Medline ® Abstract for Reference 33
of 'Palliative care: Issues in the intensive care unit in adults'
End-of-life care for the critically ill: A national intensive care unit survey.
Nelson JE, Angus DC, Weissfeld LA, Puntillo KA, Danis M, Deal D, Levy MM, Cook DJ, Critical Care Peer Workgroup of the Promoting Excellence in End-of-Life Care Project
Crit Care Med. 2006 Oct;34(10):2547-53.
OBJECTIVE: One in five Americans dies following treatment in an intensive care unit (ICU), and evidence indicates the need to improve end-of-life care for ICU patients. We conducted this study to elicit the views and experiences of ICU directors regarding barriers to optimal end-of-life care and to identify the type, availability, and perceived benefit of specific strategies that may improve this care.
DESIGN: Self-administered mail survey.
SETTING: Six hundred intensive care units.
PARTICIPANTS: A random, nationally representative sample of nursing and physician directors of 600 adult ICUs in the United States.
INTERVENTIONS: Mail survey.
MEASUREMENTS AND MAIN RESULTS: We asked participants about barriers to end-of-life care (1 = huge to 5 = not at all a barrier), perceived benefit of strategies to improve end-of-life care, and availability of these strategies. From 468 ICUs (78.0% of sample), 590 ICU directors participated (406 nurses [65.1% response]and 184 physicians [31.7% response]). Respondents had a mean of 16.6 yrs (sd 7.6 yrs) of ICU experience. Important barriers to better end-of-life care included patient/family factors, including unrealistic patient/family expectations 2.5 (1.0), inability of patients to participate in discussions 2.7 (0.9), and lack of advance directives 2.9 (1.0); clinician factors, which included insufficient physician training in communication 2.9 (1.1) and competing demands on physicians' time 3.0 (1.1); and institution/ICU factors, such as suboptimal space for family meetings 3.5 (1.2) and lack of a palliative care service 3.4 (1.2). More than 80% of respondents rated 14 of 14 strategies as likely to improve end-of-life care, including trainee role modeling by experienced clinicians, clinician training in communication and symptom management, regular meetings of senior clinicians with families, bereavement programs, and end-of-life care quality monitoring. However, few of these strategies were widely available.
CONCLUSIONS: Intensive care unit directors perceive important barriers to optimal end-of-life care but also universally endorse many practical strategies for quality improvement.
Department of Medicine, Hertzberg Palliative Care Institute, Mount Sinai School of Medicine, New York, NY 10029, USA. email@example.com