Comparing clinician ratings of the quality of palliative care in the intensive care unit*

Abstract

There are numerous challenges to successfully integrating palliative care in the intensive care unit. Our primary goal was to describe and compare the quality of palliative care delivered in an intensive care unit as rated by physicians and nurses working in that intensive care unit. Multisite study using self-report questionnaires. Thirteen hospitals throughout the United States. Convenience sample of 188 physicians working in critical care (attending physicians, critical care fellows, resident physicians) and 289 critical care nurses. Clinicians provided overall ratings of the care delivered by either nurses or physicians in their intensive care unit for each of seven domains of intensive care unit palliative care using a 0-10 scale (0 indicating the worst possible and 10 indicating the best possible care). Analyses included descriptive statistics to characterize measurement characteristics of the ten items, paired Wilcoxon tests comparing item ratings for the domain of symptom management with all other item ratings, and regression analyses assessing differences in ratings within and between clinical disciplines. We used p < .001 to denote statistical significance to address multiple comparisons. The ten items demonstrated good content validity with few missing responses or ceiling or floor effects. Items receiving the lowest ratings assessed spiritual support for families, emotional support for intensive care unit clinicians, and palliative-care education for intensive care unit clinicians. All but two items were rated significantly lower than the item assessing symptom management (p < .001). Nurses rated nursing care significantly higher (p < .001) than physicians rated physician care in five domains. In addition, although nurses and physicians gave comparable ratings to palliative care delivered by nurses, nurses' and physicians' ratings of physician care were significantly different with nurse ratings of this care lower than physician ratings on all but one domain. Our study supports the content validity of the ten overall rating items and supports the need for improvement in several aspects of palliative care, including spiritual support for families, emotional support for clinicians, and clinician education about palliative care in the intensive care unit. Furthermore, our findings provide some preliminary support for surveying intensive care unit clinicians as one way to assess the quality of palliative care in the intensive care unit.