Integrating palliative and critical care: description of an intervention

Exploring the content and delivery of feedback facilitation co-interventions: a systematic review

BACKGROUND

Policymakers and researchers recommend supporting the capabilities of feedback recipients to increase the quality of care. There are different ways to support capabilities. We aimed to describe the content and delivery of feedback facilitation interventions delivered alongside audit and feedback within randomised controlled trials.

METHODS

We included papers describing feedback facilitation identified by the latest Cochrane review of audit and feedback. The piloted extraction proforma was based upon a framework to describe intervention content, with additional prompts relating to the identification of influences, selection of improvement actions and consideration of priorities and implications. We describe the content and delivery graphically, statistically and narratively.

RESULTS

We reviewed 146 papers describing 104 feedback facilitation interventions. Across included studies, feedback facilitation contained 26 different implementation strategies. There was a median of three implementation strategies per intervention and evidence that the number of strategies per intervention is increasing. Theory was used in 35 trials, although the precise role of theory was poorly described. Ten studies provided a logic model and six of these described their mechanisms of action. Both the exploration of influences and the selection of improvement actions were described in 46 of the feedback facilitation interventions; we describe who undertook this tailoring work. Exploring dose, there was large variation in duration (15-1800 min), frequency (1 to 42 times) and number of recipients per site (1 to 135). There were important gaps in reporting, but some evidence that reporting is improving over time.

CONCLUSIONS

Heterogeneity in the design of feedback facilitation needs to be considered when assessing the intervention's effectiveness. We describe explicit feedback facilitation choices for future intervention developers based upon choices made to date. We found the Expert Recommendations for Implementing Change to be valuable when describing intervention components, with the potential for some minor clarifications in terms and for greater specificity by intervention providers. Reporting demonstrated extensive gaps which hinder both replication and learning. Feedback facilitation providers are recommended to close reporting gaps that hinder replication. Future work should seek to address the 'opportunity' for improvement activity, defined as factors that lie outside the individual that make care or improvement behaviour possible.

REVIEW REGISTRATION

The study protocol was published at: https://www.protocols.io/private/4DA5DE33B68E11ED9EF70A58A9FEAC02 .

Israeli Nurses' Palliative Care Knowledge, Attitudes, Behaviors, and Practices

OBJECTIVES

To describe and compare self-perceived end-of-life (EOL) knowledge, attitudes, behaviors, and practices of intensive care unit (ICU) nurses compared to oncology nurses.

SAMPLE & SETTING

126 Israeli nurses (79 oncology nurses and 47 ICU nurses) who were members of the Israel Association of Cardiology and Critical Care Nurses and the Israeli Oncology Nurses Organization.

METHODS & VARIABLES

This cross-sectional study used an online survey to gather demographic information, clinical setting, and study measures (EOL knowledge, attitudes, behaviors, and practices).

RESULTS

Oncology nurses and ICU nurses showed moderate levels of self-perceived knowledge and attitudes toward palliative care; however, their self-reported behaviors were low. Oncology nurses scored slightly higher than ICU nurses on knowledge and attitudes but not behaviors, although the difference was not statistically significant.

IMPLICATIONS FOR NURSING

Contrary to the current authors' expectations, oncology nurses and ICU nurses have similar levels of knowledge, attitudes, and behaviors regarding palliative care. Nurses in both settings need to be better trained and empowered to provide such care.

Evaluating the Outcomes of an Organizational Initiative to Expand End-of-Life Resources in Intensive Care Units With Palliative Support Tools and Floating Hospice

BACKGROUND

There is evidence that palliative care and floating (inpatient) hospice can improve end-of-life experiences for patients and their families in the intensive care unit (ICU). However, both palliative care and hospice remain underutilized in the ICU setting.

OBJECTIVES

This study examined palliative consultations and floating hospice referrals for ICU patients during a phased launch of floating hospice, 2 palliative order sets, and general education to support implementation of palliative care guidelines.

METHODS

This descriptive, retrospective study was conducted at a level I trauma and academic medical center. Electronic medical records of 400 ICU patients who died in the hospital were randomly selected. These electronic medical records were reviewed to determine if patients received a palliative consult and/or a floating hospice referral, as well as whether the new palliative support tools were used during the course of care. The numbers of floating hospice referrals and palliative consults were measured over time.

RESULTS

Although not significant, palliative consults increased over time (P = .055). After the initial introduction of floating hospice, 27% of the patients received referrals; however, referrals did not significantly increase over time (P = .807). Of the 68 patients who received a floating hospice referral (24%), only 38 were discharged to floating hospice. There was a trend toward earlier palliative care consults, although this was not statistically significant (P = .285).

CONCLUSION

This study provided the organization with vital information about their initiative to expand end-of-life resources. Utilization and timing of palliative consults and floating hospice referrals were lower and later than expected, highlighting the importance of developing purposeful strategies beyond education to address ICU cultural and structural barriers.

Palliative care in adult intensive care units: A nationwide survey

BACKGROUND

There are no data on the provision of palliative nursing care in Egyptian adult intensive care units (ICUs). The Palliative and End-Of-Life (PEOL) Care Index is reliable and content valid; however, its construct and criterion validities have not been examined.

AIMS AND OBJECTIVES

First, to assess palliative care education, practice, and perceived competence among adult ICU nurses in Egypt. Second, to explore factors related to palliative care nursing practice and perceived competence. Third, to assess the construct and criterion validities of the PEOL Care Index.

DESIGN

A cross-sectional survey.

METHODS

Nurse managers and staff nurses in 33 adult ICUs completed self-administered questionnaires. The questionnaires assessed nurses' palliative care practice and perceived competence. A multilevel regression analysis was used to determine the best predictors of palliative care practice and perceived competence. Theory evidence construct validity and predictive criterion validity of the PEOL Care Index were examined.

RESULTS

Thirty-three nurse managers and 403 staff nurses participated in the study-response rate = 100% and 72.5%, respectively. On a 0-100 scale, the mean scores of undergraduate education, practice, and perceived competence were 54.0 ± 18.7, 49.7 ± 18.1, and 54.5 ± 17.0, respectively. Palliative care practice was significantly related to receiving in-service training on palliative care or end-of-life care (regression coefficients: 3.39), higher job satisfaction (0.97), and higher organizational support (1.85). Palliative care perceived competence was significantly related to older nurses' age (0.20), higher job satisfaction (0.97), and higher palliative care undergraduate education (0.63).

