists


3

Clinicians

spiritual

needs

emotional

needs

physical

symptoms

commun-

ication

social

support

decision

support

cultural /

language

inform-

ational

2




2. ICU clinicians value the assistance of

palliative care specialists, but disagree about the

role of the bedside nurse Figure 1. Conceptual framework: this R21 addresses identification and care delivery gaps with a patient-centered approach.

- Psychological

distress

- Goal

concordance

- Length of stay

Aim 2 addresses the Care Delivery Gap:- Develops need-based collaborative care model

- Includes nursing, social work, clergy

- Scalable features

Aim 1 addresses the Identification Gap:- Derives needs typologies for Aim 2’s care model

- Rigorously evaluates needs vs. triggers

- Provides mobile app to measure needs & outcomes

10,000 intensivists


?

Care delivery uncertainty? Outcomes?

How to identify unmet needs?

spiritual

needs

emotional

needs

physical

symptoms

commun-

ication

social

support

decision

support

cultural /

language

inform-

ational

?

Unmet palliative care needs?

Needs unmet?

true positive

Needs met?

false positive


5.7 million ICU patients & families*

nurses, social

workers, clergy

= 10,000

*family not shown

How to deliver collaborative care?

5.7

28.8

8

7

5.2

4.9

4.4

2.6

5

22

16.5

9.8

8.3

4.3

2.8

2.6

2

3.6

12.1

7.8

7.4

4.9

4.2

2.8

0 5 10 15 20 25 30

























Challenging

3. Implications for the role of information

technology in future care models: the triggers we

like the best are the hardest to automate in EHRs

EHR

Data RegistryTrigger +

need app

standards standards

Next steps

standards

ResearcherClinicianFamily

PCplanner

app y

EHR x

Data

Registry z

3. Implications for the role of information

technology in future care models: the triggers we

like the best are the hardest to automate in EHRs

Strengths / limitations

• Strengths

–Multi-center, large sample size, high response rate

–Mixed methods approach

– Included multidisciplinary ICU team

• Limitations

–Exclusively academic

–Did not include other specialties

• eg. surgeons, oncologists, cardiologists

–Did not include palliative care specialists, PCPs,

patients, families

Conclusion

• Palliative care specialists are valued by ICU teams

• Yet ICU team dynamics are imperfect & uncertain

• Missed opportunity: nurses

• Triggers + needs is most sensible, but requires:

• Metrics & systems

• ‘Rules’ re: ICU physician – ICU nurse interactions

Thanks so much

Christopher Cox // [email protected] // DukeProSPER.org

Strategy 3: needs assessment alone

needs assessmentPhysical symptoms

Psychiatric symptoms

Spiritual support

Social support

Information

Communication / conflict

Decision making

Cultural / language

outcomes

burnout

outcomes

burnout

Families Hospital

burnout

Complex needsSimpler or no needs

Palliative care +

ICU team + digital tools


interventions

Clinicians

LOSpsych.

distress

EOL care

quality

Patients

Families Hospital

Strategy 2: poor outcome phenotype

with needs assessment

burnout

Complex needsSimpler needs

needs assessment

poor outcome phenotypes

needs assessment

Palliative care consult +



interventions

Acute

severe

illness

Chronic

critical

illness

Elderly,

poor

function

Declining

health

trajectory

Physical symptoms

Psychiatric symptoms

Spiritual support

Social support

Information

Communication / conflict

Decision making

Cultural / language

Clinicians

LOSpsych.

distress

EOL care

quality

Patients

interventions

Strategy 1: current trigger strategy

in most hospitals

c

outcomes

Hospital

LOS

Cardiac

arrest

Ventilator

>7 days

Age >65

+ vent

LOS >2

weeks

Palliative care consultants

see all trigger patients

trigger criteria

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Clinician attitudes and beliefs about ICU- based ... · Hua M, et al. 2015; Zalenski R, et al....

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