The Anatomy of Interprofessional Collaboration Around Recommendations in the Intensive Care Unit: An Exploration After Serious Illness Care Training

Background: Serious illness conversations are an iterative, interprofessional, team-based process that includes recommendations about medical care. Yet, it is not clear how clinicians in different role groups work together in this process. Objectives: We sought to examine how interprofessional clinicians in the medical intensive care unit (MICU) who were trained in the serious illness care program (SICP) document recommendations after serious illness conversations. Design: This is a retrospective chart review and inductive content analysis. Settings/Subjects: We reviewed the charts of patients admitted to the MICU of an academic hospital with a long history of palliative care (PC) in the northeastern United States between January 1 and December 31, 2019, who had at least one documented serious illness conversation. Results: Of the 207 conversations identified, 177 (85.5%) included a recommendation: 44.6% (79/177) were documented by registered nurses, 36.7% (65/177) by physician trainees (internal medicine residents and pulmonology/critical care fellows), and 18.6% (33/177) by PC consultants (physicians, nurse practitioners, and PC fellows). Recommendations were categorized into several domains: (1) code status (2) treatment interventions, (3) psychosocial support, and (4) communication. The recommendations textbox was also used to document general updates and patient education. The most common domains documented were code status and treatment interventions, respectively: Registered nurses (40.5%; 20.3%), physician trainees (52.3%; 36.4%), and PC clinicians (42.4%; 32.3%). Clinicians used the direct/active voice to document recommendations concordant with their scope of practice and the reporter/passive voice to document recommendations given by others. Conclusions: SICP-trained interprofessional MICU clinicians commonly give and document recommendations on a range of domains and flexibly use direct/active and reporter/passive voice to signal their scope of practice.