CONCLUSIONS

Palliative care education, practice, and perceived competence among adult ICU nurses in Egypt are inadequate, especially in terms of spiritual and cultural care. The PEOL Care Index is construct and criterion valid.

RELEVANCE TO CLINICAL PRACTICE

Palliative care education should begin in nursing schools and extend through clinical in-services. Guidelines should be developed to maximize staff collaboration and the utilization of chaplains in ICUs.

Assessing the Palliative and End-of-Life Care Education-Practice-Competence Triad in Intensive Care Units: Content Validity, Feasibility, and Reliability of a New Tool

BACKGROUND

To date, a comprehensive, psychometrically robust instrument to assess palliative and end-of-life (PEOL) care education, practice, and perceived competence among intensive care unit (ICU) nurses does not exist.

OBJECTIVE

To examine content validity and reliability of a proposed instrument to assess the PEOL care education-practice- competence triad among ICU nurses.

METHODS

An international modified e-Delphi and a cross-sectional pilot questionnaire survey. The Delphi involved 23 panelists from 11 countries. The pilot study involved 40 staff nurses and 3 nurse managers from 3 adult ICUs in a randomly selected hospital in Egypt. An instrument was developed and judged for content validity by international panelists, and then pretested in a pilot study, where data were collected at 2 time points using self-administered questionnaires, followed by cognitive interviews. Test-retest reliability was examined using intraclass correlation (ICC), standard error of measurement (SEM), and repeatability coefficient (RC).

RESULTS

The panelists confirmed content validity of the proposed instrument, and staff nurses confirmed its comprehensibility. At the level of the instrument's total scores, the lowest ICC was .9 (95% confidence interval: .8-.9); and the highest SEM and RC were 4.8 and 13.3, respectively.

CONCLUSIONS

The PEOL Care Index is a comprehensive, comprehensible, content valid, and reliable instrument to assess the PEOL care education-practice-competence triad among ICU nurses. Construct and criterion validities need to be confirmed in future studies. Applicability of the PEOL Care Index in different settings and cultures needs to be examined.

Critical care providers' support of families in bereavement: a mixed-methods study

PURPOSE

When people die in intensive care units (ICUs), as many as half of their family members may experience a severe grief reaction. While families report a need for bereavement support, most ICUs do not routinely follow-up with family members. Clinicians are typically involved in supporting families during death and dying, yet little is known about how they work with families in bereavement. Our goal was to explore how clinicians support bereaved families, identify factors that facilitate and hinder support, and understand their interest and needs for follow-up.

METHODS

Mixed-methods study of nurses and physicians working in one of nine adult medical-surgical ICUs in academic hospitals across Canada. Qualitative interviews followed quantitative surveys to reflect, expand, and explain the quantitative results.

RESULTS

Both physicians and nurses perceived that they provided empathetic support to bereaved families. Emotional engagement was a crucial element of support, but clinicians were not always able to engage with families because of their roles, responsibilities, experiences, or unit resources. Another important factor that could facilitate or challenge engagement was the degree to which families accepted death. Clinicians were interested in participating in a follow-up bereavement program, but their participation was contingent on time, training, and the ability to manage their own emotions related to death and bereavement in the ICU.

CONCLUSIONS

Multiple opportunities were identified to enhance current bereavement support for families, including the desire of ICU clinicians for formal follow-up programs. Many psychological, sociocultural, and structural factors would need to be considered in program design.

Pediatric palliative care in the intensive care unit and questions of quality: a review of the determinants and mechanisms of high-quality palliative care in the pediatric intensive care unit (PICU)

This article reviews the state and practice of pediatric palliative care (PC) within the pediatric intensive care unit (PICU) with specific consideration of quality issues. This includes defining PC and end of life (EOL) care. We will also describe PC as it pertains to alleviating children's suffering through the provision of "concurrent care" in the ICU environment. Modes of care, and attendant strengths, of both the consultant and integrated models will be presented. We will review salient issues related to the provision of PC in the PICU, barriers to optimal practice, parental, and staff perceptions. Opportunity areas for quality improvement and the role of initiatives and measures such as education, family-based initiatives, staff needs, symptom recognition, grief, and communication follow. To conclude, we will look to the literature for PC resources for pediatric intensivists and future directions of study.

Strategies used in improving and assessing the level of reporting of implementation fidelity in randomised controlled trials of palliative care complex interventions: A systematic review

BACKGROUND

Implementation fidelity is critical in evaluating effectiveness of interventions.

AIM

Identifying and summarising strategies to improve and assess the level of reporting of implementation fidelity in randomised controlled trials of palliative care complex interventions.

DESIGN

Systematic review.

DATA SOURCES

Published and completed randomised controlled trials from 2000 to current evaluating effectiveness of specialised palliative care services on patient-centred outcomes in adult patients were examined. MEDLINE was searched from 2008 to 29 September 2015 and supplemented by randomised controlled trials identified in a 2008 systematic review.

RESULTS

Altogether, 20 randomised controlled trials involving 8426 patients were reviewed using 40 subcomponents of five elements of implementation fidelity (resulting in 20 × 40 = 800 items). Over 88 strategies were identified, classified under the following elements: 'treatment design', 'training providers', 'delivery of treatment', 'receipt of treatment' and 'enactment of treatment skills'. No single overarching strategy was discovered. Strategies under 'treatment design' aimed to ensure equivalent treatment dose between and within intervention and control groups, and delivery of necessary ingredients. Ongoing 'training (of) providers' included supervision and ensuring skill acquisition. Use of treatment manuals and implementation checklists aimed to aid 'delivery of treatment'. Research teams aimed to improve 'receipt of treatment' by transmitting clear information and verifying understanding, while improving 'enactment of treatment skills' by reviewing and reinforcing prior content. Only 26% of the items received sufficient reporting; 34% were either not used or reported on.

CONCLUSION

Implementation fidelity in palliative care is under-recognised. A table to collate these strategies to improve implementation fidelity in palliative care research and clinical practice is proposed.

Dying in intensive care units of India: Commentaries on policies and position papers on palliative and end-of-life care

PURPOSE

This study critically examines the available policy guidelines on integration of palliative and end-of-life care in Indian intensive care units to appraise their congruence with Indian reality.

MATERIALS AND METHODS

Six position statements and guidelines issued by the Indian Society for Critical Care Medicine and the Indian Association of Palliative Care from 2005 till 2015 were examined. The present study reflects upon the recommendations suggested by these texts.

