The authors respond.

Abstract

We appreciate your dedication to providing timely and appropriate palliative care services to patients in the intensive care unit (ICU) and for your questions regarding our article. We agree that the use of the tool is central to achieving desired outcomes. Regarding your question about the use of the tool Monday through Friday, this timing was a noted process limitation in the unit where the research was being conducted. Full team ICU rounds only occurred Monday through Friday. However, the tool was completed by the bedside nurse 7 days a week. On the weekend, the results of the palliative care screening could be conveyed to the provider and a palliative care consult could be pursued.In designing this process several years ago, we discussed the use of the tool to initiate an automatic palliative care consult. We noted that we had a blended model of both the consultative model and integrative model as referenced in Nelson et al.1 This dynamic process is informed by real-time availability of palliative care consultants (consultative model) in proximity to the identified need, the complexity of the consult, and the relationship already established by an intensivist who may have already adequately addressed the palliative care needs (integrative model). We discussed the automatic consult and this existing dynamic process and determined that it would be most efficient for the process and beneficial for the patient/family if the intensivist/attending provider was to determine if the palliative care needs had already been met or if a consult to the palliative care team would be indicated.Thank you for your insightful questions regarding the race of the 7 non-White participants who did not receive palliative care. Among these 7 patients, 4 were Black/African American and 3 were Indigenous/Native American. Although the small sample precludes additional analysis, we hope future researchers will work to understand and address racial disparities in access to palliative care.Your comments regarding moral distress are thoughtfully stated, and we certainly recognize that variables contributing to moral distress should be acknowledged and addressed to the extent possible within each organization and their ICUs. This issue is complex and can present a challenge when trying to assign weight to the different variables contributing to moral distress in the care and treatment of these ICU patients. Although it would seem ideal to have an automatic consultation model, multiple factors would need to be considered to avoid causing further moral distress and/or frustration. These factors include, but are not limited to, the existence of a palliative consultation team within the organization, the team's expertise in consulting on ICU patients, the urgency of the consult, the team's availability to consult in the ICU on any given day or at a given time, the knowledge and skill of providing palliative care services among those who are not palliative care consultants, and the culture within the ICU, which is a foundational component to any ICU palliative care program.Noting these factors, it is important to consider the features of the integrative model of palliative care. This model brings additional value,addresses the limitation of formal palliative care consultation resources 24/7, and is complementary to a consultative model. We believe the challenge in addressing the moral distress related to the palliative care process is to find the appropriate balance of these 2 models within each organization and ICU. This balance involves acknowledgment of current resources, dedication to enhancing formal palliative care consultation where possible, and provision of training for staff to leverage the benefits of the integrative model. All team members, including providers, nurses, social workers, and chaplains, must be committed to establishing a culture of trust and support built on the foundation of adequate palliative care knowledge and skills, which will result in timely action when the palliative care screening is indicative of a palliative care need. Potential moral distress resulting from perceived constraints in the process can certainly be mitigated through a balanced consultative/integrative model approach. This process of provider-to-provider consultation need not be seen as a barrier but rather a benefit to the process in ensuring we have appropriately assessed the palliative care opportunity for each appropriate patient and determined the best solution to meet those needs.Your comments are timely. The coronavirus disease 2019 pandemic has exposed existing deficiencies in our health care system, including lack of access to palliative care. We are grateful for your commitment to improving ICU palliative care, and we look forward to working together as a health care community to ensure access to high-quality palliative care.