A Team-Based Early Action Protocol to Address Ethical Concerns in the Intensive Care Unit

Pavlish, Carol L.; Henriksen, Joan; Brown-Saltzman, Katherine; Robinson, Ellen M.; Warda, Umme Shefa; Farra, Christopher; Chen, Belinda; Jakel, Patricia

doi:10.4037/ajcc2020915

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Challenges in the Critical Care Workplace| January 01 2020

A Team-Based Early Action Protocol to Address Ethical Concerns in the Intensive Care Unit

Carol L. Pavlish, PhD, RN;

Carol L. Pavlish, PhD, RN

Carol L. Pavlish is an associate professor, Umme Shefa Warda is a senior statistician, Christopher Farra is a research assistant, and Belinda Chen is a statistician, University of California, Los Angeles, School of Nursing, Los Angeles, California. Joan Henriksen was the coordinator, Clinical Ethics Consultation Service, Mayo Clinic, Rochester, Minnesota; she is now senior staff ethicist at Children’s Minnesota in Minneapolis. Katherine Brown-Saltzman is a codirector, Ethics Center, and Patricia Jakel is a clinical nurse specialist, Santa Monica Hospital, University of California, Los Angeles, Health System, Los Angeles, California. Ellen M. Robinson is a nurse ethicist, Massachusetts General Hospital, Boston, Massachusetts.

Corresponding author: Carol L. Pavlish, phd, rn, faan, 5-954 Factor Building, 700 Tiverton Ave, Los Angeles, CA 90095 (email: cpavlish@sonnet.ucla.edu).

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Joan Henriksen, PhD, RN;

Joan Henriksen, PhD, RN

Carol L. Pavlish is an associate professor, Umme Shefa Warda is a senior statistician, Christopher Farra is a research assistant, and Belinda Chen is a statistician, University of California, Los Angeles, School of Nursing, Los Angeles, California. Joan Henriksen was the coordinator, Clinical Ethics Consultation Service, Mayo Clinic, Rochester, Minnesota; she is now senior staff ethicist at Children’s Minnesota in Minneapolis. Katherine Brown-Saltzman is a codirector, Ethics Center, and Patricia Jakel is a clinical nurse specialist, Santa Monica Hospital, University of California, Los Angeles, Health System, Los Angeles, California. Ellen M. Robinson is a nurse ethicist, Massachusetts General Hospital, Boston, Massachusetts.

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Katherine Brown-Saltzman, MA, RN;

Katherine Brown-Saltzman, MA, RN

Carol L. Pavlish is an associate professor, Umme Shefa Warda is a senior statistician, Christopher Farra is a research assistant, and Belinda Chen is a statistician, University of California, Los Angeles, School of Nursing, Los Angeles, California. Joan Henriksen was the coordinator, Clinical Ethics Consultation Service, Mayo Clinic, Rochester, Minnesota; she is now senior staff ethicist at Children’s Minnesota in Minneapolis. Katherine Brown-Saltzman is a codirector, Ethics Center, and Patricia Jakel is a clinical nurse specialist, Santa Monica Hospital, University of California, Los Angeles, Health System, Los Angeles, California. Ellen M. Robinson is a nurse ethicist, Massachusetts General Hospital, Boston, Massachusetts.

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Ellen M. Robinson, PhD, RN, HEC-C;

Ellen M. Robinson, PhD, RN, HEC-C

Carol L. Pavlish is an associate professor, Umme Shefa Warda is a senior statistician, Christopher Farra is a research assistant, and Belinda Chen is a statistician, University of California, Los Angeles, School of Nursing, Los Angeles, California. Joan Henriksen was the coordinator, Clinical Ethics Consultation Service, Mayo Clinic, Rochester, Minnesota; she is now senior staff ethicist at Children’s Minnesota in Minneapolis. Katherine Brown-Saltzman is a codirector, Ethics Center, and Patricia Jakel is a clinical nurse specialist, Santa Monica Hospital, University of California, Los Angeles, Health System, Los Angeles, California. Ellen M. Robinson is a nurse ethicist, Massachusetts General Hospital, Boston, Massachusetts.

