Original Research

Journal of Intensive Care Medicine

1-9
Improving Caregivers’ Perceptions ª The Author(s) 2015
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Regarding Patient Goals of Care/End-of-Life DOI: 10.1177/0885066615606063
jic.sagepub.com
Issues for the Multidisciplinary Critical Care
Team

Brian T. Wessman, MD, FACEP1,2, Carrie Sona, RN, MSN, CCRN, CCNS, ACNS-BC3,
and Marilyn Schallom, PhD, RN, CCNS, FCCM4

Abstract
Objective: With population aging and growth, use of critical care medicine at the end of life continues to rise, while many critical
care providers are not adequately trained regarding goals of care/end-of-life (GOC/EOL) issues. A multidisciplinary intensive care
unit (ICU) team intervention regarding GOC/EOL communication will enhance the clinical abilities of all critical care providers
when discussing GOC/EOL issues and increase ICU staff comfort level while improving transitions for patients to a comfort care
approach. Design: This study was a preintervention/postintervention survey evaluation. Setting: This study was conducted at an
academic tertiary surgical burn trauma ICU. Population: The intervention was provided to nursing, ancillary staff, house staff,
and attending physicians. Intervention: An initial survey was circulated among the critical care staff for baseline expecta-
tions, satisfaction, and understanding of GOC/EOL care. A robust intervention was begun including the creation of a
multidisciplinary GOC/EOL team, communication tools for providers, patient–family pamphlets, standardized EOL order
sets, and formalized didactic sessions. Subsequently, the same survey was circulated and compared to baseline data.
Measurements: Preintervention/postintervention survey data were reviewed and statistically analyzed. Main Results:
Our survey response rate for preintervention/postintervention was 50.4% and 36.1%, respectively. The intervention gen-
erated heightened interest in improving family communication and provided focal direction to foster this growth. Based on
the serial surveys regarding our intervention, statistically significant staff improvements were seen in ‘‘work stress’’ (P ¼
.04), ‘‘EOL information’’ (P ¼ .006), and ‘‘space allotment’’ (P ¼ .001). Improved congruence of families and health care
providers regarding decision over intensity of care was also noted. Conclusion: We created a novel unit-based multi-
disciplinary program for improved EOL/GOC approaches in the critical care setting. A similarly formatted program could be
adapted by other ICUs. Benefits of such a program include improving caregivers’ perceptions regarding EOL/GOC issues and
fostering critical care team growth.

Keywords
end-of-life care, goals of care, multidisciplinary, communication, education, order sets

Received June 21, 2015. Received revised August 18, 2015. Accepted for publication August 25, 2015.

Introduction 1
Division of Critical Care Medicine, Department of Anesthesiology,
Despite a staggering 1 in 5 US patients dying in or soon after a Washington University in St. Louis School of Medicine, St. Louis, MO, USA
2
stay in the intensive care unit (ICU) and projected growth in the Division of Emergency Medicine, Washington University in St. Louis School of
aging population, many critical care providers are not ade- Medicine, St. Louis, MO, USA
3
Department of Nursing, Barnes-Jewish Hospital, St. Louis, MO, USA
quately trained or skilled at goals of care/end of life (GOC/ 4
Department of Research for Patient Care Services, Barnes-Jewish Hospital,
EOL)-focused discussions.1-5 At the end of life (EOL), many St. Louis, MO, USA
patients find themselves trapped between the need for critical
care expertise and assistance and the desire to avoid invasive Corresponding Author:
procedures.6,8,9 The majority of people would prefer to die at Brian T. Wessman, Critical Care Medicine, Emergency Medicine and Anes-
thesiology, Washington University in St Louis School of Medicine, St Louis, MO
home, however, studies show that over 67% end up dying in 63110, USA.
a hospital or nursing home.10-12 Almost one-third of Medicare Email: wessmanb@anest.wustl.edu

