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We were encouraged to read of the experiences and tactics described in the article, "Integrating Palliative Care in the ICU: The Nurse in a Leading Role," by Judith Nelson, MD, JD, and her colleagues. We congratulate all the authors for their work in alerting the professions of the important role that nurses can and must play in integrating palliative care into the ICU. Our experiences at the Massachusetts General Hospital Medical ICU (MICU) have been similar. As were several of the authors of the article, we were involved early on in quality demonstration projects, funded by the Robert Wood Johnson Foundation, which were designed to merge critical and palliative care in critical care units.1


Our initial effort was to include nurses in the implementation of the initiative. We developed the role of palliative care nurse champions. Their major role was to promote palliative care principles in the MICU, with nursing colleagues, physicians, and other healthcare professionals in the ICU. Full-day sessions were held, and the educational curriculum included components of ELNEC training and transformative leadership development.


Following that, as the merged palliative and critical care practice of all clinicians improved, we discovered, as the authors in this article posit, that the family meeting is the backbone of informed, patient-/family-centered care decision. To that end, we implemented a protocol for studying the impact of a patient/family-centered, evidence-based practice change on the quality, cost, and use of services for critically ill patients at the end of life.2 Currently, we are analyzing the data collected from this study.


As we implemented this protocol, again, education was the first priority. Clinical leaders, a clinical nurse specialist, a physician champion, the nurse director, and others provided training sessions for all physician and nursing staff. Monthly sessions were also held to educate the house officers who rotated into the MICU. These sessions described the standard that all patients would have a family meeting within 72 hours of admission and that both a physician and nurse would participate.


Clerical work was redesigned to track the meeting schedules; information systems were created to document the meetings and provide data to clinicians to ensure that the meetings had been held. Nursing leadership staff participated in morning and afternoon rounds, offering reminders about family meetings that had not taken place. They also checked in with clinical nursing staff to identify barriers to completing family meeting and then worked to eliminate or reduce these barriers. Staffing issues for family meetings were facilitated with cross coverage for staff nurses and also coverage by a resource nurse or a unit-based clinical nurse specialist.


The recent Institute of Medicine's report, "The Future of Nursing: Leading Change, Advancing Health" (2011), states that given their direct and sustained contact with patients, frontline nurses are uniquely positioned to design new models of care to improve quality, efficiency, and safety. The article of Nelson et al and our experience provide proof that this change is possible.


Edward Coakley, MSN, RN


Lillian Ananian, MSN, PhD(c), RN


Adele Keeley, MA, RN


Massachusetts General Hospital


Boston, Massachusetts




1. Billings JA, Keeley A. Merging cultures: palliative care specialists in the medical intensive care unit. Crit Care Med. 2006;34:s388-s393. [Context Link]


2. Radwin LE, Ananian L, Cabral HJ, Keeley A, Currier PF. Effects of a patient/family-centered practice change on the quality and cost of intensive care: research protocol. J Adv Nurs. 2011;67:215-224. [Context Link]