RESULT

Although the policy documents conform to the universally set norms of introducing palliative and end-of-life care in intensive care units, they hardly suit Indian reality. The study illustrates local complexities that are not addressed by the policy documents. This include difficulties faced by intensivists and physicians in arriving at a consensus decision, challenges in death prognostication, hurdles in providing compassionate care, providing "culture-specific" religious and spiritual care, barriers in effective communication, limitations of documenting end-of-life decisions, and ambiguities in defining modalities of palliative care. Moreover, the policy documents largely dismiss special needs of elderly patients.

CONCLUSION

The article suggests the need to reexamine policies in terms of their attainability and congruence with Indian reality.

Patterns of Cost for Patients Dying in the Intensive Care Unit and Implications for Cost Savings of Palliative Care Interventions

BACKGROUND

Terminal intensive care unit (ICU) stays represent an important target to increase value of care.

OBJECTIVE

To characterize patterns of daily costs of ICU care at the end of life and, based on these patterns, examine the role for palliative care interventions in enhancing value.

DESIGN

Secondary analysis of an intervention study to improve quality of care for critically ill patients.

SETTING/PATIENTS

572 patients who died in the ICU between 2003 and 2005 at a Level-1 trauma center.

METHODS

Data were linked with hospital financial records. Costs were categorized into direct fixed, direct variable, and indirect costs. Patterns of daily costs were explored using generalized estimating equations stratified by length of stay, cause of death, ICU type, and insurance status. Estimates from the literature of effects of palliative care interventions on ICU utilization were used to simulate potential cost savings under different time horizons and reimbursement models.

MAIN RESULTS

Mean cost for a terminal ICU stay was 39.3K ± 45.1K. Direct fixed costs represented 45% of total hospital costs, direct variable costs 20%, and indirect costs 34%. Day of admission was most expensive (mean 9.6K ± 7.6K); average cost for subsequent days was 4.8K ± 3.4K and stable over time and patient characteristics.

CONCLUSIONS

Terminal ICU stays display consistent cost patterns across patient characteristics. Savings can be realized with interventions that align care with patient preferences, helping to prevent unwanted ICU utilization at end of life. Cost modeling suggests that implications vary depending on time horizon and reimbursement models.

End-of-life expenditure in the ICU and perceived quality of dying

OBJECTIVE

Although end-of-life care in the ICU accounts for a large proportion of health-care costs, few studies have examined the association between costs and satisfaction with care. The objective of this study was to investigate the association of ICU costs with family- and nurse-assessed quality of dying and family satisfaction.

METHODS

This was an observational study surveying families and nurses for patients who died in the ICU or within 30 h of transfer from the ICU. A total of 607 patients from two Seattle hospitals were included in the study. Survey data were linked with administrative records to obtain ICU and hospital costs. Regression analyses assessed the association between costs and outcomes assessing satisfaction with care: nurse- and family-assessed Quality of Death and Dying (QODD-1) and Family Satisfaction in the ICU (FS-ICU).

RESULTS

For family-reported outcomes, patient insurance status was an important modifier of results. For underinsured patients, higher daily ICU costs were significantly associated with higher FS-ICU and QODD-1 (P < .01 and P = .01, respectively); this association was absent for privately insured or Medicare patients (P = .50 and P = .85, QODD-1 and FS-ICU, respectively). However, higher nurse-assessed QODD-1 was significantly associated with lower average daily ICU cost and total hospital cost (P < .01 and P = .05, respectively).

CONCLUSIONS

Family-rated satisfaction with care and quality of dying varied depending on insurance status, with underinsured families rating satisfaction with care and quality of dying higher when average daily ICU costs were higher. However, patients with higher costs were assessed by nurses as having a poorer quality of dying. These findings highlight important differences between family and clinician perspectives and the important role of insurance status.

Differences in end-of-life care in the ICU across patients cared for by medicine, surgery, neurology, and neurosurgery physicians

BACKGROUND

Some of the challenges in the delivery of high-quality end-of-life care in the ICU include the variability in the characteristics of patients with certain illnesses and the practice of critical care by different specialties.

METHODS

We examined whether ICU attending specialty was associated with quality of end-of-life care by using data from a clustered randomized trial of 14 hospitals. Patients died in the ICU or within 30 h of transfer and were categorized by specialty of the attending physician at time of death (medicine, surgery, neurology, or neurosurgery). Outcomes included family ratings of satisfaction, family and nurse ratings of quality of dying, and documentation of palliative care in medical records. Associations were tested using multipredictor regression models adjusted for hospital site and for patient, family, or nurse characteristics.

RESULTS

Of 3,124 patients, the majority were cared for by an attending physician specializing in medicine (78%), with fewer from surgery (12%), neurology (3%), and neurosurgery (6%). Family satisfaction did not vary by attending specialty. Patients with neurology or neurosurgery attending physicians had higher family and nurse ratings of quality of dying than patients of attending physicians specializing in medicine (P &lt; .05). Patients with surgery attending physicians had lower nurse ratings of quality of dying than patients with medicine attending physicians (P &lt; .05). Chart documentation of indicators of palliative care differed by attending specialty.

CONCLUSIONS

Patients cared for by neurology and neurosurgery attending physicians have higher family and nurse ratings of quality of dying than patients cared for by medicine attending physicians and have a different pattern of indicators of palliative care. Patients with surgery attending physicians had fewer documented indicators of palliative care. These findings may provide insights into potential ways to improve the quality of dying for all patients.

TRIAL REGISTRY

ClinicalTrials.gov; No.: NCT00685893; URL: www.clinicaltrials.gov.

Impact of critical care medicine training programs' palliative care education and bedside tools on ICU use at the end of life

BACKGROUND

Intensive care unit (ICU) use at the end of life is rising. Little research has focused on associations among critical care fellows' training, institutional support, and bedside tools with ICU use at the end of life.

OBJECTIVE

We evaluated whether hospital and critical care medicine program interventions were associated with ICU use in the last 6 months of life for patients with chronic illness.

METHODS

Our observational, retrospective study explored associations between results from a survey of critical care program directors and hospital-level Medicare data on ICU use in the last 6 months of life. Program directors evaluated quality of palliative care education in their critical care fellowships and reported on the number of bedside tools and the presence or absence of an inpatient palliative care consultation service.