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2 Journal of Intensive Care Medicine

patients who die receive medical care in the critical care setting
during their last 6 months of life.1 Finally, although 80% of
people say that if they were seriously ill, they would want a
conversation with their physician regarding EOL issues, only •
7% of patients actually have this type of conversation.5,13
•
Oftentimes, patients and their families are exposed to con- o
flicting verbal messages and discrepant actions by the critical o
o
care team that leave them even more confused about patient •
care directions at the EOL.2,8,9 Studies show that states with •
increased focus on EOL support and education tend to have •
fewer ICU days in the last 6 months of life.14 A terminal
ICU hospitalization is approximately 4 days longer (12.9 vs
8.9 days) than a regular ICU admission, with a cost difference
of approximately US $16 000.1
Prior studies have shown that EOL communication with fam-
ilies of ICU patients is inadequate due to poor provider interac-
tions, misunderstanding of medical trajectory of the patient, and
•
lack of comprehension of employed medical phrases.7,9,15 Feel- •
ings of guilt or responsibility may permeate the thoughts of the •
family members and bedside providers. End-of-life discussions •
•
have been shown to reduce both the incidence of aggressive •
intervention and the subsequent psychological stress among sur-
viving family members.16 Previous educational interventions
have looked at separate individual curriculum for physicians and
nurses without any crossover discussions.4,17 Exceptional criti-
cal care requires a team multidisciplinary approach with coor-
dinated input from the intensivist, nurse, social worker (SW),
pharmacist, dietitian, respiratory therapist (RT), physical
therapist, and other staff members who are unified in their •
approach to the patient’s current treatment goals. •
To address this issue, we created a novel all-inclusive ICU- o
o
based GOC/EOL-focused program with the goal of providing a
multidisciplinary communication approach for families of the o
•
critically ill patient. We hypothesized that a multidisciplinary
•
ICU team intervention regarding GOC/EOL communication •
will enhance the clinical abilities of all critical care providers
when discussing GOC/EOL issues with patients and their fam-
ilies, increase ICU staff comfort level, and improve transitions Figure 1. Study design and implementation over the 3 phases.
to a comfort care approach. This study was done under Institu-
tional Review Board approval of Washington University in St
Louis School of Medicine. nurses, bedside nurses, pharmacists, dietitians, RTs, physical
therapists, SWs, pastoral care, patient care technicians, and
other support staff. An ICU-based focus group examining criti-
Materials and Methods cal care provided at the EOL identified the recurring issues
This study was conducted at an academic tertiary surgical/ among the health care team of poor communication and a poorly
trauma 24-bed surgical burn trauma intensive care unit (SICU) coordinated approach to GOC/EOL care.
expanded to a 36-bed SICU (during a planned remodeling Nursing leadership (clinical nurse manager and clinical
period) with an average of 15 deaths per month and 214 monthly nurse specialists [CNS]) of the SICU identified the need for
admissions. The preintervention/postintervention arms were improvement in EOL care and discussions regarding goals of
completed over a 2-year period (2011-2013; Figure 1). The care (GOC). A core group comprised of nurses, and key disci-
SICU staffing model embraces a multidisciplinary team approach plines were convened. The group included nurses, 2 CNSs, 2
with an in-house 24/7 attending intensivist supported by critical physicians, SW, chaplain, RT, clinical dietitian, and clinical
care fellows (background residency training in surgery, anesthe- pharmacist. The team met initially to identify issues and areas
siology, and emergency medicine), resident house staff from for improvement. Three major areas were identified: (1) com-
various disciplines, and advanced practice acute care nurse prac- fort care order set development and implementation, (2) patient
titioners. The critical care team is also comprised of charge and family needs during GOC transitions and at the EOL in

