Intensive Care Medicine

, Volume 42, Issue 1, pp 54–62 | Cite as

Prospective study of a proactive palliative care rounding intervention in a medical ICU

  • Nicholas Braus
  • Toby C. Campbell
  • Kristine L. Kwekkeboom
  • Susan Ferguson
  • Carrie Harvey
  • Anna E. Krupp
  • Tara Lohmeier
  • Michael D. Repplinger
  • Ryan P. Westergaard
  • Elizabeth A. Jacobs
  • Kate Ford Roberts
  • William J. EhlenbachEmail author



To evaluate the effects of a palliative care intervention on clinical and family outcomes, and palliative care processes.


Prospective, before-and-after interventional study enrolling patients with high risk of mortality, morbidity, or unmet palliative care needs in a 24-bed academic intensive care unit (ICU). The intervention involved a palliative care clinician interacting with the ICU physicians on daily rounds for high-risk patients.


One hundred patients were enrolled in the usual care phase, and 103 patients were enrolled during the intervention phase. The adjusted likelihood of a family meeting in ICU was 63 % higher (RR 1.63, 95 % CI 1.14–2.07, p = 0.01), and time to family meeting was 41 % shorter (95 % CI 52–28 % shorter, p < 0.001). Adjusted ICU length of stay (LOS) was not significantly different between the two groups (6 % shorter, 95 % CI 16 % shorter to 4 % longer, p = 0.22). Among those who died in the hospital, ICU LOS was 19 % shorter in the intervention (95 % CI 33–1% shorter, p = 0.043). Adjusted hospital LOS was 26 % shorter (95 % CI 31–20 % shorter, p < 0.001) with the intervention. Post-traumatic stress disorder (PTSD) symptoms were present in 9.1 % of family respondents during the intervention versus 20.7 % prior to the intervention (p = 0.09). Mortality, family depressive symptoms, family satisfaction and quality of death and dying did not significantly differ between groups.


Proactive palliative care involvement on ICU rounds for high-risk patients was associated with more and earlier ICU family meetings and shorter hospital LOS. We did not identify differences in family satisfaction, family psychological symptoms, or family-rated quality of dying, but had limited power to detect such differences.


End-of-life care Palliative care ICU decision-making Family meetings Communication Family ICU syndrome 



Dr. Ehlenbach has received grant funding from the National Institutes of Health, National Institute of Aging (K23 AG038352), funded by The Atlantic Philanthropies, The John A. Hartford Foundation, and the Starr Foundation. This work utilized the University of Wisconsin Carbone Cancer Center (UWCCC) Survey Resource Shared Resource, which is funded in part by the UWCCC Center Support Grant (P30 CA014520) from the National Cancer Institute; the authors wish to thank Amy Godecker, Ph.D., and Karen Lazar, M.S., for their work with the surveys for this study. Study data were collected and managed using REDCap (Research Electronic Data Capture) electronic data capture tools hosted at the University of Wisconsin-Madison, School of Medicine and Public Health. REDCap is supported by the Clinical and Translational Science Award (CTSA) program, through the NIH National Center for Advancing Translational Sciences (NCATS), grant UL1TR000427. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH.

Compliance with ethical standards

Conflicts of interest

On behalf of all authors, the corresponding author states that there is no conflict of interest.


