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Seminars in Oncology Nursing, Vol ■■, No ■■ (■■), 2017: pp ■■-■■ 1

PALLIATIVE CARE
COMMUNICATION IN THE ICU:
IMPLICATIONS FOR AN
ONCOLOGY-CRITICAL CARE
NURSING PARTNERSHIP
DEBORAH A. BOYLE, SUSAN BARBOUR, WENDY ANDERSON, JANICE NOORT,
MICHELLE GRYWALSKI, JEANNETTE MYER, AND HEATHER HERMANN

OBJECTIVES: To describe the development, launch, implementation, and out-

comes of a unique multisite collaborative (ie, IMPACT-ICU [Integrating
Multidisciplinary Palliative Care into the ICU]) to teach ICU nurses commu-
nication skills specific to palliative care. To identify options for collaboration
between oncology and critical care nurses when integrating palliation into
nursing care planning.
DATA SOURCES: Published literature and collective experiences of the authors
in the provision of onco-critical–palliative care.
CONCLUSION: While critical care nurses were the initial focus of education, on-
cology, telemetry, step-down, and medical–surgical nurses within five university
medical centers subsequently participated in this learning collaborative.

Deborah A. Boyle, MSN, RN, AOCNS, FAAN: Univer-
sity of California Irvine Health, Orange, CA; Advanced
Oncology Nursing Resources, Inc., Huntington Beach,
CA. Susan Barbour, MS, RN, CWON, ACHPN: Universi-
ty of California San Francisco Medical Center, San
Francisco, CA. Wendy Anderson, MD, MS: University of
California San Francisco, Division of Medicine and Pal-
liative Care, San Francisco, CA. Janice Noort, MS, RN,
NP, ACHPN: University of California Davis Health, Sac-
ramento, CA. Michelle Grywalski, BSN, RN, CCRN:
University of California Irvine Health, Orange, CA. Jean-
nette Myer, MSN, RN, CCRN, CCNS, PCCN, ACHPN:
University of California Los Angeles Medical Center,
Santa Monica, CA. Heather Hermann, MS, RN,
ANP: University of California San Diego Medical Center,
San Diego, CA.
This work was supported by the Center for Health
Quality and Innovation Quality Enterprise Risk Man-
agement (CHQIQERM) program, a joint venture of the
University of California Center for Health Quality and
Innovation and the Office of Risk Services.
Address correspondence to Deborah A. Boyle, MSN,
RN, AOCNS, FAAN, 16093 Sherlock Lane, Huntington
Beach, CA 92649. e-mail: deboyle@cox.net
© 2017 Published by Elsevier Inc.
0749-2081
https://doi.org/10.1016/j.soncn.2017.10.003
 ARTICLE IN PRESS
2 D.A. BOYLE ET AL.

Participants reported enhanced confidence in communicating with patients,

families, and physicians, offering emotional support and involvement in family
meetings.
IMPLICATIONS FOR NURSING PRACTICE: Communication education is a vital yet
missing element of undergraduate nursing education. Programs should be offered
in the work setting to address this gap in needed nurse competency, particu-
larly within the context of onco-critical–palliative care.
KEY WORDS: communication, oncology nursing, critical care nursing, palliative
care, education, collaboration.

