Patricia A. Murphy

Bio: Patricia A. Murphy is an academic researcher from University of Medicine and Dentistry of New Jersey. The author has contributed to research in topics: Palliative care & Ambulatory care. The author has an hindex of 4, co-authored 5 publications receiving 341 citations.

Changing the culture around end-of-life care in the trauma intensive care unit

Abstract: Background: Ten percent to 20% of trauma patients admitted to the intensive care unit (ICU) will die from their injuries. Providing appropriate end-of-life care in this setting is difficult and often late in the patients' course. Patients are young, prognosis uncertain, and conflict common around goals of care. We hypothesized that early, structured communication in the trauma ICU would improve end-of-life care practice. Methods: Prospective, observational, prepost study on consecutive trauma patients admitted to the ICU before and after a structured palliative care intervention was integrated into standard ICU care. The program included part I, early (at admission) family bereavement support, assessment of prognosis, and patient preferences, and part II (within 72 hours) interdisciplinary family meeting. Data on goals of care discussions, do-not-resuscitate (DNR) orders and withdrawal of life support (W/D) were collected from physician rounds, family meetings, and medical records. Results: Eighty-three percent of patients received part I and 69% part II intervention. Discussion of goals of care by physicians on rounds increased from 4% to 36% of patient-days. During intervention, rates of mortality (14%), DNR (43%), and W/D (24%) were unchanged, but DNR orders and W/D were instituted earlier in hospital course. ICU length of stay was decreased in patients who died. Conclusions: Structured communication between physician and families resulted in earlier consensus around goals of care for dying trauma patients. Integration of early palliative care alongside aggressive trauma care can be accomplished without change in mortality and has the ability to change the culture of care in the trauma ICU.

Family satisfaction following the death of a loved one in an inner city MICU.

Abstract: This study examined family satisfaction with end-of-life care in a medical intensive care unit (MICU) before and after a palliative care intervention was implemented there. This intervention consisted of early communication, family meetings, and psychosocial support. Family members of patients who died in the MICU in 2005 and 2006 were contacted 2 to 16 months after the death of their relatives. Trained interviewers used the Family Satisfaction with Care Questionnaire to assess the families' perceptions of the care given to their family members. Minorities comprised 77% of the patient population. Comparison of the levels of family satisfaction in the preintervention and postintervention groups demonstrated that the intervention significantly improved the quality of end-of-life care, particularly through increases in family members' satisfaction with decision making, communication with physicians and nurses, and the death and dying process.

Trauma care and palliative care: time to integrate the two?