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Wessman et al
the ICU setting, and (3) multidisciplinary education of best
practices during communication and provision of EOL care.
A search of the literature for best practices on each topic was
conducted. One of the CNSs attended the 2-day American
Nurses Credentialing Center End-of-Life Nursing Education
Curriculum (ELNEC).17 Palliative care nurse practitioners and
hospice registered nurses (RNs) participated in several meet-
ings in the first 6 months as consultants. An ethicist from the
affiliate university joined the team within the first year.
A previously vetted survey of Nurses’ Perception of End-of-
Life Care created by Hansen et al18 was modified to include the
multidisciplinary critical care team upon receiving permission
from the authors. The original survey has 5 core domains: (1)
knowledge and ability, (2) work environment, (3) support for
staff, (4) support for patients and families, and (5) work stress.
Cronbach a results ranged from .71 to .93 over 3 phases with
the original survey. The same integrity of surveying these 5
core domains was kept in the multidisciplinary modifications.
The revised survey was administered via an e-mail Survey
monkey link to unit nurses, intensivist physicians (attendings,
fellows), surgery/anesthesiology/emergency medicine resi-
dents rotating through the unit, SICU nurse practitioners, RTs,
SWs, chaplains, clinical dietitians, and clinical pharmacists.
Two e-mail reminders were sent as follow-up. Upon closure
of the survey, robust interventions were implemented over the
next year based on survey and literature review results.
Interventions included the creation of a multidisciplinary
GOC/EOL team, communication tools for providers, patient–
family pamphlets, standardized computerized GOC and comfort
care order sets (ICU and non-ICU selections), and formalized
didactic sessions (based partly on the ELNEC curriculum17).
Model communication templates for physicians and nurses
were created to help guide conversations with patients and fam-
ilies (Figures 2 and 3). These templates provided instructions
regarding scene setup, preparing for the conversation, involv-
ing all health care participants, and model outline discussions
to guide the conversation. The physician templates were split
into 3 sections including ‘‘the initial GOC conversation,’’ ‘‘the
update conversation,’’ and ‘‘the EOL focusing on transition to
comfort care conversation.’’ These templates were circulated
among the critical care staff via educational sessions, directed
e-mails, and included in both the nursing resource handbook
and the house staff/fellow physician handbook.
A patient–family pamphlet was created to provide basic
education for patients and family members facing GOC/EOL
decisions (Figure 4). This pamphlet included explanations and
definitions of basic medical terminology. It also included a sec-
tion with details regarding ‘‘what to expect’’ during/at the EOL.
The bedside nurses were empowered to review this educational
resource with families as well as conduct follow-up conversa-
tions to answer any questions. Nurses performed coordination
with guest and patient services for a food basket delivery on the
day of comfort care order activation. After explanation to
family, the nurse placed a lotus flower sign outside the
patient’s room (Figure 4) when the decision to change to com-
fort care was made.
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3
A standardized GOC and comfort care computer order set
was created to help direct physicians to order appropriate com-
fort care measures (Figure 5). This order set focused on discon-
tinuing any unnecessary painful interventions and eliminating
invasive monitoring. It also focused on the appropriate analge-
sics and sedatives for EOL care.
Formalized didactic sessions were held with physicians, nur-
sing, and the health care team to improve education regarding
GOC/EOL issues. Formal annual structured ‘‘Grand Rounds’’
lectures were presented as part of the critical care educational
process. Role-playing across specialty disciplines (ie, nursing
and physician) in small groups with specific case examples was
also used.17 Focused education for all existing nursing staff on
EOL care was initiated. The addition of a 2.5-hour module of
EOL care, based on ELNEC, to the critical care course for all
new ICU nurses was also used. Specific course content included
overview of dying in the ICU, communication and ethics sur-
rounding death, and EOL care discussions and ‘‘the final hours.’’
A guideline for nurses outlining important steps on the day of
comfort care order activation was developed and implemented.
Additionally, during this process, the unit was building a new
36-bed SICU physical plant. Ideas for family conference rooms,
family-centered patient care rooms, and waiting rooms were
incorporated into the design. The unit moved to the new SICU
footprint during the implementation phase of the interventions.
Subsequently, the same survey adopted from Nurses’ Per-
ception of End-of-Life Care18 was circulated among the critical
care staff for comparing data regarding expectations, satisfac-
tion, and understanding of GOC/EOL care. Baseline data and
postintervention data were then compared for the 5 subscale
scores and for 4 individual items: (1) space (support for patients
and their families’ domain), (2) ethics consultation (support for
staff domain), (3) information (support for patients and their
families’ domain), and (4) family meetings (support for staff).
These 4 items were selected prior to analysis based on antici-
pated changes from educational intervention and move to a
new ICU physical space. Baseline data and postintervention
data were then compared. Survey data were imported into
SPSS (Chicago, Illinois) for analysis. Descriptive statistics,
Cronbach a coefficients, comparison of mean scores with
t tests between time periods, respondents combined and per
role in unit, and w2 analysis of role in unit were conducted.
Results
Sample
The preintervention anonymous survey was sent to 242 providers.
A total of 122 respondents took part in the survey for a response
rate of 50.4%. The postintervention anonymous survey was sent
to an overlapping same group of providers (total 280 providers).
A total of 101 respondents (Table 1) took part in the survey for a
postintervention response rate of 36.1%. These responses were
all deidentified, and therefore, we were unable to link pre-
intervention and postintervention surveys. Compared with
the preintervention survey group, the postintervention survey
4 Journal of Intensive Care Medicine

Figure 2. Example of physician communication template/tools.