I
n high-income countries, accelerated and in-
creasingly sophisticated intensive care
resources have resulted in increased admis-
sions of patients with limited life expectancy
into the intensive care unit (ICU).1 This is true of
cancer care, where one in 10 patients experience
a life-threatening condition that requires the sup-
portive technologies and monitoring rendered within
this setting.2,3 In the United States, the presence
of cancer patients in the ICU has increased over
the past decade such that currently up to one third
of all patients have a primary diagnosis of a
malignancy.4 In Europe, every sixth to eighth patient
in critical care has cancer.5 Of note is that surviv-
al rates for this population have also increased over
the past decade.6,7
The contemporary use of aggressive cancer
therapies heightens the prevalence of emergent
scenarios. This is often the case for hematologic
malignancies (ie, acute leukemias, non-Hodgkin
lymphoma, multiple myeloma) and hematopoi-
etic stem cell transplantation (HCST), where the
risk of protracted neutropenia, sepsis, and organ
compromise is significant.8-12 Yet these scenarios
have been recently associated with benefit of ICU
admission in terms of overall survival.13-16 Addi-
tionally, some patient populations with known
risk factors for hemodynamic and respiratory
compromise around the initiation of antineoplas-
tic therapy (ie, diffuse large-B cell lymphoma
with bulky disease) can be predicted to require
acute ICU support.17 It appears that the nature
of the acute illness rather than the underlying
malignancy are most associated with short-term
mortality.7,18,19 Other peri-diagnostic corollaries
of initial cancer diagnosis will often require the
expertise of a rapid response team. These include
acute respiratory failure, pulmonary embolism,
thrombotic microangiopathies, and cytokine release
syndrome.20 Oncologic emergencies such as
hypercalcemia, syndrome of inappropriate anti-
diuretic hormone (SIADH), tumor lysis and superior
vena cava syndromes, anaphylaxis, and cardiac
tamponade are other emergent critical scenarios.21,22
Cancer patients with advanced disease may also
need intensive care support. Emergent care may
be necessary for symptom control not amenable to
therapy utilized outside the critical care setting (ie,
acute respiratory distress, pain, palliative seda-
tion, stent placement, seizures, delirium). Ideally,
these admissions are short-term once the compli-
cations or symptom distress are managed. Thus,
a diagnosis of cancer should not automatically pre-
clude admission to the ICU.23 In some instances,
however, the patient’s clinical condition deterio-
rates and death occurs in the ICU. Despite the
nature and prevalence of these oncologic disease
corollaries, considerable interpersonal and com-
munication expertise is needed to manage these
sequelae across the cancer trajectory.
Oncology and critical care nurses share many
similarities within the context of where their com-
munication proficiency is required. They often
practice in a “grey zone,” dually characterized by
hi-tech, drug-intensive, recovery-oriented treat-
ment regimens in tandem with equally diligent
therapies whose goals are the relief of symptom dis-
tress and palliation. Both specialty nurses practice
in a work culture where prognostication and sur-
vival estimates are complex. This commonly results
in physician discomfort in predicting death and
having discussions with patients and families about
a limited life expectancy. Families often interpret
this as negative and insufficient communication,
leaving them feeling vulnerable in knowing how to
perceive what is transpiring in their loved one.24
Nurses then frequently feel “in the middle,” guarded
with their conversations with patients and fami-
lies, while simultaneously experiencing frustration
about truth-telling being withheld.
 ARTICLE IN PRESS
Both oncology and critical care nurses perceive
their role to be that of translator, helping patients
and families comprehend what is transpiring. While
the disclosure of diagnostic and prognostic infor-
mation is the responsibility of the physician, this
initial discussion is only a starting point.25 Nurses
help the patient and family interpret the meaning
of biomedical information and make sense of the
illness.26 They frequently engage in multiple dia-
logues with numerous family members who require
help with deciphering the significance of medical
information. This is done within a paradigm of un-
certainty and emotional distress. Yet it is within this
context that nurses often make their most notable
contributions.
THE COMMUNICATION QUANDARY
Communication is a fundamental, core compe-
tency of nurses. It enables them to assess, teach,
counsel, question, intervene, and validate the myriad
of issues influencing the health of their patients.
Historically, nurse communication has been per-
ceived as an innate ability; the assumption being
that communication proficiency “comes natural-
ly” and that expertise in this domain does not
require substantive learning. This is contrary to
other aspects of nursing education. As a result, the
absence of formal instruction in communication skill
building devalues its’ importance, despite evi-
dence that this is an important, highly regarded
competency to both patients and their families.27-31
For nurses who practice in the hospital setting,
heightened acuity, complex decision-making, and
the presence of multiple providers characterize usual
practice. Hence, a major nursing role is that of
patient advocate. Because of their constant pres-
ence at the bedside, nurses become aware of unmet
needs, changes in patient status, and barriers to
optimal care over time. For nurses to effectively
lobby on behalf of their patients, they must be
skilled in speaking up, challenging decisions, and
offering recommendations to the patients’ plan of
care. Nurses are the “constant” in the patient’s
journey throughout an often fragmented health care
system.32 No other professional role has this degree
of enduring presence at the bedside, thus making
nurses’ perspectives and contributions unique to
the patient’s care.27,29,33-36
Barriers to effectively implementing palliative care
nursing expertise in the ICU have been delin-
eated in the literature. Table 1 depicts a compilation
PALLIATIVE CARE COMMUNICATION IN THE ICU 3
TABLE 1.
