Models for structuring a clinical initiative to enhance palliative care in the intensive care unit: a report from the IPAL-ICU Project (Improving Palliative Care in the ICU).
OBJECTIVE
To describe models used in successful clinical initiatives to improve the quality of palliative care in critical care settings.


METHODS
We searched the MEDLINE database from inception to April 2010 for all English language articles using the terms "intensive care," "critical care," or "ICU" and "palliative care"; we also hand-searched reference lists and author files. Based on review and synthesis of these data and the experiences of our interdisciplinary expert Advisory Board, we prepared this consensus report.


METHODS
We critically reviewed the existing data with a focus on models that have been used to structure clinical initiatives to enhance palliative care for critically ill patients in intensive care units and their families.


CONCLUSIONS
There are two main models for intensive care unit-palliative care integration: 1) the "consultative model," which focuses on increasing the involvement and effectiveness of palliative care consultants in the care of intensive care unit patients and their families, particularly those patients identified as at highest risk for poor outcomes; and 2) the "integrative model," which seeks to embed palliative care principles and interventions into daily practice by the intensive care unit team for all patients and families facing critical illness. These models are not mutually exclusive but rather represent the ends of a spectrum of approaches. Choosing an overall approach from among these models should be one of the earliest steps in planning an intensive care unit-palliative care initiative. This process entails a careful and realistic assessment of available resources, attitudes of key stakeholders, structural aspects of intensive care unit care, and patterns of local practice in the intensive care unit and hospital. A well-structured intensive care unit-palliative care initiative can provide important benefits for patients, families, and providers.
Nelson
Judith E
JE
Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine and Hertzberg Palliative Care Institute, Mount Sinai School of Medicine, New York, NY, USA. Judith.nelson@mssm.edu
Bassett
Rick
R
Boss
Renee D
RD
Brasel
Karen J
KJ
Campbell
Margaret L
ML
Cortez
Therese B
TB
Curtis
J Randall
JR
Lustbader
Dana R
DR
Mulkerin
Colleen
C
Puntillo
Kathleen A
KA
Ray
Daniel E
DE
Weissman
David E
DE
D003422:Critical Care / Q000458:organization & administration* / Q000592:standards; D006801:Humans; D017146:Models, Organizational; D010166:Palliative Care / Q000592:standards*