Early Palliative Care Consultation in the Medical ICU: A Cluster Randomized Crossover
      Trial

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Abstract

OBJECTIVE:

To assess the impact of early triggered palliative care consultation on the outcomes of high risk ICU patients.

DESIGN:

Single-center cluster randomized crossover trial.

SETTING:

Two medical ICUs at Barnes Jewish Hospital.

PATIENTS:

Patients ( n=199) admitted to the medical ICUs from August 2017 to May 2018 with a positive palliative care screen indicating high risk for morbidity or mortality.

INTERVENTIONS:

The medical ICUs were randomized to intervention or usual care followed by washout and crossover, with independent assignment of patients to each ICU on admission. Intervention arm patients received a palliative care consultation from an interprofessional team led by board-certified palliative care providers within 48 hours of ICU admission.

MEASUREMENTS AND MAIN RESULTS:

97 patients (48.7%) were assigned to the intervention and 102 (51.3%) to usual care. Transition to do-not-resuscitate/do-not-intubate (DNR/DNI) occurred earlier and significantly more often in the intervention group than the control group (50.5% vs 23.4%, p<0.0001). The intervention group had significantly more transfers to hospice care (18.6% vs 4.9%; p<0.01) with fewer ventilator days (median 4 vs 6 days; p<0.05), tracheostomies performed (1% vs 7.8%; p<0.05), and post-discharge emergency department visits and/or readmissions (17.3% vs 38.9%; p<0.01). While total operating cost was not significantly different, medical ICU ( p<0.01) and pharmacy ( p<0.05) operating costs were significantly lower in the intervention group. There was no significant difference in ICU length of stay (median 5 vs 5.5 days), hospital length of stay (median 10 vs 11 days), in-hospital mortality (22.6% vs 29.4%), or 30-day mortality between groups (35.1% vs 36.3%) ( p values>0.05).

CONCLUSIONS:

Early triggered palliative care consultation was associated with greater transition to DNR/DNI and to hospice care, as well as decreased ICU and post-ICU healthcare resource utilization. Our study suggests that routine palliative care consultation may positively impact the care of high risk, critically ill patients.

TRIAL REGISTRATION:

ClinicalTrials.gov Identifier: [Related object:]

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Most cited references 40

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End-of-life discussions, goal attainment, and distress at the end of life: predictors and outcomes of receipt of care consistent with preferences.

W Mack, Peter D. Block, Jennifer Weeks … (2010)

Physicians have an ethical obligation to honor patients' values for care, including at the end of life (EOL). We sought to evaluate factors that help patients to receive care consistent with their preferences. This was a longitudinal multi-institutional cohort study. We measured baseline preferences for life-extending versus symptom-directed care and actual EOL care received in 325 patients with advanced cancer. We also measured associated sociodemographic, health, and communication characteristics, including EOL discussions between patients and physicians. Preferences were assessed a median of 125 days before death. Overall, 68% of patients (220 of 325 patients) received EOL care consistent with baseline preferences. The proportion was slightly higher among patients who recognized they were terminally ill (74%, 90 of 121 patients; P = .05). Patients who recognized their terminal illness were more likely to prefer symptom-directed care (83%, 100 of 121 patients; v 66%, 127 of 191 patients; P = .003). However, some patients who were aware they were terminally ill wished to receive life-extending care (17%, 21 of 121 patients). Patients who reported having discussed their wishes for EOL care with a physician (39%, 125 of 322 patients) were more likely to receive care that was consistent with their preferences, both in the full sample (odds ratio [OR] = 2.26; P < .0001) and among patients who were aware they were terminally ill (OR = 3.94; P = .0005). Among patients who received no life-extending measures, physical distress was lower (mean score, 3.1 v 4.1; P = .03) among patients for whom such care was consistent with preferences. Patients with cancer are more likely to receive EOL care that is consistent with their preferences when they have had the opportunity to discuss their wishes for EOL care with a physician.

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Use of intensive care at the end of life in the United States: an epidemiologic study.

Derek C Angus, Amber E. Barnato, Walter Linde-Zwirble … (2004)

Despite concern over the appropriateness and quality of care provided in an intensive care unit (ICU) at the end of life, the number of Americans who receive ICU care at the end of life is unknown. We sought to describe the use of ICU care at the end of life in the United States using hospital discharge data from 1999 for six states and the National Death Index. Retrospective analysis of administrative data to calculate age-specific rates of hospitalization with and without ICU use at the end of life, to generate national estimates of end-of-life hospital and ICU use, and to characterize age-specific case mix of ICU decedents. All nonfederal hospitals in the states of Florida, Massachusetts, New Jersey, New York, Virginia, and Washington. All inpatients in nonfederal hospitals in the six states in 1999. None. We found that there were 552,157 deaths in the six states in 1999, of which 38.3% occurred in hospital and 22.4% occurred after ICU admission. Using these data to project nationwide estimates, 540,000 people die after ICU admission each year. The age-specific rate of ICU use at the end of life was highest for infants (43%), ranged from 18% to 26% among older children and adults, and fell to 14% for those >85 yrs. Average length of stay and costs were 12.9 days and $24,541 for terminal ICU hospitalizations and 8.9 days and $8,548 for non-ICU terminal hospitalizations. One in five Americans die using ICU services. The doubling of persons over the age of 65 yrs by 2030 will require a system-wide expansion in ICU care for dying patients unless the healthcare system pursues rationing, more effective advanced care planning, and augmented capacity to care for dying patients in other settings.