Obstacles and Barriers to ICU Nurses’ Involvement in
Palliative Care
• Nurse-Focused:
o Need for additional communication skills training
o Time constraints
o Not knowing patient wishes prior to admission
o Interactions with emotional family-members
o Language barriers
• Physician-Focused:
o Lack of training and comfort with goals of care
discussions
o Time constraints
o Exclusion of nurses and their perspectives from
discussions
o Differing opinions (between intensivists,
oncologists, and consulting specialists) on current
and future treatment options and prognosis
o Evasiveness, avoidance of interactions with families
o Delay in discussing patient decline/deterioration
o Offer “false hope”
o Defensiveness toward others who question
decisions
o Bias or misunderstanding about disease trajectory
o Uncertainty about prognostic accuracy
• Family-Focused:
o Not understanding terminology of lifesaving
measures and the limitations and complications of
life-sustaining therapies
o Non-acceptance of poor prognosis of loved one
o Requests for care despite patient wishes
o Internal family dissension regarding the use of life
support
o Enduring family expectations incongruent with
patient prognosis
Data from references:.24,26,37-43
of these obstacles that relate to nurse, physician,
and family sources. All of these have particular rel-
evance when the ICU patient has cancer.37-43 While
communication barriers in critical care have been
prominently portrayed in the literature, interven-
tions to minimize these impediments have received
less attention.
PALLIATIVE CARE COMMUNICATION SKILL
TRAINING FOR ICU NURSES
Deficiencies in communication have been iden-
tified as the most prevalent barrier to end-of-life
care in the critical care setting.26,27,29,33,44-46 Educa-
tion that promotes skill in this realm not only
enhances nurse’s interactions with patients and fami-
lies, but also augments intentional communication
 ARTICLE IN PRESS
4 D.A. BOYLE ET AL.
and collaboration amongst the interdisciplinary
team.33 Critical care nurses acknowledge their need
for further training to enhance their palliative care
nursing potential. Important to the development of
such programs is the awareness of teaching methods
best suited for effecting change in communication
behaviors.47 Some of these education options include
simulation, role play, psychodrama, role modeling
with feedback, and reflective teaching practice.48-50
Here, we report on a trajectory of work that has
focused on defining the roles of nurses in the crit-
ical care setting in communication about prognosis,
goals of care, and palliative care, and the provision
of communication skills training to help nurses ac-
tualize these roles. This approach has been described
by Milic et al.33 and Krimshtein and colleagues.51
Our work is relevant for oncology patients who are
cared for in ICUs, but also addresses the roles and
challenges of nurses caring for oncology patients
in other settings.
Historical Perspective
The genesis of our initiative began when nurses
in the Medical–Surgical ICU at the University of Cal-
ifornia San Francisco Medical Center (UCSF)
identified a need for enhanced communication skills
and increased specialty palliative care support in
the ICU. To address this need, an interprofessional
team including clinicians with experience in com-
munication skills training and serious illness
communication created an 8-hour learner-centered
workshop focusing on the role of nurses in serious
illness communication.33 The workshop included
education about the “4 C’s” palliative communi-
cation model:
Convening – ensuring necessary communication
occurs between the patient, family, and
interprofessional team;
Checking – for understanding;
Caring – conveying empathy and responding to
emotion; and
Continuing – following up with patients and fami-
lies after discussions to provide support and
clarify information.45,51
The workshop also highlighted three core con-
versations in which nurses can lead serious illness
communication with families, physicians, and in
the family conference setting. Specific tasks and
goals were identified for each conversation (Table 2).
The training was based on findings that outlined
nurse-identified communication barriers and used
evidence-based methods for communication skills
TABLE 2.
Conversation Focus and Goals of Bedside Nurses in
Discussing Prognosis and Goals of Care
Conversation focus Goals
Nurse–family • Elicit family’s goals and needs
• Elicit understanding of prognosis
• Provide emotional support
Nurse–physician • Elicit physician’s perspective on
prognosis and goals
• Present perspectives of patient’s
family and nurse
• Develop plan to address needs of
patients’ families
Nurse advocacy • Ensure key topics are discussed
in family meeting • Ensure family understands
information
• Provide emotional support
Data from Milic et al.33
training.51 Throughout the workshop, the nurses’
ethical responsibility to the patient and family was
emphasized, acknowledging that this duty is not
only a right, but an obligation.52,53
Between 2011 and 2013, 82 UCSF critical care
nurses completed the workshop, which under-
went ongoing refinement based on participant
feedback. Evaluation of the initial cohort indi-
cated that participation increased nurses’ confidence
to perform palliative care communication tasks,
such as assessing families’ understanding of prog-
nosis and goals of care, addressing families’
emotional needs, and contributing to family meet-
ings. Qualitative evaluation also indicated that
implementation of the workshop impacted the unit
culture positively, such that nurses supported one
another and were more involved in palliative-
related communications.47 A strong alliance with
nursing management not only enabled staff to attend
the workshop, but also supported their involve-
ment with ongoing workshop offerings.