  1. 1.
    Angus DC, Barnato AE, Linde-Zwirble WT, Weissfeld LA, Watson RS, Rickert T, Rubenfeld GD, Robert Wood Johnson Foundation ICU End-Of-Life Peer Group (2004) Use of intensive care at the end of life in the United States: an epidemiologic study. Crit Care Med 32:638–643CrossRefPubMedGoogle Scholar
  2. 2.
    Teno JM, Gozalo PL, Bynum JP, Leland NE, Miller SC, Morden NE, Scupp T, Goodman DC, Mor V (2013) Change in end-of-life care for medicare beneficiaries: site of death, place of care, and health care transitions in 2000, 2005, and 2009. JAMA 309:470–477PubMedCentralCrossRefPubMedGoogle Scholar
  3. 3.
    Cox CE, Martinu T, Sathy SJ, Clay AS, Chia J, Gray AL, Olsen MK, Govert JA, Carson SS, Tulsky JA (2009) Expectations and outcomes of prolonged mechanical ventilation. Crit Care Med 37:2888–2894 (quiz 2904)PubMedCentralCrossRefPubMedGoogle Scholar
  4. 4.
    Cox CE, Carson SS, Lindquist JH, Olsen MK, Govert JA, Chelluri L, Quality of Life After Mechanical Ventilation in the Aged (QOL-MV) Investigators (2007) Differences in one-year health outcomes and resource utilization by definition of prolonged mechanical ventilation: a prospective cohort study. Crit Care 11:R9PubMedCentralCrossRefPubMedGoogle Scholar
  5. 5.
    Wunsch H, Guerra C, Barnato AE, Angus DC, Li G, Linde-Zwirble WT (2010) Three-year outcomes for medicare beneficiaries who survive intensive care. JAMA 303:849–856CrossRefPubMedGoogle Scholar
  6. 6.
    Ehlenbach WJ, Hough CL, Crane PK, Haneuse SJ, Carson SS, Curtis JR, Larson EB (2010) Association between acute care and critical illness hospitalization and cognitive function in older adults. JAMA 303:763–770PubMedCentralCrossRefPubMedGoogle Scholar
  7. 7.
    Iwashyna TJ, Ely EW, Smith DM, Langa KM (2010) Long-term cognitive impairment and functional disability among survivors of severe sepsis. JAMA 304:1787–1794PubMedCentralCrossRefPubMedGoogle Scholar
  8. 8.
    Needham DM, Davidson J, Cohen H, Hopkins RO, Weinert C, Wunsch H, Zawistowski C, Bemis-Dougherty A, Berney SC, Bienvenu OJ, Brady SL, Brodsky MB, Denehy L, Elliott D, Flatley C, Harabin AL, Jones C, Louis D, Meltzer W, Muldoon SR, Palmer JB, Perme C, Robinson M, Schmidt DM, Scruth E, Spill GR, Storey CP, Render M, Votto J, Harvey MA (2012) Improving long-term outcomes after discharge from intensive care unit: report from a stakeholders’ conference. Crit Care Med 40:502–509CrossRefPubMedGoogle Scholar
  9. 9.
    Truog RD, Campbell ML, Curtis JR, Haas CE, Luce JM, Rubenfeld GD, Rushton CH, Kaufman DC (2008) Recommendations for end-of-life care in the intensive care unit: a consensus statement by the American College of Critical Care Medicine. Crit Care Med 36:953–963CrossRefPubMedGoogle Scholar
  10. 10.
    Lanken PN, Terry PB, Delisser HM, Fahy BF, Hansen-Flaschen J, Heffner JE, Levy M, Mularski RA, Osborne ML, Prendergast TJ, Rocker G, Sibbald WJ, Wilfond B, Yankaskas JR, ATS End-of-Life Care Task Force (2008) An official American Thoracic Society clinical policy statement: palliative care for patients with respiratory diseases and critical illnesses. Am J Respir Crit Care Med 177:912–927CrossRefPubMedGoogle Scholar
  11. 11.
    Aslakson R, Cheng J, Vollenweider D, Galusca D, Smith TJ, Pronovost PJ (2014) Evidence-based palliative care in the intensive care unit: a systematic review of interventions. J Palliat Med 17:219–235PubMedCentralCrossRefPubMedGoogle Scholar
  12. 12.
    Lau BD, Aslakson RA, Wilson RF, Fawole OA, Apostol CC, Martinez KA, Vollenweider D, Bass EB, Dy SE (2014) Methods for improving the quality of palliative care delivery: a systematic review. Am J Hosp Palliat Care 31:202–210CrossRefPubMedGoogle Scholar
  13. 13.
    Nelson JE, Puntillo KA, Pronovost PJ, Walker AS, McAdam JL, Ilaoa D, Penrod J (2010) In their own words: patients and families define high-quality palliative care in the intensive care unit. Crit Care Med 38:808–818PubMedCentralCrossRefPubMedGoogle Scholar
  14. 14.
    Lilly CM, De Meo DL, Sonna LA, Haley KJ, Massaro AF, Wallace RF, Cody S (2000) An intensive communication intervention for the critically ill. Am J Med 109:469–475CrossRefPubMedGoogle Scholar
  15. 15.
    Lilly CM, Sonna LA, Haley KJ, Massaro AF (2003) Intensive communication: four-year follow-up from a clinical practice study. Crit Care Med 31:S394–S399CrossRefPubMedGoogle Scholar
  16. 16.
    Azoulay E, Chevret S, Leleu G, Pochard F, Barboteu M, Adrie C, Canoui P, Le Gall JR, Schlemmer B (2000) Half the families of intensive care unit patients experience inadequate communication with physicians. Crit Care Med 28:3044–3049CrossRefPubMedGoogle Scholar
  17. 17.
    Nelson JE, Angus DC, Weissfeld LA, Puntillo KA, Danis M, Deal D, Levy MM, Cook DJ, Critical Care Peer Workgroup of the Promoting Excellence in End-of-Life Care Project (2006) End-of-life care for the critically ill: a national intensive care unit survey. Crit Care Med 34:2547–2553CrossRefPubMedGoogle Scholar
  18. 18.
    Penrod JD, Pronovost PJ, Livote EE, Puntillo KA, Walker AS, Wallenstein S, Mercado AF, Swoboda SM, Ilaoa D, Thompson DA, Nelson JE (2012) Meeting standards of high-quality intensive care unit palliative care: clinical performance and predictors. Crit Care Med 40:1105–1112PubMedCentralCrossRefPubMedGoogle Scholar
  19. 19.
    Campbell ML, Guzman JA (2003) Impact of a proactive approach to improve end-of-life care in a medical ICU. Chest 123:266–271CrossRefPubMedGoogle Scholar
  20. 20.
    Campbell ML, Guzman JA (2004) A proactive approach to improve end-of-life care in a medical intensive care unit for patients with terminal dementia. Crit Care Med 32:1839–1843CrossRefPubMedGoogle Scholar