RESULTS

For the 89 hospitals and 71 affiliated training programs analyzed, there were statistically significant relationships between 2 of the explanatory variables-the quality of palliative care education and the number of bedside tools-in ICU use. Each level of increased educational quality (1-5 Likert scale) was associated with a 0.57-day decrease in ICU days, whereas, for each additional, evidence-based bedside tool, there was a 0.31-day decrease. The presence of an inpatient palliative care program was not a significant predictor of ICU use.

CONCLUSIONS

We found that the quality of palliative care training in critical care medicine programs and the use of bedside tools were independently associated with reduced ICU use at the end of life.

Effectiveness of integration of palliative medicine specialist services into the intensive care unit of a community teaching hospital

BACKGROUND

Collaboration between palliative medicine and the intensive care unit (ICU) represents best practice and offers important benefits. However, achieving effective collaboration between these two specialties can be challenging.

OBJECTIVE

Assess effectiveness of integrating palliative medicine specialists in the ICU.

DESIGN

Retrospective chart review.

RESULTS

Of 201 patients who qualified for palliative consultation using a palliative screening tool, 92 were referred and 109 were not referred for palliative medicine consultation. The number of screening criteria met was similar between the two groups. Palliative medicine consult volume increased significantly compared with preintegration (7.7±3.4 versus 4.4±2.8 consults per month, p=0.04). No significant difference in hospital mortality was found between the referred and unreferred groups (32/92 [35%] versus 26/109 [24%], p=0.09). ICU length of stay was significantly shorter in the referred group (7 versus 11 days, p<0.001). Referred patients were more frequently enrolled in hospice compared with unreferred patients (32/92 [37%] versus 3/109 [3%], p<0.001). ICU physicians referred patients significantly more often for dementia and ventilator withdrawal (13/16, p=0.003; 24/29, p<0.001, respectively) and significantly less often for ICU stay longer than 10 days (21 versus 49, p=0.001).

CONCLUSIONS

Integrating palliative medicine specialists into intensive care was associated with a significant increase in use of palliative medicine services and a significant decrease in ICU length of stay for referred patients without a significant increase in mortality. The screening tool effectively identified patients at high risk of death. Given the high mortality rate of the unreferred patients, the criteria could be more widely adopted by ICU physicians to consider expanding palliative medicine referrals.

Hospital variation and temporal trends in palliative and end-of-life care in the ICU

OBJECTIVES

Although studies have shown regional and interhospital variability in the intensity of end-of-life care, few data are available assessing variability in specific aspects of palliative care in the ICU across hospitals or interhospital variability in family and nurse ratings of this care. Recently, relatively high family satisfaction with ICU end-of-life care has prompted speculation that ICU palliative care has improved over time, but temporal trends have not been documented.

DESIGN/SETTING

Retrospective cohort study of consecutive patients dying in the ICU in 13 Seattle-Tacoma-area hospitals between 2003 and 2008.

MEASUREMENTS

We examined variability over time and among hospitals in satisfaction and quality of dying assessed by family, quality of dying assessed by nurses, and chart-based indicators of palliative care. We used regression analyses adjusting for patient, family, and nurse characteristics.

MAIN RESULTS

Medical charts were abstracted for 3,065 of 3,246 eligible patients over a 55-month period. There were significant differences between hospitals for all chart-based indicators (p < 0.001), family satisfaction (p < 0.001), family-rated quality of dying (p = 0.03), and nurse-rated quality of dying (p = 0.003). There were few significant changes in these measures over time, although we found a significant increase in pain assessments in the last 24 hours of life (p < 0.001) as well as decreased documentation of family conferences (p < 0.001) and discussion of prognosis (p = 0.020) in the first 72 hours in the ICU.

CONCLUSIONS

We found significant interhospital variation in ratings and delivery of palliative care, consistent with prior studies showing variation in intensity of care at the end of life. We did not find evidence of temporal changes in most aspects of palliative care, family satisfaction, or nurse/family ratings of the quality of dying. With the possible exception of pain assessment, there is little evidence that the quality of palliative care has improved over the time period studied.

Identifying elements of ICU care that families report as important but unsatisfactory: decision-making, control, and ICU atmosphere

BACKGROUND

One in fi ve deaths in the United States occurs in the ICU, and many of these deaths are experienced as less than optimal by families of dying people. The current study investigated the relationship between family satisfaction with ICU care and overall ratings of the quality of dying as a means of identifying targets for improving end-of-life experiences for patients and families.

METHODS

This multisite cross-sectional study surveyed families of patients who died in the ICU in one of 15 hospitals in western Washington State. Measures included the Family Satisfaction in the ICU (FS-ICU) and the Single-Item Quality of Dying (QOD-1) questionnaires. Associations between FS-ICU items and the QOD-1 were examined using multivariate linear regression controlling for patient and family demographics and hospital site.

RESULTS

Questionnaires were returned for 1,290 of 2,850 decedents (45%). Higher QOD-1 scores were significantly associated (all P < .05) with (1) perceived nursing skill and competence (β= 0.15), (2) support for family as decision-makers ( β= 0.10), (3) family control over the patient’s care( β= 0.18), and (4) ICU atmosphere (β= 0.12). FS-ICU items that received low ratings and correlated with higher QOD-1 scores (ie, important items with room for improvement) were (1) support of family as decision-maker, (2) family control over patient’s care, and (3) ICU atmosphere.

CONCLUSIONS

Increased support for families as decision-makers and for their desired level of control over patient care along with improvements in the ICU atmosphere were identified as aspects of the ICU experience that may be important targets for quality improvement.

TRIAL REGISTRY

ClinicalTrials.gov; No.: NCT00685893; URL: www.clinicaltrials.gov.

Measuring family satisfaction with care and quality of dying in the intensive care unit: does patient age matter?

RATIONALE

Few studies have examined the role of patient age on family experiences of end-of-life care.

OBJECTIVES

To assess measurement characteristics of two family-assessed questionnaires across three patient age groups.

METHODS

Four hundred and ninety-six patients who died in an intensive care unit (ICU) at a single hospital were identified and one family member per patient was sent two questionnaires: 1) Family Satisfaction in the ICU (FS-ICU); and 2) Quality of Dying and Death (QODD). Two hundred and seventy-five surveys were returned (55.4%). We analyzed three age groups: <35, 35-64, and ≥65 years. Differences were evaluated using χ(2) tests to evaluate ceiling, floor, and missing responses; Kruskal-Wallis tests to compare median scores on items and total scores; and linear regression controlling for patient sex, race, diagnosis, and family-member sex, race, education, and relationship to provide adjusted comparisons of total and subscale scores.