group included more attending physicians (w2[1] ¼ 4.66; P <
.05) and fewer residents (w2[1] ¼ 11.05; P < .01).
The percentage of respondents by specialty preintervention
was RN 60 of 80 (75%), attending MD 10 of 20 (50%), fellow
MD 7 of 10 (70%), resident MD 32 of 108 (29.6%), nurse
practitioner 2 of 5 (40%), RT 7 of 14 (50%), SW 1 of
1 (100%), registered dietitian (RD) 1 of 1 (100%), pharmacist
1 of 1 (100%), CNS 1 of 1 (100%) and chaplain 0 of 1 (0%).
The postintervention response rate by specialty was RN 47 of
100 (47%), attending MD 18 of 28 (64.2%), fellow MD 8 of
12 (67%), resident MD 9 of 108 (8%), nurse practitioner 8
of 12 (67%), RT 5 of 14 (35.7%), SW 1 of 1 (100%), RD 2
of 2 (100%), pharmacist 1 of 1 (100%), CNS 1 of 1 (100%),
and chaplain 1 of 1 (100%).

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Wessman et al 5

Figure 3. Example of nursing communication template/tools.

Reliability of Instrument Survey Results

Based on survey revisions and modifications, Cronbach a coef- Staff improvements, specifically ‘‘work stress,’’ were signifi-
ficients were analyzed. Cronbach a coefficients ranged from cantly improved between the preinterventions/postinterven-
.74 to .88 in the 2 phases (Table 2). Generally, a value of .70 tions (P ¼ .04). Specific family/patient improvements were
or greater is acceptable, and values .80 are preferable.19 seen in the areas of ‘‘space allotment’’ (P ¼ .001) and ‘‘EOL

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6 Journal of Intensive Care Medicine

information’’ provided (P ¼ .006; Table 3). Nonsignificant

(P ¼ .41) improvements were seen in the ‘‘knowledge and abil-
ity’’ domain regarding GOC/EOL communication. When the
knowledge and ability domain was examined per individual
provider role, attendings showed no change in score between
time periods, whereas the fellows and residents demonstrated
minimal change. Advanced practice clinicians showed non-
significant improvements.
Analysis of subgroups found significant improvement in sup-
port for patients and their families (P < .05), space (P < .01), and
information (P < .01) for the attending/fellow subgroup. Support
for staff was also significantly improved (P < .01) for the nursing
subgroup. However, knowledge and ability significantly wor-
sened (P < .01) for the nursing subgroup. Among the advanced
practice clinicians subgroup and resident subgroup, no signifi-
cant findings between time periods were observed.

Discussion
We report significant improvements in the domains of ‘‘work
Figure 4. Lotus flower/pamphlet image. stress,’’ ‘‘EOL information,’’ and ‘‘space allotment’’ with the

Figure 5. Representative screen shot of the end-of-life order set.

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Wessman et al 7

Table 1. Responder Characteristics. Table 3. Overall Scores and Significant Individual Items.