The IMPACT-ICU Initiative
Given the success of the UCSF experience, the
UC Office of the President for Health Quality and
Innovation Quality Enterprise Risk Management
(CHQIQERM) funded an expansion of the program
across the other four UC academic medical centers
(ie, Davis, Irvine, Los Angeles, San Diego). The ex-
pansion, now formally titled IMPACT-ICU (ie,
Integrating Multidisciplinary Palliative Care into
the ICU) was funded for 2 years as a quality im-
provement initiative.
 ARTICLE IN PRESS
Communicate the value of a palliative care consultation to a physician
Use self-care practices to prevent burnout and compassion fatigue
Elicit a family's understanding of a patient's goals of care
Provide families with emotional support during family meetings
Ensure that a family member understands information presented in a
family meeting
Identify a family's need for information about a patient's illness and
treatments
Pre
Post
FIGURE 1. Six elements of greatest change in nurse communication confidence pre- to post-workshop (P < .001; n = 458
critical care nurses, 35 workshops). Data from Anderson et al.55
Two nursing leaders from each site (educators
or advance practice nurses) were selected to im-
plement the project at their campus. They
participated in a 3-day “Train-the-Trainer” program
at UCSF where were they were instructed in small
group role-play methods.54,55 Upon return to their
hospitals, the nurse leaders offered day-long work-
shops for the nursing staff and regularly rounded
at the bedside in target ICUs at their campuses. In
this role, they helped bedside nurses translate the
skills from the workshop into practice, and pro-
vided real-time support in navigating barriers.
OUTCOMES
Traditionally, critical care outcome metrics have
focused on cost, length of stay, survival after intu-
bation, and use of CPR. Our endeavor focused on
the communication indices that drive these
deliverables.54-56
Within a 2-year period, 35 workshops across the
UC system were offered. A total of 458 bedside
nurses practicing in 10 critical care units partici-
pated in this project. There were numerous
evaluation metrics that included: bedside ICU nurse
surveys pre- and immediately post- workshop par-
ticipation that rated perceived skill level in 15
palliative care communication tasks on Likert scales,
records of coaching rounds in the ICU, and qual-
itative data sources (ie, nurse lead notes regarding
the program process and perceived effectiveness).55
PALLIATIVE CARE COMMUNICATION IN THE ICU 5
Of note was the immediate overall impact of the
workshop on ICU nurses’ perceptions of improved
confidence and skill in palliative care communi-
cations (Fig. 1). One institution (UC Irvine) collected
3-month post-workshop data. Results at that junc-
ture revealed that three communication measures
were sustained at the same level immediately post-
workshop. This included “Define palliative care,”
‘Describe palliative care and how it may be useful
to a patient’s family,’ and “Contribute to discus-
sions of prognosis and goals of care in family
meetings.”
During the grant period, the nurse co-leaders were
consistently asked about non-ICU nurses’ poten-
tial participation in the workshop. Because the grant
targeted critical care nurses, we were unable to
respond to these requests during this time. However,
following the grant’s completion, the workshop con-
tinues to be offered and made available to all nurses
regardless of specialty and type of setting (ie, acute
care, ambulatory). The total number of nurse work-
shop participants throughout the UC system has
now nearly doubled from that noted at the grant’s
completion.
OPPORTUNITIES TO ENHANCE ONCOLOGIC–
PALLIATIVE–CRITICAL CARE COMMUNICATION
A concerted effort to improve oncologic–critical–
palliative communication is rooted in the intention
 ARTICLE IN PRESS
6 D.A. BOYLE ET AL.
to ameliorate patient and family suffering. This in-
cludes the implementation of measures to enhance
quality of life, regardless of which phase of the
cancer trajectory the patient is situated. Optimal
communication in the critical care setting can also
lessen the prominence of negative bereavement-
related psychosocial sequelae in families.57-59
There is no established prototype or delineated
guidelines for oncologic critical care. Currently there
are only a few cancer-specific ICUs in the US, and
they exist in large comprehensive cancer centers.