RESULTS

Measurement characteristics varied by age groups for both questionnaires. Missing values and floor endorsements were more common for the younger age groups for six items and one overall rating score. Ceiling endorsements were more common for the older group for 11 items. Fifteen items and four total scores were significantly higher in the older group.

CONCLUSIONS

The FS-ICU and QODD questionnaires performed differently across patient age groups. Assessments of family satisfaction and quality of dying and death were higher in the oldest group, particularly in the area of clinician-family communication. Studies of the dying experience of older adults may not generalize to patients of other ages, and study instruments should be validated among different age groups.

Nurse champions of older people: a national audit and critical review

AIMS

This paper aims to equip nurses working with older people with an understanding of the roles and activities of Champions for Older People.

BACKGROUND

The position of Older People's Champion was established in England to help implement the National Service Framework for Older People at local level.

METHODS

This paper reports on the findings of a national survey of older people's Champions. It sets this in the context of developments around health polices for older people.

FINDINGS

Forty-three of the 209 Champions who participated in this study were nurses. Nurses were the most commonly appointed clinical Champions in National Health Service Trusts responding to the survey; they used this position to promote changes within their organisation and locality. While focusing on the implementation of National Service Framework for Older People targets and requirements, some used their position to work with organisations of local older people and advocated for older patients' interests.

CONCLUSION

Nurses conceived their position as clinical Champions broadly and reported that they used this role to promote service improvements for older people. Those who established networks with other Champions and older people's groups found this useful. Their role as Champions appeared to encourage a proactive and outward-looking perspective and provides evidence of the workings of one model of Championship.

IMPLICATIONS FOR PRACTICE

Embedding championing roles within organisations may be one way of bringing about change in the way that services to older people are developed.

The influence of race/ethnicity and socioeconomic status on end-of-life care in the ICU

BACKGROUND

There is conflicting evidence about the influence of race/ethnicity on the use of intensive care at the end of life, and little is known about the influence of socioeconomic status.

METHODS

We examined patients who died in the ICU in 15 hospitals. Race/ethnicity was assessed as white and nonwhite. Socioeconomic status included patient education, health insurance, and income by zip code. To explore differences in end-of-life care, we examined the use of (1) advance directives, (2) life-sustaining therapies, (3) symptom management, (4) communication, and (5) support services.

RESULTS

Medical charts were abstracted for 3,138/3,400 patients of whom 2,479 (79%) were white and 659 (21%) were nonwhite (or Hispanic). In logistic regressions adjusted for patient demographics, socioeconomic factors, and site, nonwhite patients were less likely to have living wills (OR, 0.41; 95% CI, 0.32-0.54) and more likely to die with full support (OR, 1.59; 95% CI, 1.30-1.94). In documentation of family conferences, nonwhite patients were more likely to have documentation that prognosis was discussed (OR, 1.47; 95% CI, 1.21-1.77) and that physicians recommended withdrawal of life support (OR, 1.57; 95% CI, 1.11-2.21). Nonwhite patients also were more likely to have discord documented among family members or with clinicians (OR, 1.49; 95% CI, 1.04-2.15). Socioeconomic status did not modify these associations and was not a consistent predictor of end-of-life care.

CONCLUSIONS

We found numerous racial/ethnic differences in end-of-life care in the ICU that were not influenced by socioeconomic status. These differences could be due to treatment preferences, disparities, or both. Improving ICU end-of-life care for all patients and families will require a better understanding of these issues.

TRIAL REGISTRY

ClinicalTrials.gov; No.: NCT00685893; URL: www.clinicaltrials.gov.

The essence of the family critical illness experience and nurse-family meetings

Nursing care of families is essential to strong family support and maintenance of family health during a critical illness. Secondary data analysis of interviews conducted with 11 families with a family member in the intensive care unit revealed two essences: the family critical illness experience and the family vision for the kind of care families required and desired from nurses. The purpose of this article was to explicate the essence of these phenomena and their implications for family nursing practice. Findings affirm the need for a family intervention described in the literature, that of regularly scheduled nurse-family meetings. Although developed for work with families experiencing a chronic illness, bringing families together and inviting meaningful conversation about their experiences is appropriate for families experiencing critical illness. Nurse-family meetings acknowledge suffering and vulnerability of families when a loved one is critically ill and afford families an opportunity for honest sensitive communication with nurses.

Effect of a quality-improvement intervention on end-of-life care in the intensive care unit: a randomized trial

RATIONALE

Because of high mortality, end-of-life care is an important component of intensive care.

OBJECTIVES

We evaluated the effectiveness of a quality-improvement intervention to improve intensive care unit (ICU) end-of-life care.

METHODS

We conducted a cluster-randomized trial randomizing 12 hospitals. The intervention targeted clinicians with five components: clinician education, local champions, academic detailing, clinician feedback of quality data, and system supports. Outcomes were assessed for patients dying in the ICU or within 30 hours of ICU discharge using surveys and medical record review. Families completed Quality of Dying and Death (QODD) and satisfaction surveys. Nurses completed the QODD. Data were collected during baseline and follow-up at each hospital (May 2004 to February 2008). We used robust regression models to test for intervention effects, controlling for site, patient, family, and nurse characteristics.

MEASUREMENTS AND MAIN RESULTS

All hospitals completed the trial with 2,318 eligible patients and target sample sizes obtained for family and nurse surveys. The primary outcome, family-QODD, showed no change with the intervention (P = 0.33). There was no change in family satisfaction (P = 0.66) or nurse-QODD (P = 0.81). There was a nonsignificant increase in ICU days before death after the intervention (hazard ratio = 0.9; P = 0.07). Among patients undergoing withdrawal of mechanical ventilation, there was no change in time from admission to withdrawal (hazard ratio = 1.0; P = 0.81).

CONCLUSIONS

We found this intervention was associated with no improvement in quality of dying and no change in ICU length of stay before death or time from ICU admission to withdrawal of life-sustaining measures. Improving ICU end-of-life care will require interventions with more direct contact with patients and families. Clinical trial registered with www.clinicaltrials.gov (NCT00685893).

ICU care associated with symptoms of depression and posttraumatic stress disorder among family members of patients who die in the ICU

BACKGROUND

Psychologic symptoms of posttraumatic stress disorder (PTSD) and depression are relatively common among family members of patients who die in the ICU. The patient-level risk factors for these family symptoms are not well understood but may help to target future interventions.