Characteristic Preintervention Postintervention Pretest Mean Posttest Mean

Domain Scores (N ¼ 122) (N ¼ 101) F P
Years in current position
<1 19 (16%) 21(21%) Knowledge and ability 2.04 2.11 0.67 .41
1-5 50 (41%) 40 (40%) Work environment 2.29 2.26 0.06 .81
6-10 0 0 Support for staff 2.9 2.74 2.37 .13
11-15 0 0 Support for patients 2.16 2.06 1.33 .25
16-20 30 (25%) 21 (21%) and their families
21-25 12 (10%) 5 (5%) Work stress 2.92 2.75 4.44 .04
>25 2 (2%) 3 (3%) Individual items
Years in critical care Space (n ¼ 121/101) 2.03 1.66 11.15 .001
<1 31 (25%) 25 (25%) Information 2.35 2.06 7.77 .006
1-5 39 (32%) 33 (33%) (n ¼ 120/99)
6-10 32 (26%) 19 (19%) Ethics consultation 2.76 2.89 0.93 .34
11-15 9 (7%) 11 (11%) (n ¼ 177/98)
16-20 4 (3%) 5 (5%) Family meetings 2.03 2.06 0.05 .82
21-25 7 (6%) 4 (4%)
>25 0 4 (4%)
Role in unit
Registered nurse 60 (49%) 47 (47%) providers. This ICU workforce, by sheer patient interaction
Attending physician 10 (8%) 18 (18%) hours, is not only dominated by nurses and physicians but also
Fellow 7 (6%) 8 (8%) includes pharmacists, RTs, physical therapists, SWs, pastoral
Resident 32 (26%) 9 (9%)
care, patient care technicians, and other support staff. The
Nurse practitioner 2 (2%) 8 (8%)
Respiratory therapist 7 (6%) 5 (5%) EOL/GOC issues and observations were elicited from all of
Social worker 1 (1%) 1 (1%) these groups as they all had unique perspectives on patient and
Registered dietitian 1 (1%) 2 (2%) family interactions. This study also provided the training in a
Clinical pharmacist 1 (1%) 1 (1%) multidisciplinary approach through role-play opportunities for
Clinical nurse specialist 1 (1%) 1 (1%) nursing physician and SW interactions. We also quickly dis-
Pastoral care 0 1 (1%) covered that similar stressors in regard to EOL/GOC issues
existed among this multidisciplinary group of critical care pro-
viders. The most common stressor expressed among the group
Table 2. Reliability Results. was the idea of continuing aggressive levels of care and inva-
sive procedures for a critically ill patient when it did not seem
Cronbach Cronbach compatible with any broadly defined basic quality of life
a coefficients: a coefficients: outcome.
Domain Preimplementation Postimplementation
We report a preintervention survey response rate of 50.4%
Knowledge and ability .88 .83 and a postintervention survey response rate of 36.1%. Our sur-
Work environment .82 .82 vey was distributed online. The published acceptable response
Support for staff .74 .78 rate for online surveys is reported to be 33%,22 which means we
Support for patients .77 .79 had more than an adequate response for both arms of our sur-
and families
vey. The decline in response rate between the presurveys and
Work stress .79 .84
postsurveys was tightly associated with a drop-off in the house
staff response rate, which dropped from 26% to 9%. It is
unclear why this occurred, but historically, it can be difficult
implementation of our EOL/GOC program. The strength of this to get rotating house staff who are required to complete a
study is found in its design, implementation, and focus on critical care clinical experience integrated into unit-based
inclusion of all individuals of the multidisciplinary critical care improvement projects. This was a deidentified survey, which
team. From our review of the literature, this is the first multi- does not allow direct comparison of answers from respondents.
disciplinary team-based approach with the goal of improving Some house staff have required repeat rotations with graduated
EOL/GOC approaches in the critical care setting. The Institute responsibilities in the SICU as they advance from intern to resi-
of Medicine recently issued a new report, ‘‘Dying in America,’’ dent in their training cycle. The decreased response rate noted
on improving quality of care near the EOL. A major focus of from house staff may also be due to some residents completing
this report is a call for universal education and training for all the first survey and not the second survey. The follow-up sur-
health professionals and clinicians in the core principles and vey asked whether they had cared for ICU patients in the pre-
practices of palliative care.20,21 vious year with an ‘‘opt out’’ if this was answered negatively.
With the inception of our program, a core decision was The cohort of residents who completed the initial survey (and
made to solicit and include input from all critical care not the subsequent due to having only 1 scheduled critical care

