Each hospital unit has a name, and that name is meant to describe the specific patient services it provides, by a staff specially trained in that expertise. An acute-care facility such as the JGH, however, treats many critically ill patients whose medical needs cannot be so neatly classified.
The JGH Intensive Care Unit team, in theory, performs medical feats to cure all its gravely ill patients. They are trained and equipped to provide aggressive care with advanced technologies. It happens, though, that 1 in 10 of these patients will not pull through—and if these patients cannot be placed in a dedicated palliative unit or facility, they are entitled to receive quality palliative care, even if in a setting that was not originally intended to offer it.
ICU nurses and other members of the team had expressed their readiness to further improve the care provided to patients at high risk of dying by applying palliative care principles. That willingness led them to participate in a Quebec-wide research project, led by Dr. Céline Gélinas, a nurse researcher at the JGH Centre for Nursing Research and Lady Davis Institute, whose aim is to improve the quality of care provided patients at high risk of dying or at the end of life. The first phase of the study, known as SATIN, was completed two years ago. It identified stressors experienced by nurses providing end-of-life care outside of palliative care units.
A committee is now engaging staff in the second phase of the SATIN project, offering staff the opportunity to drive improvements in the palliative care delivered in the ICU. ICU members include Joanna Bailey, a clinical nurse specialist of the ICU Patient and Family Support Program, Clinical Nurse Specialist Stephanie Petizian, Head Nurse Jacki Raboy-Thaw, Clinical Educator Martine Gagnon and Adult Critical Care Chief Dr. Paul Warshawsky. Rounding out the multidisciplinary committee are Palliative Care Clinical Nurse Specialist Marie-Laurence Fortin, Clinical Ethicist Lucie Wade, Social Worker Vivian Myron and Respiratory Therapy Educator Vanessa Roberts.
All ICU staff were invited through a questionnaire to develop solutions to the problems identified in phase 1 of the project, in the areas they themselves named as priorities. ICU staff considered whether they, their patients and patients’ families would benefit most from consultations with the hospital’s palliative care, or alternatively, by building their own expertise within the unit. A third possibility would be to adopt a mixed-methods approach, involving both.
One area staff identified as a challenge, where they would like to work toward improvements ‘on the ground’, is communication within the multidisciplinary team. “This is a concern because a patient’s treatment plan is largely determined by physicians, whereas active palliation at bedside is conducted by nurses,” explains Ms. Bailey.
Other priorities include improved communication between the medical team and the patient as well as their family members; training in principles of palliation related to pain and symptom management; and coaching or support in working through ethical dilemmas. “The committee has presented literature on what’s been done in these areas, and encourages feedback on whether solutions adopted elsewhere, or some variation of these, would work at the JGH,” says Ms. Bailey, who notes that families have also been interviewed for their perspective.
Staff are also considering how best to implement solutions. Should the team develop new policies on what to do in a given situation? If they undergo specialized training, how will they balance this demand on their time with their bedside duties? If the nurses have indicated they feel it’s important to attend family meetings along with physicians, how will the team ensure that this will happen? If a nurse is attending a family meeting and not at a patient’s bedside, who will look after the patient in that time?
The committee plans on presenting a staff-driven curriculum by this fall.