METHODS

We performed a cohort study of family members of patients who died in the ICU or within 30 h of ICU transfer. Outcomes included self-reported symptoms of PTSD and depression. Predictors included patient demographics and elements of palliative care.

RESULTS

Two hundred twenty-six patients had chart abstraction and family questionnaire data. Family members of older patients had lower scores for PTSD (P = .026). Family members that were present at the time of death (P = .021) and family members of patients with early family conferences (P = .012) reported higher symptoms of PTSD. When withdrawal of a ventilator was ordered, family members reported lower symptoms of depression (P = .033). There were no other patient characteristics or elements of palliative care associated with family symptoms.

CONCLUSIONS

Family members of younger patients and those for whom mechanical ventilation is not withdrawn are at increased risk of psychologic symptoms and may represent an important group for intervention. Increased PTSD symptoms among family members present at the time of death may reflect a closer relationship with the patient or more involvement with the patient's ICU care but also suggests that family should be offered the option of not being present.

Communication in critical care: family rounds in the intensive care unit

BACKGROUND

Communication with family members of patients in intensive care units is challenging and fraught with dissatisfaction.

OBJECTIVES

We hypothesized that family attendance at structured interdisciplinary family rounds would enhance communication and facilitate end-of-life planning (when appropriate).

METHODS

The study was conducted in the 26-bed medical intensive care unit of a tertiary care, academic medical center from April through October 2006. Starting in July 2006, families were invited to attend daily interdisciplinary rounds where the medical team discussed the plan for care. Family members were surveyed at least 1 month after the patient's stay in the unit, completing the validated "Family Satisfaction in the ICU" tool before and after implementation of family rounds.

RESULTS

Of 227 patients enrolled, 187 patients survived and 40 died. Among families of survivors, participation in family rounds was associated with higher family satisfaction regarding frequency of communication with physicians (P = .004) and support during decision making (P = .005). Participation decreased satisfaction regarding time for decision making (P = .02). Overall satisfaction scores did not differ between families who attended rounds and families who did not. For families of patients who died, participation in family rounds did not significantly change satisfaction.

CONCLUSIONS

In the context of this pilot study of family rounds, certain elements of satisfaction were improved, but not overall satisfaction. The findings indicate that structured interdisciplinary family rounds can improve some families' satisfaction, whereas some families feel rushed to make decisions. More work is needed to optimize communication between staff in the intensive care unit and patients' families, families' comprehension, and the effects on staff workload.

Improving social work in intensive care unit palliative care: results of a quality improvement intervention

OBJECTIVE

The intensive care unit (ICU) is a focal point for decision making in end-of-life care. Social workers are involved in providing this care for patients and families. Our goal was to examine the social worker component of an intervention to improve interdisciplinary palliative care in the ICU.

METHODS

The study took place at a 350-bed hospital with 65 ICU beds. We surveyed family members and social workers caring for patients who died in the ICU or within 30 hours of transfer from ICU. Clustered regression was used to assess the effect of the intervention on three outcomes: (1) families' satisfaction with social work, (2) social workers' reported palliative and supportive activities, and (3) social workers' satisfaction with meeting family needs.

RESULTS

Of 590 eligible patients, 275 families completed surveys (response rate, 47%). Thirty-five social workers received 353 questionnaires concerning 353 unique patients and completed 283 (response rate, 80%). Social workers reported significant increase in the total number of activities for family members after the intervention. Some of the activities included addressing spiritual or religious needs, discussing disagreement among the family, and assuring family the patient would be kept comfortable. Neither social workers' satisfaction with meeting families' needs nor family ratings of social workers were higher after the intervention. Increased social worker experience and smaller social worker caseload were both associated with increased family satisfaction with social work.

DISCUSSION

The increase in social worker-reported activities supports the value of the interdisciplinary intervention, but we did not demonstrate improvements in other outcomes. Increased social-worker experience and decreased social worker caseload were independently associated with better family ratings of social workers suggesting future directions for interventions to improve care by social workers. Future studies will need more powerful interventions or more sensitive outcome measures to document improvements in family-assessed outcomes.

Predictors of time to death after terminal withdrawal of mechanical ventilation in the ICU

BACKGROUND

Little information exists about the expected time to death after terminal withdrawal of mechanical ventilation. We sought to determine the independent predictors of time to death after withdrawal of mechanical ventilation.

METHODS

We conducted a secondary analysis from a cluster randomized trial of an end-of-life care intervention. We studied 1,505 adult patients in 14 hospitals in Washington State who died within or shortly after discharge from an ICU following terminal withdrawal of mechanical ventilation (August 2003 to February 2008). Time to death and its predictors were abstracted from the patients' charts and death certificates. Predictors included demographics, proxies of severity of illness, life-sustaining therapies, and International Classification of Diseases, 9th ed., Clinical Modification codes.

RESULTS

The median (interquartile range [IQR]) age of the cohort was 71 years (58-80 years), and 44% were women. The median (IQR) time to death after withdrawal of ventilation was 0.93 hours (0.25-5.5 hours). Using Cox regression, the independent predictors of a shorter time to death were nonwhite race (hazard ratio [HR], 1.17; 95% CI, 1.01-1.35), number of organ failures (per-organ HR, 1.11; 95% CI, 1.04-1.19), vasopressors (HR, 1.67; 95% CI, 1.49-1.88), IV fluids (HR, 1.16; 95% CI, 1.01-1.32), and surgical vs medical service (HR, 1.29; 95% CI, 1.06-1.56). Predictors of longer time to death were older age (per-decade HR, 0.95; 95% CI, 0.90-0.99) and female sex (HR, 0.86; 95% CI, 0.77-0.97).

CONCLUSIONS

Time to death after withdrawal of mechanical ventilation varies widely, yet the majority of patients die within 24 hours. Subsequent validation of these predictors may help to inform family counseling at the end of life.

Predictors of symptoms of posttraumatic stress and depression in family members after patient death in the ICU

BACKGROUND

Patients' deaths in the ICU have been associated with a high burden of psychologic symptoms in families. This study identifies characteristics associated with psychologic symptoms in family members.

METHODS

Families of patients dying in the ICU or within 30 h of ICU discharge in 11 hospitals previously participated in a randomized trial. In the current study, we assessed these families for symptoms of posttraumatic stress disorder (PTSD) and depression with follow-up surveys. Outcomes included validated measures of PTSD (PTSD Checklist) and depressive (Patient Health Questionnaire) symptoms. Predictors included family member mental-health history, involvement in decision making, and demographics.