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8 Journal of Intensive Care Medicine
rotation) is not only a potential limitation to the results but also
typical of the scheduling nuances that occur at large academic
institutions.
Our survey was developed previously and published as an
accepted evaluation tool for the perception of EOL care.18
We sought approval of the prior authors to change the potential
respondents of the survey from nurses to the multidisciplinary
practitioners who work in the critical care domain. However,
nurses and physicians dominated our responses, as they com-
prise the majority of our SICU workforce. It should also be
noted that at our large academic center, greater than 80% (pre)
and 70% (post) of our respondents have less than 10 years of
critical care experience. This provides ample opportunity for
further education and career development in an area such as
EOL/GOC. We also believe a similar mixture of ICU provider
population/experience level exists at other large academic
training centers.
One of our major goals was to improve the perception and
experience of the critical care provider, as they help both
patients and their families transition into the EOL spectrum
of care. In our opinion, this is an integral part of critical care
but one that lacks organized formal training for both nurses and
physicians. Innate empathy can provide a nice framework, but
more formalized education and guidance will help the provider
with their own emotional challenges as they face these stressful
interactions. One of our goals was to provide the multidisci-
plinary team with the building tools and strategies of how to
approach these EOL/GOC discussions. This was done through
formalized didactics, mock discussion templates, role-playing,
and directed feedback. The respondents of our survey noted
that this overall intervention did lead to a statistically signifi-
cant improvement in work stress.
Our improvement strategy also focused on providing the
patient and families with applicable resources that they could
refer to on their own time frame. A formalized EOL family
educational pamphlet was developed and then put through a
group editing process to make sure all applicable components
were covered. Per report, our nurses enjoyed having a forma-
lized resource that they could provide a patient’s family and
review with them as needed. Our postintervention survey rated
overall improved critical care provider satisfaction with this
initiative. We also started the process of hanging a lotus flower
(accepted international flower for palliative care)23 sign outside
a patient room for a patient on a comfort care trajectory after
completion of a formal comfort care discussion with the family.
The lotus flower also became an easy way for all of our staff to
communicate and show quiet respect for that patient and their
family.
Physical space allotment also received high satisfaction
marks in the postintervention survey. Our EOL/GOC initiative
overlapped with the redesign and movement of our physical
ICU plant. Our SICU expanded from a 24-bed unit to a
36-bed unit. Our preintervention data included feedback
regarding the need to improve family space resources. As part
of the design for the new unit, we referenced these results and
made sure to stress the need for improved family support space.
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This was provided as extra space in each patient room as well
as formalized patient/family conference rooms to allow private
EOL/GOC discussions in an adequate venue. Our findings sug-
gest that future unit designs should incorporate family support
space in the room as well as in the conference areas that accom-
modate privacy and large numbers.
As part of our education process, we created educational
discussion templates for both nurses and physicians. Our tem-
plates were designed with a 3-part process, based on develop-
ment of a trusting relationship model with the family. The
templates encourage engaging the family in the discussion with
appropriate prompts to allow for listening and showing empa-
thy. These discussion templates were reviewed in formalized
didactic sessions as well as added as available resources in
existing SICU handbooks. Subgroup analysis of the postinter-
vention survey found that this additional information was well
received by the physician (attending/fellow) subgroup. Previ-
ous studies have shown that EOL/GOC education is a short-
coming of current medical education.4 Simple resources can
at least provide a framework to help intensivists improve their
EOL communication skills/tools while also providing them
personal satisfaction with the extra guidance of published
information.
In the knowledge domain, the intervention appeared to help
the advanced practice clinicians the most. This group was pri-
marily comprised of advanced practice RNs in the nurse practi-
tioner role. An increase in the number of nurse practitioners
due to ICU staffing requirements occurred in 2011 with a large
majority of them being recent graduates. Their initial inexperi-
ence of managing patients at the EOL may explain the observed
improvement being greater with them than the attendings and
fellows. However, we did not originally include further subana-
lysis questions to explore reasons from the items asked on the
survey.
A major weakness of our study is that it was completed
at a single institution. As reported previously, this was done
at a large academic center with a high-acuity SICU. As an
academic center, we have very ‘‘junior-level’’ trainees
involved in critical care. Some of the approaches to this
EOL/GOC intervention may not be available at smaller
institutions. However, we do feel that this material is appli-
cable to institutions of all sizes. The change in our physical
ICU location during this study with construction of new
family support spaces would not be a realistic expectation
for all institutions. This study also did not evaluate sustain-
ability of this intervention. Obviously, an intervention such
as this one needs to have longevity and integration into the
normal critical care culture. Anecdotally, we have noted that
our physician fellow graduates who have remained as attend-
ing faculty at our institution do have an improved skill set
at EOL/GOC discussions and patient care. We did not directly
survey patients or family members to determine patient-
centered impact. Finally, although this study followed a prein-
tervention/postintervention format, the data were gathered in
survey format and is subject to the innate weaknesses of this
type of study.
Wessman et al
Conclusion
We created a novel multidisciplinary-based training program
for improved EOL/GOC approaches in the critical care set-
ting. Our EOL/GOC program involved input from diverse
critical care providers with specific focus on improved educa-
tion, improved family communication and support, improved
order sets, and improved ICU resources to support EOL care.
A similarly formatted program could be adapted by other
ICUs. Benefits of such a program include improving care-
givers’ perceptions regarding EOL/GOC issues, lowering
self-perceived work stress, and fostering critical care team
growth. Further studies need to evaluate patient-/family-
centered impact.
Acknowledgments
A special thanks to the critical care providers who work in the 4400
ICU at Barnes-Jewish Hospital for their daily willingness to provide
world-class critical care medicine and still be introspective enough
to look for ways to improve themselves. Special thanks to Dean
Klinkenberg, PhD, for his statistical assistance and guidance.
Authors’ Note
This submission is not under consideration elsewhere. The content
of this submission has not been previously published. I have read
and approved the manuscript, and all corresponding authors are in
agreement.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to
the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, author-
ship, and/or publication of this article.
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