Predicting Which Patients Will Benefit From Palliative Care: Use of Bundles, Triggers, and Protocols

Development, Implementation, and Evaluation of a Social Work Needs Assessment Tool: An Innovative Approach When the Palliative Care Request Is Unclear

Determining the specific needs and greatest distress of a patient requires thoughtful purposeful assessment. The objective of this article is to present a palliative care needs assessment tool utilized in an inpatient palliative care service, and to discuss the process of implementation and evaluation of outcomes. The tool is specifically designed to identify palliative care needs when there is no initial clarity on the appropriate palliative care intervention. It will support practitioners in understanding the lived experience of the patient, assess readiness to discuss future planning, and offer specific language as a guide. A team of social workers evaluated 50 completed needs assessments to determine if the tool successfully identified a palliative care intervention, elicited values, and treatment preferences, and assisted in the completion and documentation of advance directives. After analysis, the four outcomes were consistently met, demonstrating that this tool has value in the hospital setting with certain referral types. These four outcomes identified are valuable in capturing where a patient currently is in their disease trajectory, while also providing a potential framework for future decision making. Recommendations for future exploration were presented along with feedback from the social work team.

Increasing Access to Palliative Care Services in the Intensive Care Unit

BACKGROUND

The Institute of Medicine's report, Dying in America, highlights the critical need for the widespread implementation of palliative care to improve end-of-life care. Approximately 20% of all deaths in America occur during or shortly after an intensive care unit (ICU) admission; therefore, it is important for critical care units to have systems in place to facilitate patient access to palliative care services.

OBJECTIVES

The aim of this quality improvement (QI) project was to develop and implement a palliative care screening tool using evidence-based triggers to help increase the proportion of palliative care consultations in the ICU setting.

METHODS

A QI project was designed and implemented in a 14-bed medical-surgical ICU in the southeastern United States using the Plan-Do-Study-Act cycle. A palliative care screening tool was developed by an interdisciplinary team of key stakeholders in the ICU using evidence-based triggers, and staff were educated on the intervention. The proportion of ICU patients who received a palliative care consultation was compared preintervention and postintervention to determine whether the QI project contributed to an increased proportion of palliative care consultations.

RESULTS

The proportion of palliative care consultations among patients admitted to the ICU by the pulmonary critical care team increased from 1 of 10 preintervention to 3 of 10 postintervention, resulting in a promising increase in patients receiving palliative care services consistent with evidence-based recommendations.

CONCLUSION

The use of an evidence-based screening tool to trigger palliative care consultation in the ICU setting can aid in increasing the proportion of critical care patients who receive a palliative care referral. The increase in the proportion of palliative care referrals by the pulmonary critical care service warrants expansion of the intervention to include additional medical subspecialists who frequently admit patients in this ICU setting. Further assessment of the intervention is warranted to determine whether the screening tool can aid in increasing palliative care consultations for more patients admitted to the hospital's ICU.

Advance care planning (ACP) for specialists managing cirrhosis: A focus on patient-centered care

Advance care planning (ACP) and goals of care designation (GCD) are being integrated into modern health care. In cirrhosis, uptake and adoption of these practices have been limited with physicians citing many perceived barriers and limitations. Recognizing the many tangible benefits of ACP and GCD processes in patients with life-limiting chronic diseases, the onus is on health practitioners to initiate and direct these conversations with their patients and surrogates. Drawing upon the literature and our experiences in palliative care and cirrhosis, we provide an actionable framework that can be readily implemented into a busy clinical setting by a practitioner. Conversation starters, visual aids, educational resources (for patients and practitioners), and videos of mock physician-patient scenarios are presented and discussed. Importantly, we have customized each of these tools to meet the unique health care needs of patients with cirrhosis. The inherent flexibility of our approach to ACP discussions and GCD can be further modified to accommodate practitioner preferences.

CONCLUSION

In our clinics, this assemblage of "best practice tools" has been well received by patients and surrogates enabling us to increase the number of outpatients with cirrhosis who have actively contributed to their GCD before acute health events and are supported by well-informed surrogates. (Hepatology 2018;67:2025-2040).