Background     What are the indications for intensive care unit (ICU) admission in the chronically and/or terminally ill and how can one integrate palliative care principals into the daily interdisciplinary agenda?  A good approach is to determine the patient-centered goals of care and then decide if ICU care will help promote or detract from these goals. The use of a pre-admission checklist can be helpful to determine the appropriateness of ICU therapy and to initiate communication about goals and preferences before a trial of ICU care.  This Fast Fact will discuss the pre-ICU-admission assessment of patients with advanced illnesses; Fast Fact #123 will discuss ongoing ICU assessment of these patients to ensure appropriate symptom management and medical decision-making as they continue to receive ICU level care.

Pre-Admission ICU Checklist  

A. Clarify the underlying medical condition and possibilities with ICU treatment: 

1. What is/are the underlying chronic illness disease(s)? Are any of these illnesses anticipated to be terminal (meaning high likelihood of death in less than a year?).
2. What has been the clinical course of the chronic illness over the past few months/year?
3. What was the patient’s functional status and quality of life in the weeks preceding admission?
4. What are the acute illnesses and conditions that the ICU might improve?
5. What interventions do you expect will be required in the first 48 hours?
6. What do you foresee as the best possible outcome from treatment in ICU:
   a. Cure the acute process with return to baseline function (e.g. pneumonia).
   b. Cure or improve the acute process but the patient will likely have a reduced functional capacity permanently (e.g. large stroke).
7. Is there prognostic information to guide you/patient/family in decision making?

B. Address and document decision-making with patient/family/surrogate: 

1. Does the patient have decision-making capacity (see Fast Fact #55)?
2. Does the patient have an advance care planning document or a legally designated agent?
3. Who are the important people that assist the patient in decision making?
4. With or without an advance directive, has the patient or surrogate expressed clear goals of care with their physician in the recent past or during the current illness?

C. Discuss and document ICU-based and patient-focused goals and preferences: 

1. Identify if the primary goal of medical therapies is for cure of the underlying illness, life prolongation, physical/mental rehabilitation, or comfort in the anticipation of impending death.
2. Review what therapeutic trials and palliative care issues can be addressed by an interdisciplinary ICU team; consider whether needs can be met in alternative care settings.
3. Document advance care planning and do not resuscitate orders (see Fast Fact #23, Fast Fact #24, Fast Fact #292).
4. Agree upon specific, time-limited, ICU goals (e.g. three days trial of mechanical ventilation).
5. Identify physical symptoms and develop a treatment plan for palliation.

D. Coordinate interdisciplinary communication & time reappraisal of therapy and goals: 

1. Meet with ICU team members to review goals of care, symptoms, family needs, etc.
2. Document goals of care and details of decision making in medical record.
3. Aim to have a family meeting within 3 days of ICU admission and routinely thereafter for prolonged ICU stays.
4. Schedule a time to assess clinical response and whether goals need to be changed.

References 

1. Back AL, Arnold RM, Quill T. Hope for the best, and prepare for the worst. Ann Intern Med. 2003; 138(5):439-43.
2. Mularski RA, Osborne ML.  End-of-life care in the critically ill geriatric population. Crit Care Clin. 2003; 19:793-810.
3. Mularski RA, Bascom P, Osborne ML.  Educational agendas for interdisciplinary end-of-life curricula.  Crit Care Med. 2001; 29(2 Suppl):N16-23.
4. Gay EB , Pronovost PJ , Bassett RD , et al. The intensive care unit family meeting: making it happen. J Crit Care  2009; 24(4): 62 ,e1-e12.
5. Kynoch K; Chang, A; Coyer F; et al. The effectiveness of interventions to meet family needs of critically ill patients in an adult intensive care unit: a systematic review update. JBI Database of Systematic Reviews and Implementation Reports 2016; 14(3):p 181-234.

Version History:  This Fast Fact was originally edited by David E Weissman MD and published in September 2004. Reviewed and updated in April 2009; revised again July 2015; and again in April 2025.
Conflicts of Interest: None to report.