Thus, the majority of oncology patients who require
critical care services receive such in general in-
tensive care settings. To that end, there are
numerous possibilities to enhance oncologic–
critical–palliative care communication. They involve
both nurse education and clinical practice
innovation.
Nursing Education
Generalist critical care nurses frequently have
little education about oncologic concepts and goals
related to a cancer patients’ ICU admission. In the
absence of such, nurses’ impressions about the
cancer patients’ trajectory in the ICU are often neg-
atively skewed by past experiences where death was
common. This results in critical care staff’s fre-
quent reaction of clinical pessimism and perceiving
admissions as pointless and a waste of limited
resources.20,60 This lack of knowledge also influ-
ences the ICU nurses’ ability to inform or translate
information for the patient and family. Hence, the
following three recommendations are proposed.
Communication workshops like the IMPACT-
ICU exemplar should be mandatory for all staff
practicing in ICU and oncology settings. Case studies
used for the role plays should describe common sce-
narios with oncology patients, their families, and
physicians. For new nursing staff, this offering
should be part of their orientation, validating that
communicant skill is required to the same degree
as being proficient in physiologically based com-
petencies. Ideally, workshops should include a mix
of participants representing oncology and critical
care units and various disciplines practicing within
each specialty. This participant diversity en-
hances group discussion and awareness of specialty
issues.
Critical care nurses should receive education
about the two main models of palliative care in-
tegration in the ICU. These models include the
primary care model, which is grounded on the prin-
ciple of embedding palliative care expertise into the
daily practices of the ICU team (ie, multiple dis-
ciplines providing a holistic orientation to care,
symptom management knowledge, family inclu-
sion, emphasis on quality of life, communication
proficiency). These basic tenets should be part of
all ICU staff’s knowledge set that then facilitates the
routine integration of palliation into patient care.
The consultation model consists of a specialized
team of palliative care specialists who offer rec-
ommendations to the ICU staff to consider. Like
other consult teams, their care is episodic, based
on the clinical status of the patient. They do not
assume overall responsibility of the patient once
consulted. In many settings, palliative care con-
sultation teams are asked to participate in the care
of the more complex patients. These models of care
delivery can be taught within the IMPACT-ICU
workshop.
Basic critical care nurse education courses should
include a major tract focusing on the care of the
oncology patient in the ICU. The onco-critical care
module should include three major components:
cancer pathophysiology and disease overviews of
malignancies commonly seen in critical care, acute
oncologic scenarios requiring ICU admission, and
oncologic emergencies. This module should be
taught or co-taught by an oncology advanced prac-
tice nurse or educator.
Institution-specific unit admission data should be
retrieved that details the numbers and types of
cancer patients cared for in the ICU setting(s). This
information should be shared within the onco-
critical care module. Special emphasis should be
placed on clarifying the various needs for a cancer
patients’ ICU admission. One often not recog-
nized by critical care nurses is the “acute on chronic
scenario” where a potentially reversible complica-
tion can co-occur with cancer. Thus, indications
within the acute, acute on chronic, and latent im-
plications of needed ICU admission require
emphasis (Table 3). This fosters the critical care
nurses’ recognition of patient admissions where
physiologic stability and recovery are goals, versus
the assumption that all oncologic admissions end
with patient death. A review of patient and family
psychosocial responses and emotional support
options should also be included.
Innovative Patient and Family Support
Moving an oncology patient to the ICU inter-
rupts patient/family/staff relationships that often
have formed over time. Upon transfer to a new crit-
ical care environment during an emergent event,
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PALLIATIVE CARE COMMUNICATION IN THE ICU 7

TABLE 3.