RESULTS

Surveys were completed by 226 families. Response rate was 46% in the original randomized trial and 82% in this study. Prevalence (95% CI) of PTSD and depressive symptoms were 14.0% (9.7%-19.3%) and 18.4% (13.5%-24.1%), respectively. Family characteristics associated with increased symptoms included: female gender (PTSD, P = .020; depression, P = .005), knowing the patient for a shorter duration (PTSD, P = .003; depression, P = .040), and discordance between family members' preferences for decision making and their actual decision-making roles (PTSD, P = .005; depression, P = .049). Depressive symptoms were also associated with lower educational level (P = .002). Families with psychologic symptoms were more likely to report that access to a counselor (PTSD, P < .001; depression, P = .003) and information about spiritual services might have been helpful while the patient was in the ICU (PTSD, P = .024; depression, P = .029).

CONCLUSIONS

Families demonstrated a high prevalence of psychologic symptoms after a death in the ICU. Characteristics associated with symptoms may help target interventions to reduce these symptoms.

TRIAL REGISTRATION

clinicaltrials.gov; Identifier: NCT00685893.

Potential for response bias in family surveys about end-of-life care in the ICU

BACKGROUND

After-death surveys are an important source of information about the quality of end-of-life care, but response rates generally are low. Our goal was to understand the potential for nonresponse bias in survey studies of family members after a patient's death in the hospital ICU by identifying differences in patient demographics and delivery of palliative care between patients whose families respond to a survey about end-of-life care and those whose families do not.

METHODS

We performed a cohort study of patients who died in the ICU at 14 hospitals. Surveys were mailed to family members 1 to 2 months after the patient's death. Chart abstraction was completed on all patients, assessing demographic characteristics and previously validated indicators of palliative care.

RESULTS

Of the 2,016 surveys sent to families, 760 were returned, for a response rate of 38%. Patients whose family members returned the surveys were more likely to be white (88% vs 74%, respectively; p < 0.001); to be older (71 years vs 69 years, respectively; p = 0.015); and to have received more indicators of palliative care, including medical record documentation of family present at death, involvement of spiritual care, and dying after a decision to limit life-sustaining therapies (p < 0.05).

CONCLUSIONS

Patients whose family members responded to a survey about end-of-life care were more likely to be white, older, and have indicators of palliative care documented in the medical record. Because these patients likely received higher quality palliative care, these findings suggest that the response bias in end-of-life care research is toward overestimating the quality of palliative care.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT00685893.

Practical guidance for evidence-based ICU family conferences

Because most critically ill patients lack decision-making capacity, physicians often ask family members to act as surrogates for the patient in discussions about the goals of care. Therefore, clinician-family communication is a central component of medical decision making in the ICU, and the quality of this communication has direct bearing on decisions made regarding care for critically ill patients. In addition, studies suggest that clinician-family communication can also have profound effects on the experiences and long-term mental health of family members. The purpose of this narrative review is to provide a context and rationale for improving the quality of communication with family members and to provide practical, evidence-based guidance on how to conduct this communication in the ICU setting. We emphasize the importance of discussing prognosis effectively, the key role of the integrated interdisciplinary team in this communication, and the importance of assessing spiritual needs and addressing barriers that can be raised by cross-cultural communication. We also discuss the potential value of protocols to encourage communication and the potential role of quality improvement for enhancing communication with family members. Last, we review issues regarding physician reimbursement for communication with family members within the context of the US health-care system. Communication with family members in the ICU setting is complex, and high-quality communication requires training and collaboration of a well-functioning interdisciplinary team. This communication also requires a balance between adhering to processes of care that are associated with improved outcomes and individualizing communication to the unique needs of the family.

Managing a good death in critical care: can health policy help?

AIM

This paper discusses end-of-life care (EoLC) in critical care through exploration of what is known from the international literature and what is currently presented within UK policy.

BACKGROUND AND CONTEXT

EoLC is an important international critical care issue, and currently provides a key focus for health care policy in the UK. While society holds that critical care is delivered in a highly technical area with a strong focus on cure and recovery, mortality rates in this speciality remain at approximately 20%. When patient recovery is not an outcome, discussions with patient, family and extended care teams turn towards futility of treatment and end-of-life management. However, there are specific barriers to overcome in EoLC for the critically ill.

CONCLUSION

A key issue for EoLC in critical care is a lack of robust systems to prospectively identify individuals who are most at risk of dying. A further challenge is divergent perspectives within and across clinical teams on treatment withdrawal and limitation practices. To streamline patient management and underpin a hospice approach to care, EoLC policies are currently being used within the UK. While this provides a national framework to address some key critical care clinical issues in the UK, there is a need for further refinement of the tool to reflect the reality of EoLC for the critically ill. It is important that international best practice exemplars are examined and clinicians actively engage and contribute to ensure that any local EoLC frameworks are fit for purpose.

Family satisfaction following the death of a loved one in an inner city MICU

This study examined family satisfaction with end-of-life care in a medical intensive care unit (MICU) before and after a palliative care intervention was implemented there. This intervention consisted of early communication, family meetings, and psychosocial support. Family members of patients who died in the MICU in 2005 and 2006 were contacted 2 to 16 months after the death of their relatives. Trained interviewers used the Family Satisfaction with Care Questionnaire to assess the families' perceptions of the care given to their family members. Minorities comprised 77% of the patient population. Comparison of the levels of family satisfaction in the preintervention and postintervention groups demonstrated that the intervention significantly improved the quality of end-of-life care, particularly through increases in family members' satisfaction with decision making, communication with physicians and nurses, and the death and dying process.

Integrating palliative and critical care: evaluation of a quality-improvement intervention

RATIONALE

Palliative care in the intensive care unit (ICU) is an important focus for quality improvement.

OBJECTIVES

To evaluate the effectiveness of a multi-faceted quality improvement intervention to improve palliative care in the ICU.

METHODS

We performed a single-hospital, before-after study of a quality-improvement intervention to improve palliative care in the ICU. The intervention consisted of clinician education, local champions, academic detailing, feedback to clinicians, and system support. Consecutive patients who died in the ICU were identified pre- (n = 253) and postintervention (n = 337). Families completed Family Satisfaction in the Intensive Care Unit (FS-ICU) and Quality of Dying and Death (QODD) surveys. Nurses completed the QODD. The QODD and FS-ICU were scored from 0 to 100. We used Mann-Whitney tests to assess family results and hierarchical linear modeling for nurse results.

