Article Text

Improving comfort and communication in the ICU: a practical new tool for palliative care performance measurement and feedback
  1. J E Nelson1,
  2. C M Mulkerin2,
  3. L L Adams3,
  4. P J Pronovost4
  1. 1Division of Pulmonary and Critical Care Medicine, Department of Medicine, and Hertzberg Palliative Care Institute, Brookdale Department of Geriatrics and Adult Development, Mount Sinai School of Medicine, New York, NY, USA
  2. 2Palliative Medicine Consult Service, Hartford Hospital, Hartford, CT, USA
  3. 3Rhode Island Quality Institute, Providence, RI, USA
  4. 4The Johns Hopkins University School of Medicine and The Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
  1. Correspondence to:
 J E Nelson MD, JD
 Box 1232, Mount Sinai School of Medicine, New York, NY 10029, USA; judith.nelson{at}


Objective: To develop a practical set of measures for routine monitoring, performance feedback, and improvement in the quality of palliative care in the intensive care unit (ICU).

Design: Use of an interdisciplinary iterative process to create a prototype “bundle” of indicators within previously established domains of ICU palliative care quality; operationalization of indicators as specified measures; and pilot implementation to evaluate feasibility and baseline ICU performance.

Setting: The national Transformation of the Intensive Care Unit program developed in the United States by VHA Inc.

Patients: Critically ill patients in ICUs for 1, >3, and >5 days.

Measurements and main results: Palliative care processes including identification of patient preferences and decision making surrogates, communication between clinicians and patients/families, social and spiritual support, and pain assessment and management, as documented in medical records. Application is triggered by specified lengths of ICU stay. Pilot testing in 19 ICUs (review of >100 patients’ records) documented feasibility, while revealing opportunities for quality improvement in clinician-patient/family communication and other key components of ICU palliative care.

Conclusions: The new bundle of measures is a prototype for routine measurement of the quality of palliative care in the ICU. Further investigation is needed to confirm associations between measured processes and outcomes of importance to patients and families, as well as other aspects of validity.

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  • Dr Nelson is the recipient of an Independent Scientist Research Career Development Award K02 AG024476, from the National Institute on Aging. This work was sponsored in part by VHA Inc as part of its Transformation of the Intensive Care Unit Program, for which Drs. Nelson and Pronovost and Ms. Adams have served as consultants.

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