Developing guidelines that identify patients who would benefit from palliative care services in the surgical intensive care unit

Objective: The convergence of end-of-life care and surgical practice often occurs in the surgical intensive care unit (SICU). Because many patients who encounter difficult end-of-life issues in the SICU do not receive palliative care services, there is a need to educate surgeons on how to better identify those patients. Design: A group of 29 national and local experts were identified based on qualifications as surgical intensivists, palliative care specialists, or members of the American College of Surgeons Surgical Palliative Care Task Force. A smaller representative group initially identified responses to the question, "Which patients in the SICU should receive a palliative care consultation?" Using a modified Delphi technique, 31 proposed criteria were distributed electronically to the larger group and ranked through three rounds to generate a final list of ten. Setting. E-mail-based Delphi consensus panel. Subjects: National and local surgical palliative care experts. Interventions: Survey in three rounds. Results: Thirteen participants responded to the first round and 12 to the second. In the third round, the entire group was given the ten criteria for final approval. One half of the respondents were national authorities and the other half were local experts. The top five "triggers" for a palliative care consultation in descending order were: family request; futility considered or declared by the medical team; family disagreement with the medical team, the patient's advance directive, or each other lasting >7 days; death expected during the same SICU stay; and SICU stay >month. Conclusions: We offer a set of consensus guidelines derived from expert opinion that identifies critically ill surgical patients who would benefit from palliative care consultation. These criteria can be used to educate surgeons at large on the variety of clinical scenarios where palliative care specialists can offer support. (Crit Care Med 2009; 37:946-950)