Optimizing Palliative Care Delivery in the Intensive Care Unit:A Multi-Institutional Qualitative Study of Palliative Care Clinicians' Views on Their Role in the ICU.

Abstract

Specialty palliative care (SPC) consultation in the intensive care unit (ICU) has become increasingly common, yet intensivists face uncertainty about how to optimally integrate SPC to maximize benefit. Prior qualitative work has examined ICU clinicians' perspectives, but SPC clinicians' views on optimizing their role remain largely unexplored. When do SPC clinicians believe specialist consultation is most and least beneficial for critically ill patients? What integration models do they prefer? We conducted semi-structured interviews with a purposive sample of SPC clinicians (physicians, nurse practitioners, and social workers) from five academic medical centers in the United States. Transcripts were analyzed using a codebook approach to thematic analysis. We interviewed 19 SPC clinicians and identified four themes: Attending to Suffering, Communication, and Meaning in Critical Illness; Gaps in Shared Understanding of Need Drive Misallocation of Specialty Expertise; Balancing Intensivists' Primary Palliative Care Skill Development with Specialty Consultation; and Embedding Palliative Care in the ICU: Presence and Partnership. Participants located their distinct value in attending to the human dimensions of critical illness. They often judged whether a consult reflected a true specialist need by its proximity to decision-making, and gaps in this shared understanding of need led to perceived misallocation of specialty expertise. Participants emphasized the need to improve ICU teams' primary palliative care skills to reserve consultation for true specialist need. They favored embedded models of care for their ability to improve patient access to SPC while strengthening relationships between SPC and ICU teams. Optimizing SPC-ICU integration may depend on building a shared understanding of when specialist input is needed and sustaining relationships between SPC and ICU teams. These findings provide actionable guidance for intensivists on how to consult strategically and offer a framework for institutions seeking to optimize SPC-ICU collaboration.