Using a Modified Surprise Question in the Intensive Care Unit for Early Palliative Care.

Background: Patients with critical illness often seek meaningful relationships with members of their care teams. The patient experience can be enhanced through a goals-of-care conversation, an aspect of palliative care that focuses on the patient-clinician relationship. Despite recommendations for early palliative care interventions, no standardized time for generalists to initiate palliative care interventions in the acute care setting has been established.

Local problem: An academic hospital identified a need for earlier palliative care interventions for patients admitted to the medical intensive care unit. The aim of this quality improvement project was to improve early palliative care interventions in the intensive care unit by increasing numbers of documented surrogate decision-makers and goals-of-care conversations. Newman's theory of health as expanding consciousness was used as a guide to improve the patient-clinician relationship through communication, early establishment of goals of care, and development of patient-centered care.

Methods: Recently admitted patients were screened during interprofessional team huddles with a modified surprise question ("Would you be surprised if this patient died during this hospitalization?") to identify those who might benefit from an early goals-of-care conversation. The preimplementation group included all admitted patients and the postimplementation group included only patients with a "no" on the surprise question.

Results: Analysis included 174 patients (139 before implementation, 35 after implementation). In the preimplementation group, 99 patients (71%) had documented surrogate decision-makers and 26 (19%) had documented goals-of-care conversations. In the postimplementation group, 34 patients (97%) had documented surrogate decision-makers and 14 (40%) had documented goals-of-care conversations.

Conclusion: Patients screened with the modified surprise question upon admission to the intensive care unit received earlier palliative care interventions, enhancing patient-centered care.