  21. 21.
    Norton SA, Hogan LA, Holloway RG, Temkin-Greener H, Buckley MJ, Quill TE (2007) Proactive palliative care in the medical intensive care unit: effects on length of stay for selected high-risk patients. Crit Care Med 35:1530–1535CrossRefPubMedGoogle Scholar
  22. 22.
    Villarreal D, Restrepo MI, Healy J, Howard B, Tidwell J, Ross J, Hartronft S, Jawad M, Sanchez-Reilly S, Reed K, Espinoza SE (2011) A model for increasing palliative care in the intensive care unit: enhancing interprofessional consultation rates and communication. J Pain Symptom Manage 42:676–679CrossRefPubMedGoogle Scholar
  23. 23.
    Sihra L, Harris M, O’Reardon C (2011) Using the improving palliative care in the intensive care unit (IPAL-ICU) project to promote palliative care consultation. J Pain Symptom Manage 42:672–675CrossRefPubMedGoogle Scholar
  24. 24.
    Braus N, Ferguson S, Campbell TC, Kehl K, Krupp A, Kwekkeboom K, Roberts KF, Ehlenbach WJ (2015) Effects of proactive palliative care on processes and outcomes in a medical ICU. Am J Respir Crit Care Med 191:A5127Google Scholar
  25. 25.
    DiMartini A, Crone C, Fireman M, Dew MA (2008) Psychiatric aspects of organ transplantation in critical care. Crit Care Clin 24:949–981PubMedCentralCrossRefPubMedGoogle Scholar
  26. 26.
    Weiss CH, Moazed F, McEvoy CA, Singer BD, Szleifer I, Amaral LA, Kwasny M, Watts CM, Persell SD, Baker DW, Sznajder JI, Wunderink RG (2011) Prompting physicians to address a daily checklist and process of care and clinical outcomes: a single-site study. Am J Respir Crit Care Med 184:680–686PubMedCentralCrossRefPubMedGoogle Scholar
  27. 27.
    Thaler RH, Sunstein CR (2008) Nudge: improving decisions about health, wealth, and happiness. Yale University Press, New HavenGoogle Scholar
  28. 28.
    Taichman DB, Christie J, Biester R, Mortensen J, White J, Kaplan S, Hansen-Flaschen J, Palevsky HI, Elliott CG, Hopkins RO (2005) Validation of a brief telephone battery for neurocognitive assessment of patients with pulmonary arterial hypertension. Respir Res 6:39PubMedCentralCrossRefPubMedGoogle Scholar
  29. 29.
    Wall RJ, Engelberg RA, Downey L, Heyland DK, Curtis JR (2007) Refinement, scoring, and validation of the family satisfaction in the intensive care unit (FS-ICU) survey. Crit Care Med 35:271–279CrossRefPubMedGoogle Scholar
  30. 30.
    Kroenke K, Spitzer RL (2002) The PHQ-9: a new depression diagnostic and severity measure. Psychiatric Annals 32:509–521CrossRefGoogle Scholar
  31. 31.
    Kroenke K, Strine TW, Spitzer RL, Williams JB, Berry JT, Mokdad AH (2009) The PHQ-8 as a measure of current depression in the general population. J Affect Disord 114:163–173CrossRefPubMedGoogle Scholar
  32. 32.
    Ruggiero KJ, Del Ben K, Scotti JR, Rabalais AE (2003) Psychometric properties of the PTSD checklist-civilian version. J Trauma Stress 16:495–502CrossRefPubMedGoogle Scholar
  33. 33.
    Glavan BJ, Engelberg RA, Downey L, Curtis JR (2008) Using the medical record to evaluate the quality of end-of-life care in the intensive care unit. Crit Care Med 36:1138–1146PubMedCentralCrossRefPubMedGoogle Scholar
  34. 34.
    Zhang J, Yu KF (1998) What’s the relative risk? A method of correcting the odds ratio in cohort studies of common outcomes. JAMA 280:1690–1691CrossRefPubMedGoogle Scholar
  35. 35.
    American Psychiatric Association (2000) Diagnostic and statistical manual of mental disorders, 4th edn. American Psychiatric Association, Washington, DCGoogle Scholar
  36. 36.
    Weathers F, Ford J (1996) Psychometric review of PTSD checklist AND (PCL-C, PCL-S, PCL-M, PCL-PR). In: Stamm B (ed) Measurement of stress, trauma and adaptation. Sidran, Lutherville, pp 250–251Google Scholar
  37. 37.
    Kross EK, Engelberg RA, Gries CJ, Nielsen EL, Zatzick D, Curtis JR (2011) ICU care associated with symptoms of depression and posttraumatic stress disorder among family members of patients who die in the ICU. Chest 139:795–801PubMedCentralCrossRefPubMedGoogle Scholar
  38. 38.
    Azoulay E, Pochard F, Kentish-Barnes N, Chevret S, Aboab J, Adrie C, Annane D, Bleichner G, Bollaert PE, Darmon M, Fassier T, Galliot R, Garrouste-Orgeas M, Goulenok C, Goldgran-Toledano D, Hayon J, Jourdain M, Kaidomar M, Laplace C, Larche J, Liotier J, Papazian L, Poisson C, Reignier J, Saidi F, Schlemmer B, FAMIREA Study Group (2005) Risk of post-traumatic stress symptoms in family members of intensive care unit patients. Am J Respir Crit Care Med 171:987–994CrossRefPubMedGoogle Scholar
  39. 39.
    Lautrette A, Darmon M, Megarbane B, Joly LM, Chevret S, Adrie C, Barnoud D, Bleichner G, Bruel C, Choukroun G, Curtis JR, Fieux F, Galliot R, Garrouste-Orgeas M, Georges H, Goldgran-Toledano D, Jourdain M, Loubert G, Reignier J, Saidi F, Souweine B, Vincent F, Barnes NK, Pochard F, Schlemmer B, Azoulay E (2007) A communication strategy and brochure for relatives of patients dying in the ICU. N Engl J Med 356:469–478CrossRefPubMedGoogle Scholar
  40. 40.
    Curtis JR, Nielsen EL, Treece PD, Downey L, Dotolo D, Shannon SE, Back AL, Rubenfeld GD, Engelberg RA (2011) Effect of a quality-improvement intervention on end-of-life care in the intensive care unit: a randomized trial. Am J Respir Crit Care Med 183:348–355PubMedCentralCrossRefPubMedGoogle Scholar
  41. 41.
    Bowling A (2005) Mode of questionnaire administration can have serious effects on data quality. J Public Health (Oxf) 27:281–291CrossRefGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg and ESICM 2015