MEASUREMENTS AND MAIN RESULTS

There were 590 patients who died in the ICU or within 24 hours of transfer; 496 had an identified family member. The response rate for family members was 55% (275 of 496) and for nurses, 89% (523/590). The primary outcome, the family QODD, showed a trend toward improvement (pre, 62.3; post, 67.1), but was not statistically significant (P = 0.09). Family satisfaction increased but not significantly. The nurse QODD showed significant improvement (pre, 63.1; post, 67.1; P < 0.01) and there was a significant reduction in ICU days before death (pre, 7.2; post, 5.8; P < 0.01).

CONCLUSIONS

We found no significant improvement in family-assessed quality of dying or in family satisfaction with care, we found but significant improvement in nurse-assessed quality of dying and reduction in ICU length of stay with an intervention to integrate palliative care in the ICU. Improving family ratings may require interventions that have more direct contact with family members.

Using the medical record to evaluate the quality of end-of-life care in the intensive care unit

RATIONALE

We investigated whether proposed "quality markers" within the medical record are associated with family assessment of the quality of dying and death in the intensive care unit (ICU).

OBJECTIVE

To identify chart-based markers that could be used as measures for improving the quality of end-of-life care.

DESIGN

A multicenter study conducting standardized chart abstraction and surveying families of patients who died in the ICU or within 24 hrs of being transferred from an ICU.

SETTING

ICUs at ten hospitals in the northwest United States.

PATIENTS

Overall, 356 patients who died in the ICU or within 24 hrs of transfer from an ICU.

MEASUREMENTS

The 22-item family assessed Quality of Dying and Death (QODD-22) questionnaire and a single item rating of the overall quality of dying and death (QODD-1).

ANALYSIS

The associations of chart-based quality markers with QODD scores were tested using Mann-Whitney U tests, Kruskal-Wallis tests, or Spearman's rank-correlation coefficients as appropriate.

RESULTS

Higher QODD-22 scores were associated with documentation of a living will (p = .03), absence of cardiopulmonary resuscitation performed in the last hour of life (p = .01), withdrawal of tube feeding (p = .04), family presence at time of death (p = .02), and discussion of the patient's wish to withdraw life support during a family conference (p < .001). Additional correlates with a higher QODD-1 score included use of standardized comfort care orders and occurrence of a family conference (p < or = .05).

CONCLUSIONS

We identified chart-based variables associated with higher QODD scores. These QODD scores could serve as targets for measuring and improving the quality of end-of-life care in the ICU.

Proactive palliative care in the medical intensive care unit: effects on length of stay for selected high-risk patients

OBJECTIVE

The purpose of this study was to examine the effect of proactive palliative care consultation on length of stay for high-risk patients in the medical intensive care unit (MICU).

DESIGN

A prospective pre/post nonequivalent control group design was used for this performance improvement study.

SETTING

Seventeen-bed adult MICU.

PATIENTS

Of admissions to the MICU, 191 patients were identified as having a serious illness and at high risk of dying: 65 patients in the usual care phase and 126 patients in the proactive palliative care phase. To be included in the sample, a patient had to meet one of the following criteria: a) intensive care admission following a current hospital stay of >or=10 days; b) age >80 yrs in the presence of two or more life-threatening comorbidities (e.g., end-stage renal disease, severe congestive heart failure); c) diagnosis of an active stage IV malignancy; d) status post cardiac arrest; or e) diagnosis of an intracerebral hemorrhage requiring mechanical ventilation.

INTERVENTIONS

Palliative care consultations.

MEASUREMENTS AND MAIN RESULTS

Primary measures were patient lengths of stay a) for the entire hospitalization; b) in the MICU; and c) from MICU admission to hospital discharge. Secondary measures included mortality rates and discharge disposition. There were no significant differences between the usual care and proactive palliative care intervention groups in respect to age, gender, race, screening criteria, discharge disposition, or mortality. Patients in the proactive palliative care group had significantly shorter lengths of stay in the MICU (8.96 vs. 16.28 days, p = .0001). There were no differences between the two groups on total length of stay in the hospital or length of stay from MICU admission to hospital discharge.

CONCLUSIONS

Proactive palliative care consultation was associated with a significantly shorter MICU length of stay in this high-risk group without any significant differences in mortality rates or discharge disposition.

Family satisfaction in the ICU: differences between families of survivors and nonsurvivors

BACKGROUND

We previously noted that the families of patients dying in the ICU reported higher satisfaction with their ICU experience than the families of survivors. However, the reasons for this finding were unclear. In the current study, we sought to confirm these findings and identify specific aspects of care that were rated more highly by the family members of patients dying in the ICU compared to family members of ICU survivors.

METHODS

A total of 539 family members with a patient in the ICU were surveyed. Family satisfaction was measured using the 24-item family satisfaction in the ICU questionnaire. Ordinal logistic regression identified which components of family satisfaction were associated with the patient's outcome (ie, whether the patient lived or died).

RESULTS

A total of 51% of respondents had a loved one die in the ICU. Overall, the families of patients dying in the ICU were more satisfied with their ICU experience than were families of ICU survivors, and the largest differences were noted for care aspects directly affecting family members. Significant differences were found for inclusion in decision making, communication, emotional support, respect and compassion shown to family, and consideration of family needs (p<0.01).

CONCLUSIONS

The families of patients dying in the ICU were more satisfied with their ICU experience than were the families of ICU survivors. The reasons for this difference were higher ratings on family-centered aspects of care. These findings suggest that efforts to improve the support of ICU family members should focus not only on the families of dying patients but also on the families of patients who survive their ICU stay.

Improving palliative care in intensive care units: identifying strategies and interventions that work

The disciplines of critical care and palliative care may initially seem to be polar opposites, yet they share fundamental features. Both focus on the sickest patients in the healthcare system. Each discipline's primary goal-extending life for critical care and comfort and quality of life for palliative care-represents an important secondary goal for the other. A tremendous body of work in the last decade has laid the foundation for improving palliative care in intensive care units of the future. Pioneering projects have demonstrated the feasibility and acceptance of integrating palliative aspects of care within critical care settings and practice. This article introduces this special supplement of Critical Care Medicine, which describes the developments that have occurred moving us toward integration of palliative and critical care, and lays the foundation for the articles published in this supplement.