Straddling the fence: ICU nurses advocating for hospice care.

A key factor in nurses' experiencing moral distress is their feeling of powerlessness to initiate discussions about code status, EOL issues, or patients' preferences. Moreover, nurses encounter physicians who give patients and their families a false picture of recovery or, worse, block EOL discussions from occurring. Since its release in 1995, the landmark study of almost 10,000 patients in the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT) reported a widespread gap with physicians' discussions in honest prognosis and EOL issues. Since the SUPPORT report, other studies have validated patients' and their families' preference for realistic discussions of disease trajectory and life expectancy. Unfortunately, the phenomenon of physicians failing to discuss bad news or terminal disease trajectory persists. Moreover, with a burgeoning geriatric population, coupled with advances in medical treatments, a growing segment of chronically ill patients are admitted to the ICU. With these communication shortcomings, it becomes an essential element of practice for the ICU nurse to initiate discussions about healthcare goals, preferences, and choices. The ICU nurse must be integral in fostering those discussions, particularly in cases where the family asks if hospice should be considered. Nurses have a long history of patient advocacy, with both the American Nurses Association and the American Association of Critical-Care Nurses stating that nurses have a duty to educate and promote dialogue about patients' preferences, goals, and EOL issues. With these tenets in the forefront, the ICU nurse is an integral member of the healthcare team, working with patients and their families to distinguish between what can be done and what should be done. Too often, hospice is thought of as a last resort. Rather, it is a model of care that centers on the belief that each of us has the right to die pain free and with dignity, and that our families will receive the necessary support to allow us to do so. Despite the high satisfaction reported by decedents of hospice enrollees, 35% of all hospice patients die within 7 days of enrollment owing to late referrals. An ICU stay presents the perfect opportunity to weave EOL care planning into the fabric of everyday patient care. Clearly, the ICU setting cares for the very sickest patients, and knowing what patients and families desire must take precedence in all treatment decisions. The ICU nurse should be proficient in communication skills, using evidence-based communication related to functional status, performance scales, disease trajectory, and prognosis. ICU nurses recognize that not every patient survives their ICU stay; yet, for those patients who will not survive, every ICU nurse wants their patient to experience a "good death." Hospice and the palliative care are important aspects of our care continuum and should not be ignored until the last days or hours of a patient's life. Recognizing eligibility for hospice and its alignment with patient EOL preferences can result in optimal EOL care.