Background     A pre-admission checklist (see Fast Fact #122) can be used before intensive care unit (ICU) admission to initiate communication about goals and preferences for an ICU trial.  An ICU daily care plan checklist can be used to promote palliative care, simultaneously with curative or life-prolonging therapies. The checklist can help clarify the goals of care for the ICU team, consultants, patients, and significant others and serve as a vehicle for quality improvement.

Palliative ICU Daily Care Plan Checklist

A.    Address short-term medical progress and goals:

1. Assess whether specific criteria toward progress has been met (e.g. mental status or ventilator needs).  Has there been improvement, stability, or worsening in the past 24 hours?
2. Have there been clinical changes that will impact the patient’s ability to meet desired clinical goals (e.g. new GI bleeding)?
3. Review interventions that may be needed in the next 48 hours and set overt criteria to measure progress (e.g. objective indicators of progress towards ventilator weaning).
4. Use this information to review goals and determine if there are changes in prognosis that can guide you/patient/family in decision making.

B.    Address patient symptoms and psychosocial needs:

1. Review progress in managing current symptoms and psychosocial needs (patient and family).
2. Identify existing or new physical symptoms and psychosocial needs; discuss among team members (e.g. patient depression, family stress).
3. Develop a treatment plan for each symptom/need for the next 24 hours.
4. Identify both ICU and non-ICU resources to assist in care plan (e.g. palliative care nurse, clinical psychologist, etc.) and clarify roles for members of the interdisciplinary team.

C.   Clarify understanding and coordinate patient/family communication:

1. Review patient/family understanding and concerns about diagnosis, prognosis, possible outcomes, and details of above items.
   1. Inquire if the patient or significant others have new information or new perspectives that can help clarify the understanding of the patient’s goals and preferences.
   2. Decide if goals of care need refinement or change.
   3. Agree on specific criteria for reassessment of clinical responses and goals.
2. Determine what new information needs to be communicated within next 24 hours.
3. Agree on who and how the team will communicate with family/patient today (e.g. attending will meet with family at 3 PM; resident will attend then call out-of-town relative after meeting).

D.    Document care plan and coordinate follow-up and next day’s assessment:

1. Document clinical status, symptoms, daily goals of care, and details of decision making.
2. Change orders as necessary (e.g. new do-not-resuscitate order).
3. Schedule next meeting for interdisciplinary team that includes patient (if able) and family to update goals, medical evaluation, responses to current therapy, and future plans.

Suggestion for Faculty – Improving the Process of Care

Establish a written checklist containing the above elements that can be completed during daily rounds and entered into the medical record.

References

1. Curtis JR, Rubenfeld GD, eds. Managing Death in the ICU:  The Transition from Cure to Comfort. New York, NY: Oxford University Press; 2000.
2. Lilly CM, De Meo DL, Sonna LA, et al.  An intensive communication intervention for the critically ill. Am J Med. 2000; 109(6):469-75.
3. Mularski RA. Pain management in the intensive care unit. Crit Care Clin. 2004; 20:381-401.
4. Mularski RA, Bascom P, Osborne ML.  Educational agendas for interdisciplinary end-of-life curricula.  Crit Care Med. 2001; 29(2 Suppl):N16-23. (Copyright permission to reproduce modified checklist obtained from Lippincott June 2004.)

Version History:  This Fast Fact was originally edited by David E Weissman MD and published in October 2004. Version re-copy-edited in April 2009; revised again July 2015.