A new care model is needed to describe work and responsibilities between primary and specialist palliative care in the ICU. Generally, palliative care is provided as primary and specialized palliative care, indicating that primary care physicians have some basic skills while advanced palliation is provided by the specialists.
However, the distinction between primary and specialist palliative care is more difficult in the ICU, from where palliation originated in the 1980s. ICU physicians and nurses are already highly skilled to assess and manage pain, agitation and breathing problems as demonstrated by international guidelines. Clinicians communicate with families and practice shared decision-making. Palliative care specialists can advise ICU clinicians on complex clinical problems provided they understand the practice and culture in ICU.
This concept was first suggested by J.R. Curtis, I.J. Higginson and D.B. White in 2022 (Curtis, J.R., I.J. Higginson, and D.B. White, Integrating palliative care into the ICU: a lasting and developing legacy. Intensive Care Med, 2022. 48(7): p. 939-942).
In practice, the EPIC model relies on a systems-based approach using trained specialist palliative care consultations, a trigger checklist to identify patients in need, and education of ICU physicians and nurses.
The EPIC model of primary and specialist palliative care in ICU.
The EPIC clinical trial tests the EPIC model
The EPIC model is implemented in 7 clinical centres from 5 European countries and 23 multi-disciplinary ICUs in the context of a multicentre clinical trial.
The primary objective is to reduce patient and family suffering by reducing the length of stay in ICU. Secondary objectives include perceptions of surviving patients and family members about changes in their health-related quality of life, as well as care and communication in the ICU. In addition, secondary objectives include clinician perceptions about ethical practices and decision-making, moral distress and emotional exhaustion. Further outcomes facilitators and barriers of palliative care in the ICU among all stakeholder. Effectiveness and cost-effectiveness of the new model will be tested by a stepped wedge, cluster-randomized controlled trial. The ICU is the unit of randomization. All ICUs start in the control period and cross over at randomized time-points to the intervention period. In the control period, patients are treated according to usual care.
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A complex intervention with the following components
- Education of ICU clinicians
During the crossover period, ICU physicians and nurses are educated in basic palliative care by e-Learning and interactive workshops. This education is customized to the special requirements of palliative care in ICU. It is effective to improve knowledge of, confidence in and attitude towards palliative care amongst physicians and nurses. The educational content is created by palliative care specialists in cooperation with intensive care clinicians.
- Trigger Checklist
A trigger checklist is developed and implemented to identify patients in need of palliative care. This checklist is based on a literature review and developed by a Delphi process with all clinical partners. The checklist is used in the intervention period to trigger the initiation of a specialist palliative care consultation.
- Specialist Palliative Care Consultation provided by telemedicine
The consultation is provided by a trained specialist from the clinical centre to the ICU physician at the bedside via telemedicine. All specialists will have received training in form of e-learning prior to study start. Knowledge will be refreshed at least every 6 months. The protocol permits 1 consultation, but additional consultations are possible and will be documented in the study log.
- Telemedicine
Telemedicine is used to deliver consultations. Two clinical centres employ telerobots, other centres use conventional video call technologies as established and IRB-approved.