Authors and Affiliations

  • Nicholas Braus
    • 1
  • Toby C. Campbell
    • 2
  • Kristine L. Kwekkeboom
    • 3
  • Susan Ferguson
    • 1
  • Carrie Harvey
    • 4
  • Anna E. Krupp
    • 3
    • 5
  • Tara Lohmeier
    • 1
  • Michael D. Repplinger
    • 6
  • Ryan P. Westergaard
    • 7
  • Elizabeth A. Jacobs
    • 8
    • 9
  • Kate Ford Roberts
    • 5
  • William J. Ehlenbach
    • 10
    Email author
  1. 1.Department of MedicineUniversity of Wisconsin School of Medicine and Public HealthMadisonUSA
  2. 2.Division of Hematology and Oncology, Department of MedicineUniversity of Wisconsin School of Medicine and Public HealthMadisonUSA
  3. 3.School of NursingUniversity of WisconsinMadisonUSA
  4. 4.Department of AnesthesiologyUniversity of MichiganAnn ArborUSA
  5. 5.University of Wisconsin Hospital and ClinicsMadisonUSA
  6. 6.Department of Emergency MedicineUniversity of Wisconsin School of Medicine and Public HealthMadisonUSA
  7. 7.Division of Infectious Diseases, Department of MedicineUniversity of Wisconsin School of Medicine and Public HealthMadisonUSA
  8. 8.Division of General Internal Medicine, Department of MedicineUniversity of Wisconsin School of Medicine and Public HealthMadisonUSA
  9. 9.Department of Population Health SciencesUniversity of Wisconsin School of Medicine and Public HealthMadisonUSA
  10. 10.Divisions of Pulmonary and Critical Care Medicine, Allergy and Geriatrics and Gerontology, Department of MedicineUniversity of Wisconsin School of Medicine and Public HealthMadisonUSA

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