Abstract: The phrase “palliative care in trauma” might seem an oxymoron if we think of the traditional definitions of palliative care and trauma care. Palliative care as defined by the World Health Organization is “the active total care of patients whose disease is not responsive to curative treatment. Control of pain, of other symptoms, and of psychological, social, and spiritual problems is paramount.” The principles of palliative care encompass excellent communication, pain and symptom management, goals of care, bereavement, and spiritual support, usually for patients who are at the end of life. Conversely, trauma surgery is focused on acute care of the critically injured, where decisions and care are provided to rapidly cure the patient and prolong life, often no matter the cost in suffering and resources. If the patient dies it is often suddenly, in the emergency room or the operating room, leaving little room for the traditional notions of palliative care as we know it. Recent developments in society and medicine have highlighted the importance of end-of-life care and the gap between how we wish to die and how many of us do die. These developments have spread to surgery as well, with increased attention to palliative and end-of-life care in the practice and study of surgery, as demonstrated by the recent publications in this journal and others. But this trend brings with it inherent conflict in values, both for society at large and within medicine. Nowhere is this more apparent than on the trauma service. On one hand, the public increasingly values death with dignity, free of life-prolonging machines, but it also values hightechnology trauma and critical care, with its potential for cure and dramatic life-saving maneuvers. Death from trauma is a tragic event, often afflicting young and previously healthy people. It is rarely peaceful or dignified. This conflict is further played out in the current practice of trauma care. The role of end-of-life care in trauma surgery remains ill defined, and is often something to offer only when all other options have failed. The American College of Surgeons Committee on Trauma Optimal Resource Manual defines an ideal trauma system to “include all the components identified with optimal trauma care, such as prevention, access, acute hospital care, rehabilitation, and research activities.” Palliative or endof-life care has not been considered an essential feature of the trauma system and, if provided, is often relegated to other services or providers, often in the last minutes or hours of the patient’s life when care is deemed futile. Trauma surgeons and other specialists have little expertise and training in the skills of palliative care, such as communication, and pain and symptom management. If all of this is so, then how can palliative care be integrated into trauma care and, more importantly, should it? Several trends in healthcare in general and trauma care in particular suggest that palliative care can and should be integrated into trauma. First, despite all efforts, 10% to 15% of trauma patients who make it to the hospital will die from their injuries. An additional percentage of survivors will be disabled or functionally impaired. Clearly, because end-of-life care is increasingly valued, appropriate management of death must become part of the daily workings of a trauma service. Second, demographics suggest that the population is aging; this is reflected in the demographics of trauma admissions. The elderly are increasingly represented on the trauma service, with the oldest old a fast growing group suffering from injury. Outcomes studies clearly demonstrate increased mortality for the elderly trauma patient, both in the hospital and after discharge, compared with younger adults or age-matched elderly who have not been injured. This group is more likely to have chronic lifethreatening illness, advance directives, and preferences for end-of-life care that may involve limitation of lifesupporting technologies. As the situation of elderly trauma patients becomes more frequent, quality end-oflife care becomes a more important part of trauma care. Finally, the evolution of trauma care itself portends a This article is based on work supported by a Faculty Scholars Grant from the Project on Death in America, Soros Foundation.

Guidelines for Family-Centered Care in the Neonatal, Pediatric, and Adult ICU.

Abstract: Objective:To provide clinicians with evidence-based strategies to optimize the support of the family of critically ill patients in the ICU.Methods:We used the Council of Medical Specialty Societies principles for the development of clinical guidelines as the framework for guideline development. We a

An Official ATS/AACN/ACCP/ESICM/SCCM Policy Statement: Responding to Requests for Potentially Inappropriate Treatments in Intensive Care Units.

Abstract: Background: There is controversy about how to manage requests by patients or surrogates for treatments that clinicians believe should not be administered.Purpose: This multisociety statement provides recommendations to prevent and manage intractable disagreements about the use of such treatments in intensive care units.Methods: The recommendations were developed using an iterative consensus process, including expert committee development and peer review by designated committees of each of the participating professional societies (American Thoracic Society, American Association for Critical Care Nurses, American College of Chest Physicians, European Society for Intensive Care Medicine, and Society of Critical Care).Main Results: The committee recommends: (1) Institutions should implement strategies to prevent intractable treatment conflicts, including proactive communication and early involvement of expert consultants. (2) The term “potentially inappropriate” should be used, rather than futile, to describe...

The Changing Role of Palliative Care in the ICU

Abstract: Objectives Palliative care is an interprofessional specialty as well as an approach to care by all clinicians caring for patients with serious and complex illness. Unlike hospice, palliative care is based not on prognosis but on need and is an essential component of comprehensive care for critically ill patients from the time of ICU admission. In this clinically focused article, we review evidence of opportunities to improve palliative care for critically ill adults, summarize strategies for ICU palliative care improvement, and identify resources to support implementation.

Models for structuring a clinical initiative to enhance palliative care in the intensive care unit: A report from the IPAL-ICU Project (Improving Palliative Care in the ICU)

Abstract: Objective:To describe models used in successful clinical initiatives to improve the quality of palliative care in critical care settings.Data Sources:We searched the MEDLINE database from inception to April 2010 for all English language articles using the terms “intensive care,” “critical care,” or

Estimating the Effect of Palliative Care Interventions and Advance Care Planning on ICU Utilization: A Systematic Review*

Abstract: Objective:We conducted a systematic review to answer three questions: 1) Do advance care planning and palliative care interventions lead to a reduction in ICU admissions for adult patients with life-limiting illnesses? 2) Do these interventions reduce ICU length of stay? and 3) Is it possible to pro