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Recommendations for end-of-life care in the intensive care unit: a consensus statement by the American College [corrected] of Critical Care Medicine.

Robert Truog, Margaret Campbell, J Randall Curtis … (2008)

These recommendations have been developed to improve the care of intensive care unit (ICU) patients during the dying process. The recommendations build on those published in 2003 and highlight recent developments in the field from a U.S. perspective. They do not use an evidence grading system because most of the recommendations are based on ethical and legal principles that are not derived from empirically based evidence. Family-centered care, which emphasizes the importance of the social structure within which patients are embedded, has emerged as a comprehensive ideal for managing end-of-life care in the ICU. ICU clinicians should be competent in all aspects of this care, including the practical and ethical aspects of withdrawing different modalities of life-sustaining treatment and the use of sedatives, analgesics, and nonpharmacologic approaches to easing the suffering of the dying process. Several key ethical concepts play a foundational role in guiding end-of-life care, including the distinctions between withholding and withdrawing treatments, between actions of killing and allowing to die, and between consequences that are intended vs. those that are merely foreseen (the doctrine of double effect). Improved communication with the family has been shown to improve patient care and family outcomes. Other knowledge unique to end-of-life care includes principles for notifying families of a patient's death and compassionate approaches to discussing options for organ donation. End-of-life care continues even after the death of the patient, and ICUs should consider developing comprehensive bereavement programs to support both families and the needs of the clinical staff. Finally, a comprehensive agenda for improving end-of-life care in the ICU has been developed to guide research, quality improvement efforts, and educational curricula. End-of-life care is emerging as a comprehensive area of expertise in the ICU and demands the same high level of knowledge and competence as all other areas of ICU practice.

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Author and article information

Journal

Journal ID (nlm-journal-id): 0355501

Journal ID (pubmed-jr-id): 3206

Journal ID (nlm-ta): Crit Care Med

Journal ID (iso-abbrev): Crit. Care Med.

Title: Critical care medicine

ISSN (Print): 0090-3493

ISSN (Electronic): 1530-0293

Publication date Nihms-submitted: 27 August 2019

Publication date (Print): December 2019

Publication date PMC-release: 01 December 2020

Volume: 47

Issue: 12

Pages: 1707-1715

Affiliations

[1 ]Duke Palliative Care, Department of Medicine, Duke University and Health System, Durham, NC, USA

[2 ]Department of Medicine, Washington University School of Medicine, St. Louis, MO, USA

[3 ]Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, St. Louis, MO, USA

[4 ]Division of Palliative Medicine, Washington University School of Medicine, St. Louis, MO, USA

[5 ]Division of Biostatistics, Washington University School of Medicine, St. Louis, MO, USA

Author notes

Corresponding Author: Marin H. Kollef, MD, Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, 4523 Clayton Avenue, Campus Box 8052, St. Louis, MO 63110, Phone (314) 454-8764; Fax (314) 454-5571, kollefm@ 123456wustl.edu

Authorship: Substantial contributions to conception or design of the work: JM, SC, BB, KP, MM, CK, MK, MD; Substantial contributions to the acquisition, analysis, and interpretation of data for the work: JM, SC, BB, KP, MM, CK, NA-H, LC, MK, MD; Drafting of the work or revising it critically for important intellectual content: JM, SC, BB, KP, MM, CK, MK, MD; Final approval of the version to be published: JM, SC, BB, KP, MM, CK, NA-H, LC, MK, MD; Agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved: JM, SC, BB, KP, MM, CK, NA-H, LC, MK, MD

Article

Accession ID: PMC6861688 Pmcid ID: PMC6861688 Pmc-uid ID: 6861688 Manuscript ID: nihpa1538232

DOI: 10.1097/CCM.0000000000004016

PMC ID: 6861688

PubMed ID: 31609772

SO-VID: 8af01714-2751-4b52-8c0a-bbdbfee74bd2

Early Palliative Care Consultation in the Medical ICU: A Cluster Randomized Crossover Trial

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Abstract

OBJECTIVE:

DESIGN:

SETTING:

PATIENTS:

INTERVENTIONS:

MEASUREMENTS AND MAIN RESULTS:

CONCLUSIONS:

TRIAL REGISTRATION:

Related collections

The Physician

Most cited references 40

End-of-life discussions, goal attainment, and distress at the end of life: predictors and outcomes of receipt of care consistent with preferences.

Use of intensive care at the end of life in the United States: an epidemiologic study.

Recommendations for end-of-life care in the intensive care unit: a consensus statement by the American College [corrected] of Critical Care Medicine.

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