Table 2.

Domains of quality palliative care with considerations for critical care nurses during the COVID-19 pandemic²⁴

Domain	Considerations
1: Structure and Processes of Care	Deliver primary palliative care for all patients (eg, symptom management, advance care planning guidance, health proxy and decision-making support) Ensure timely specialist consultation of palliative care as needed, given visitor restrictions and rapid decline of patients Identify pathways for rapid consultation and involvement of palliative care team within health system/institution
Interdisciplinary approach to patient- and family-centered care, including elements of palliative care delivery and systems and processes considerations
2: Physical Aspects of Care	Advocate for adequate sedation of patients receiving mechanical ventilation when appropriate Educate patients and families about proning therapy for ARDS Ensure adequate pain management for patients with chronic or cancer pain, in addition to sedatives and necessary anxiolytic support Treat dyspnea, gastrointestinal distress, and other symptoms to optimize comfort and function Partner with palliative care pharmacist and other specialists for complex symptoms and patients with multimorbidity
Palliative care assessment, care planning, and treatment of physical symptoms, emphasizing holistic patient- and family-directed care
3: Psychological and Psychiatric Aspects of Care	Assess for underlying psychological and psychiatric needs Provide ongoing support through therapeutic presence, active listening, and other communication strategies, as possible Partner with palliative care social workers and psychiatric practitioners to address the impact of COVID-19 in the ICU and in conjunction with serious illness
Assessing psychological and psychiatric needs in serious illness context
4: Social Aspects of Care	Identify patient/family relationships, dynamics, and support systems in place Foster relationship with proxy and/or surrogate given likelihood of patient receiving mechanical ventilation in the ICU Engage family through telemedicine, phone, or other means to promote social cohesion during visitor prohibition
Addressing support needs of patient and family
5: Spiritual, Religious, and Existential Aspects of Care	Assess for spiritual, religious, and existential needs early in the ICU stay Considerately elicit any specific rituals or considerations related to dying, death, and bereavement given high mortality rates once patient is receiving mechanical ventilation Collaborate with palliative care chaplain to assess and attend to spiritual injury, existential anxiety, and so forth
Emphasizing spiritual, religious, and existential care, including eliciting unmet needs
6: Cultural Aspects of Care	Promote care that is culturally competent and humble to the expertise of individuals, families, and various cultural communities Assess patient’s and family’s understanding of COVID-19, if the disease has any specific meaning for them, and if they are seeking any treatment in alignment with cultural traditions Ensure interpreter services early in relationship, as needed to ensure transparency and clear understanding
Exploring how culture influences delivery of palliative care and the patient/family experience of the care received throughout the trajectory of illness and into bereavement
7: Care of the Patient Nearing the End of Life	Foster relationship-based care early in the ICU stay, inviting difficult conversations for patients and family members as appropriate Identify signs of anticipatory bereavement and support with coping strategies Collaborate with palliative care team to help patients and families process their grief and feel supported at the end of life
Focusing on symptoms and situations most common in final days and weeks of life
8: Ethical and Legal Aspects of Care	Even if uncomfortable, ensure advance care planning discussions and identifications of proxy/surrogate upon ICU admission, given unpredictable COVID-19 trajectory Promote communication of moral distress openly with members of interdisciplinary and palliative care team to promote healthy and supportive work environment Collaborate with palliative care and ethics committee members when available to address ethical or legal concerns, questions, and to optimize patient autonomy throughout the ICU experience
Advance care planning, surrogate decision-making, regulatory/legal considerations, related palliative care issues; focusing on ethical mandates to promote patient autonomy

Abbreviations: ARDS, acute respiratory distress syndrome; COVID-19, coronavirus disease 2019; ICU, intensive care unit.

Used with permission from the National Consensus Project for Quality Palliative Care.²⁴ Clinical Practice Guidelines for Quality Palliative Care. 4th edition. Richmond, VA: National Coalition for Hospice and Palliative Care; 2018. https://www.nationalcoalitionhpc.org/ncp