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What Affects Adoption of Specialty Palliative Care in Intensive Care Units: A Qualitative Study

  • Author Footnotes
    1 Support: Dr. Hua is supported by a Paul B. Beeson Career Development Award K08AG051184 from the National Institute on Aging and the American Federation for Aging Research.
    May Hua
    Correspondence
    Address correspondence to: May Hua, MD, MS, Department of Anesthesiology, Columbia University College of Physicians and Surgeons, 622 West 168th Street PH5, Room 527-D New York, NY 10032, USA.
    Footnotes
    1 Support: Dr. Hua is supported by a Paul B. Beeson Career Development Award K08AG051184 from the National Institute on Aging and the American Federation for Aging Research.
    Affiliations
    Department of Anesthesiology, Columbia University College of Physicians and Surgeons, New York, USA

    Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, USA
    Search for articles by this author
  • Author Footnotes
    2 Support: None.
    Laura D. Fonseca
    Footnotes
    2 Support: None.
    Affiliations
    Department of Anesthesiology, Columbia University College of Physicians and Surgeons, New York, USA
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  • Author Footnotes
    3 Support: Dr. Morrison is supported by the National Palliative Care Research Center and the Mount Sinai Older Adult Independence Center (P30AG028741/AG/NIA).
    R. Sean Morrison
    Footnotes
    3 Support: Dr. Morrison is supported by the National Palliative Care Research Center and the Mount Sinai Older Adult Independence Center (P30AG028741/AG/NIA).
    Affiliations
    Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, USA

    James J Peters VA, Bronx, New York, USA
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  • Author Footnotes
    4 Support: Hannah Wunsch is supported by a Canada Research Chair [Tier 2] in Critical Care Organization and Outcomes.
    Hannah Wunsch
    Footnotes
    4 Support: Hannah Wunsch is supported by a Canada Research Chair [Tier 2] in Critical Care Organization and Outcomes.
    Affiliations
    Department of Anesthesiology, Columbia University College of Physicians and Surgeons, New York, USA

    Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada

    Department of Anesthesiology and Pain Medicine and Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
    Search for articles by this author
  • Author Footnotes
    5 Support: None.
    Robert Fullilove
    Footnotes
    5 Support: None.
    Affiliations
    Department of Sociomedical Sciences, Mailman School of Public Health, Columbia University, New York, USA
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  • Author Footnotes
    6 Support: Dr. White is supported by an award number K24 HL148314 from the National Institutes of Health, National Heart, Lung and Blood Institute during the conduct of the study.
    Douglas B. White
    Footnotes
    6 Support: Dr. White is supported by an award number K24 HL148314 from the National Institutes of Health, National Heart, Lung and Blood Institute during the conduct of the study.
    Affiliations
    Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
    Search for articles by this author
  • Author Footnotes
    1 Support: Dr. Hua is supported by a Paul B. Beeson Career Development Award K08AG051184 from the National Institute on Aging and the American Federation for Aging Research.
    2 Support: None.
    3 Support: Dr. Morrison is supported by the National Palliative Care Research Center and the Mount Sinai Older Adult Independence Center (P30AG028741/AG/NIA).
    4 Support: Hannah Wunsch is supported by a Canada Research Chair [Tier 2] in Critical Care Organization and Outcomes.
    5 Support: None.
    6 Support: Dr. White is supported by an award number K24 HL148314 from the National Institutes of Health, National Heart, Lung and Blood Institute during the conduct of the study.

      Abstract

      Context

      Although many patients with critical illness may benefit from involvement of palliative care specialists, adoption of these services in the intensive care unit (ICU) is variable.

      Objective

      To characterize reasons for variable buy-in for specialty palliative care in the ICU, and identify factors associated with routine involvement of specialists in appropriate cases.

      Methods

      Qualitative study using in-depth, semi-structured interviews with ICU attendings, nurses, and palliative care clinicians, purposively sampled from eight ICUs (medical, surgical, cardiothoracic, neurological) with variable use of palliative care services within two urban, academic medical centers. Interviews were transcribed and coded using an iterative and inductive approach with constant comparison.

      Results

      We identified three types of specialty palliative care adoption in ICUs, representing different phases of buy-in. The “nascent” phase was characterized by the need for education about palliative care services and clarification of which patients may be appropriate for involvement. During the key “transitional” phase, use of specialists depended on development of “comfort and trust”, which centered on four aspects of the ICU-palliative care clinician relationship: 1) increasing familiarity between clinicians; 2) navigating shared responsibility with primary clinicians; 3) having a collaborative approach to care; and 4) having successful experiences. In the “mature” phase, ICU and palliative care clinicians worked to strengthen their existing collaboration, but further adoption was limited by the availability and resources of the palliative care team.

      Conclusion

      This conceptual framework identifying distinct phases of adoption may assist institutions aiming to foster sustained adoption of specialty palliative care in an ICU setting.

      Key Words

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