Critical care pathway guides decisions, actions
Includes switch to comfort measures
In a fine-tuned attempt to change the philosophy and subsequent quality of care in the intensive care unit (ICU), a collaborative group of critical caregivers at Ellis Hospital in Schenectady, NY, has developed a critical care pathway that includes aggressive life-saving measures, comfort measures, and a referral to hospice.
Working as a partner in the Boston-based Institute for Healthcare Improvement’s (IHI) breakthrough series on adult intensive care, Ellis sought to define all options in critical care, including limitations to that care, explains Carol Clay, RN, MS, vice president of patient services.
"We want each member of the multidisciplinary team to understand what is important to do, who will assume the responsibility to do it, and when and about what it is important to ask questions," she says.
"Regardless of the tool itself, the use of these types of models helps the health care team get a much better sense of what the family expects and wants out of the patient’s care," says Connie A. Jastremski, RN, MS, a critical care management consultant and leader of the IHI collaborative group on communication in the ICU.
"The sharing that occurs during the first step between all the different disciplines in the [Ellis Hospital] ICU helps everyone understand the goals of care for that patient," Clay says. Ongoing team meetings identify when there is a change in those goals and what action steps will be taken.
Understanding patients’ goals
During the initial phase of admission to the ICU, a formal assessment is made of each patient’s values and treatment goals. The assessment tool prompts more traditional questions about code status, the surrogate decision maker, and religion; documents the patient’s support system, including spiritual support; and determines how the patient might feel about being totally dependent, physically impaired, or mentally impaired, after leaving the ICU.
In the pathway, which is being refined, Ellis’s team chose to use the term "critical life decisions" rather than "end-of-life care," Clay says. "By changing the language, we are not limited to waiting until the patient is at the end of life’ before we initiate comfort measures."
The pathway follows the patient and caregiving team through a process of extubation from a ventilator, skin care, and switching from IV medications to physician’s orders only.
It is important for the team to agree that the critical assessment tool should be used several times throughout the course of the ICU stay, upon admission and discharge, and at appropriate management times in between, Clay says.
It also is important to formalize plans for caring for patients in this stage of the disease. "Physicians are much more comfortable if there is a policy that says, I can or cannot do this.’"
If a physician can’t comply with the pathway for personal reasons, it is easier with this method to transfer the patient’s care to another physician, she adds.
Remember the basics
Many hospitals have been reticent to use clinical pathways for comfort or palliative care because "death is so individual,"she says, but there also are many similarities. "When you are working in a complex environment like the ICU, it is easy to lose sight of the basics. The bottom line with this program is that it helps the patient and family see death as a final growth experience."
It is important to incorporate the family into the decision making process, Jastremski stresses. This inclusion will facilitate other ICU improvements as well, namely fewer failed resuscitation attempts, better ventilator management, and reduction of inappropriate ICU days, she says. All of these improved outcomes benefit the patient, the family, and the health care provider alike.
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