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Umme Shefa Warda, MS;

Umme Shefa Warda, MS

Carol L. Pavlish is an associate professor, Umme Shefa Warda is a senior statistician, Christopher Farra is a research assistant, and Belinda Chen is a statistician, University of California, Los Angeles, School of Nursing, Los Angeles, California. Joan Henriksen was the coordinator, Clinical Ethics Consultation Service, Mayo Clinic, Rochester, Minnesota; she is now senior staff ethicist at Children’s Minnesota in Minneapolis. Katherine Brown-Saltzman is a codirector, Ethics Center, and Patricia Jakel is a clinical nurse specialist, Santa Monica Hospital, University of California, Los Angeles, Health System, Los Angeles, California. Ellen M. Robinson is a nurse ethicist, Massachusetts General Hospital, Boston, Massachusetts.

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Christopher Farra, MS, RN;

Christopher Farra, MS, RN

Carol L. Pavlish is an associate professor, Umme Shefa Warda is a senior statistician, Christopher Farra is a research assistant, and Belinda Chen is a statistician, University of California, Los Angeles, School of Nursing, Los Angeles, California. Joan Henriksen was the coordinator, Clinical Ethics Consultation Service, Mayo Clinic, Rochester, Minnesota; she is now senior staff ethicist at Children’s Minnesota in Minneapolis. Katherine Brown-Saltzman is a codirector, Ethics Center, and Patricia Jakel is a clinical nurse specialist, Santa Monica Hospital, University of California, Los Angeles, Health System, Los Angeles, California. Ellen M. Robinson is a nurse ethicist, Massachusetts General Hospital, Boston, Massachusetts.

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Belinda Chen, MPH;

Belinda Chen, MPH

Carol L. Pavlish is an associate professor, Umme Shefa Warda is a senior statistician, Christopher Farra is a research assistant, and Belinda Chen is a statistician, University of California, Los Angeles, School of Nursing, Los Angeles, California. Joan Henriksen was the coordinator, Clinical Ethics Consultation Service, Mayo Clinic, Rochester, Minnesota; she is now senior staff ethicist at Children’s Minnesota in Minneapolis. Katherine Brown-Saltzman is a codirector, Ethics Center, and Patricia Jakel is a clinical nurse specialist, Santa Monica Hospital, University of California, Los Angeles, Health System, Los Angeles, California. Ellen M. Robinson is a nurse ethicist, Massachusetts General Hospital, Boston, Massachusetts.

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Patricia Jakel, MN, RN, AOCN

Carol L. Pavlish is an associate professor, Umme Shefa Warda is a senior statistician, Christopher Farra is a research assistant, and Belinda Chen is a statistician, University of California, Los Angeles, School of Nursing, Los Angeles, California. Joan Henriksen was the coordinator, Clinical Ethics Consultation Service, Mayo Clinic, Rochester, Minnesota; she is now senior staff ethicist at Children’s Minnesota in Minneapolis. Katherine Brown-Saltzman is a codirector, Ethics Center, and Patricia Jakel is a clinical nurse specialist, Santa Monica Hospital, University of California, Los Angeles, Health System, Los Angeles, California. Ellen M. Robinson is a nurse ethicist, Massachusetts General Hospital, Boston, Massachusetts.

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Am J Crit Care (2020) 29 (1): 49–61.

https://doi.org/10.4037/ajcc2020915

Background

Ethical conflicts complicate clinical practice and often compromise communication and teamwork among patients, families, and clinicians. As ethical conflicts escalate, patient and family distress and dissatisfaction with care increase and trust in clinicians erodes, reducing care quality and patient safety.

Objective

To investigate the effectiveness of a proactive, team-based ethics protocol used routinely to discuss ethics-related concerns, goals of care, and additional supports for patients and families.

Methods

In a pre-post intervention study in 6 intensive care units (ICUs) at 3 academic medical centers, the electronic medical records of 1649 patients representing 1712 ICU admissions were studied. Number and timing of family conferences, code discussions with the patient or surrogate, and ethics consultations; palliative care, social work, and chaplain referrals; and ICU length of stay were measured. Preintervention outcomes were compared with outcomes 3 and 6 months after the intervention via multivariate logistic regression controlled for patient variables.

Results

The odds of receiving a family conference and a chaplain visit were significantly higher after the intervention than at baseline. The number of palliative care consultations and code discussions increased slightly at 3 and 6 months. Social work consultations increased only at 6 months. Ethics consultations increased at both postintervention time points. Length of ICU stay did not change.

Conclusions

When health care teams were encouraged to communicate routinely about goals of care, more patients received needed support and communication barriers were reduced.

2020

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