COMFORTTMSM in the ICU: Advancing ICU Nurses' Role in Primary Palliative Care

•Describe effective RN-focused strategies to improve primary palliative care in the critical care setting.•Describe the customization of the COMFORT Communication Training Curriculum for ICU nurses.•Discuss the application of a quality improvement approach to advance engagement in palliative care by RNs in a critical care or other specialty setting. Cancer patients are being treated with greater frequency in ICUs, where nurses (RNs) often provide the most consistent clinical presence. Critically ill patients and their families hope for recovery, but may encounter uncertainty, complications, and poor outcomes. Such patients benefit from palliative care (PC) to assist with clarification of goals of care and alignment of treatment choices to wishes. Opportunity exists to engage ICU RNs as primary PC team members to help explore patient and family hopes, promote understanding, and assist with decision-making. ICU RNs at our cancer center expressed moral distress and barriers to PC engagement. To improve ICU nurses' engagement in primary palliative care. An RN-led interdisciplinary ICU PC Committee was formed and launched a quality improvement project to address challenges. Concerns outside of nursing scope were presented to the center-wide Critical Care Committee (CCC). A self-report survey was conducted to assess frequency of PC discussions by ICU RNs with patients/families and physicians, and to gauge confidence and experience with such talks. Results indicated gaps in knowledge, engagement, and ease with communications in the ICU. Action plans were developed to broaden the RNs' role in primary PC. The COMFORTTMSM Communication Curriculum was customized to address ICU nurses' needs and concerns. A workshop including presentations and role play were designed for four RNs per session. Fifty-four ICU RNs attended workshops over a period of 8 months. Repeat surveys indicated increases in ICU RNs' average scores for confidence, frequency and experience with conducting PC conversations by over 25%. Patient satisfaction with coordination of care, nurses' communication style, and family participation improved an average of 17%. Specialty-level PC consultation increased by 31%. RN participation in COMFORTTMSM-based workshops promoted PC in the ICU. Future work will include efforts to sustain improvements and to collaborate with the CCC to increase provision of primary and specialty-level PC in the ICU.