Communication Opportunities Related to Onco-Critical–Palliative Nursing

Oncologic Problem ICU Treatment Aim Examples Nurses Role

Acute
(peri-diagnosis and initial
treatment)
Acute or chronic
(episodic event along the
cancer trajectory)
Latent
(associated with advanced
disease)
Manage sequelae of a
new diagnosis requiring
aggressive anti-
neoplastic therapy
Treat oncologic
emergency associated
with a new diagnosis
and/or initial treatment
Monitor and manage
treatment-related HSCT
toxicity
Provide post-operative
support
Control symptoms
Control symptoms
Control symptoms,
enhance quality of life,
support the transition to
comfort care
• Infection (sepsis, pneumonia)
• Non-infectious ARDS
• Adverse drug reaction
(anaphylaxis, cytokine
release syndrome)
• Cardiovascular (acute MI,
CHF, arrhythmias, embolism)
• Sepsis
• Tumor lysis syndrome
• Superior vena cava syndrome
• Hypercalcemia
• Increased intracranial pressure
• Infection (sepsis, pneumonia)
• GvHD
• ARDS
• GI bleed
• Major cytoreductive surgery
• Amputation
• Extensive plastic surgery
• Seizures
• Pain
• Delirium
• Obstruction-related
respiratory or neurologic
distress
• Obstruction-related pain
• Embolism
• Adverse drug reaction
• Invasive monitoring
required to control symptoms
• Palliative sedation
• Hemorrhage
• Acute exacerbation with
change in goals of care
• Develop therapeutic
relationships with patient
and family
• Determine need for
advance care planning
• Evaluate education needs
and barriers
• Provide education/
anticipatory guidance in
relation to treatment plan
• Advocate for patients and
families (eg, symptom
management, goals of
care, support)
• Elicit patient and family
needs and understanding
of prognosis
• Elicit patient and family
values, goals and
preferences
• Utilize interdisciplinary
resources and collaborate
with team members
• Elicit physician
perspectives on prognosis
• Develop plan to address
family needs
• Participate in family
meetings/conferences
supporting patient and
family perspectives
• Provide continuity across
settings of care

Abbreviations: ARDS, acute respiratory distress syndrome; CHF, congestive heart failure; GI, gastrointestinal; GvHD, graft versus
host disease; HSCT, hematopoietic stem cell transplant; MI, myocardial infarction.

families experience stress, a lack of continuity, and
a sense of abandonment. Families turn to the on-
cology nurses as the health professionals with whom
they have established trust, and often a long-term
relationship. Subsequently, families often return to
the oncology unit to seek support and explana-
tion of what is, or has, transpired in the ICU.
Interventions are needed that demonstrate and so-
lidify the partnership between critical care and
oncology nurses. These can reduce patient and
family anxiety associated with changing the setting
of care during a time of crisis. Novel interven-
tions are necessary to address the final “C”
(continuing) in the palliative nursing model.51 Con-
sider the following:
• If the oncology nurse senses a disconnect
between messages offered by multiple physi-
cian providers and what the patient and family
are hearing during an evolving emergent sce-
nario, call a Family Meeting; be sure a nurse is
in attendance and document the key points from
the meeting;61
• If the oncology nurse anticipates a probable need
for transfer to the ICU, inquire if the ICU charge
nurse could come to the oncology unit to explain
to the patient and family what they can expect
in this setting;
• Establish a standard of care on the oncology unit
that when patients are transferred to the ICU,
a nurse always accompanies them; introduces
 ARTICLE IN PRESS
8 D.A. BOYLE ET AL.
the patient and family to the ICU nurse; when
possible gives a report to the ICU nurse with
the family present, in addition to medical status
information; shares what is known about the pa-
tients preferences, who their main support is,
if they have copies of or voiced decisions about,
life-sustaining choices; and asks the ICU nurse
to share what the family can expect in the
coming hours;
• Develop a system for an oncology nurse to make
routine brief visits to the ICU for all patients
known from the oncology unit; upon transfer
back to the oncology unit, establish a process
for the ICU nurse to visit the patient on the on-
cology unit;
• Critical care nurses should inform the oncol-
ogy unit nurses of upcoming Family Meetings
and invite a staff member to participate; inform
the critical care team that there are time limi-
tations for the oncology unit nurse’s participation
so that scheduling accommodates multiple
constraints.
If an oncology patient known by the in-patient
unit nursing staff is near death or dies in the ICU,
there is significant benefit to the family of a known
nurse’s presence, particularly to engage in rituals
around death. Often it is the physical nearness of
the oncology nurse that provides support to the
family in the room. However, other behaviors such
as praying, encouraging the family to spend time
alone with their loved one before they die, and ex-
plaining what the family is seeing in terms of
physical changes in their loved one, are other ways
the oncology nurse can offer support in tandem with
the critical care staff.
CONCLUSION
When death is inevitable in the ICU, the quality
of the dying experience becomes an essential
outcome measure. This is paramount as evidence
suggests that the ICU is the least preferred site of
death and is often correlated with family reports
of poor end-of-life care.62,63
The provision of palliative care in critical care
represents a pressing national agenda of impor-
tance. Because of the prominence of cancer patients
in the ICU setting now and in the future, a major
focus on onco-critical–palliative care is required.
Both oncology and critical care nurses are key
drivers of quality improvement specific to enhanc-
ing communication and the utilization of palliative
care expertise in their settings.45,64-69 The replica-
tion potential of the IMPACT-ICU exemplar is
considerable. Based on the lack of historical and
contemporary formal education of bedside nursing
staff in this important element of nursing commu-
nication, additional training and practice innovation
serves to enhance the partnership between oncol-
ogy and critical care nurses whose central role as
translator and patient and family advocate pre-
vails now and in the future.
Case Example
Mr. S was a 59-year-old man with stage IV lym-
phoma who was admitted to the ICU from the
emergency department for increasing respiratory
distress. A pleural effusion was diagnosed and Mr.
S subsequently underwent a 1-liter pleuracentesis
with stabilization of his shortness of breath. During
the procedure, Mrs. S went to the Oncology Unit
looking for familiar staff for support. She spoke with
several of the nurses she knew on the night shift.
The next morning the intensivist advised that a
pleura vac catheter be inserted for subsequent drain-
age of expected future recurrent effusions. Following
the visit, Mr. S said to the ICU nurse, “I don’t know
why he said I needed that catheter. I just fin-
ished my chemo and the fluid is gone now. We have
a cruise planned and we’ll be gone for three weeks.
I don’t want a tube hanging out of my chest. I’m
going to tell him I don’t want it.” The ICU nurse
was immediately alarmed that the patient and his
wife were not aware of the advanced nature of the
patient’s illness. Soon after, one of the oncology
nurses who knew the patient well visited the patient
and his wife. The ICU nurse relayed her earlier con-
versations with the patient. The oncology nurse and
the ICU nurse agreed that they both should explore
the couple’s understanding of the immediate future.
They approached the patient and his wife and sat
down at the bedside. The oncology nurse then
asked, “What’s your understanding of where things
are now with your cancer?” The patient replied,
“Oh, this breathing problem is just temporary. It
doesn’t have anything to do with my cancer. I think
I just tried to exert myself too much last week.”
The ICU nurse then replied, “It sounds like you
and the intensive care specialist need to clarify
why this catheter is important. Would it be helpful
if I arranged a time to talk more about this?” The
patient agreed.
Both nurses then approached the intensivist and
shared the exchanges they had with the patient and
 ARTICLE IN PRESS
his wife. They suggested that the medical oncolo-
gist and the intensivist speak with the patient and
his wife about expectations for the near future. The
ICU nurse arranged a meeting at the bedside with
the two physicians, the patient, his wife, herself,
and she invited the oncology nurse to attend.
During the family meeting later that day, the
gravity of the current situation was made clear to
the patient and his wife. They tearfully relayed that
they didn’t realize his condition was so bad. They
opted to be discharged the following morning with
home hospice services. The nurse provided emo-
tional support to the patient and his wife after the
physicians left. She stayed present with the couple
(ie, making eye contact, using touch, nodding her
head affirmatively), listening to their disbelief about
the cancer treatments not working and their fears
about the future. The ICU nurse subsequently docu-
mented what transpired in the Family Meeting Note
in the electronic medical record. The oncology nurse
offered to call the Oncology Social Worker who the
couple knew well. During report that evening, the
ICU nurse informed her night shift colleague of the
specifics of the meeting and they identified ways
to support the patient that night.
This case study characterizes optimum nurse–
nurse collaboration in advocating for interventions
to address the patient and wife’s need for addi-
tional information to clarify the nature of his illness.
It also exemplifies the nurses’ concern for the pa-
tient’s future safety following hospital discharge.
Following awareness of the patient’s misunder-
standing of the gravity of his late-stage lymphoma,
the nurses advocated on his behalf for additional
time with the physician. Mr. S’s scenario is repre-
sentative of the “4Cs” in action.51
The nurses Checked for understanding by asking
the patient to relay in his words where he stood
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The authors would like to acknowledge the assistance of Kath-
leen Puntillo, PhD, RN, FAAN, FCCM, Jenica Cimino, BA, and
Steve Pantilat, MD, FAAHPM, SFHM from the University of Cal-
ifornia San Francisco for their considerable support of the
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