Care Planning for Inpatients Referred for Palliative Care Consultation

Abstract

<div class="section"> <a class="named-anchor" id="ab-ioi170107-1"> <!-- named anchor --> </a> <h5 class="section-title" id="d1687492e299">Question</h5> <p id="d1687492e301">What are the characteristics of patients referred to inpatient palliative care (PC) consultation teams for advance care planning (ACP) or goals of care (GOC) discussions, what ACP/GOC needs are identified, and what are the outcomes? </p> </div><div class="section"> <a class="named-anchor" id="ab-ioi170107-2"> <!-- named anchor --> </a> <h5 class="section-title" id="d1687492e304">Findings</h5> <p id="d1687492e306">In this cohort study of 73 145 patients in inpatient palliative care teams, a need for ACP/GOC was the most common reason for inpatient PC consultation, and ACP/GOC needs were frequently identified even when the consultation request was for other reasons. During PC consultation, surrogates were identified and patients’ preferences regarding life-sustaining treatments were updated; however, only a minority of patients completed legal forms to document their preferences. </p> </div><div class="section"> <a class="named-anchor" id="ab-ioi170107-3"> <!-- named anchor --> </a> <h5 class="section-title" id="d1687492e309">Meaning</h5> <p id="d1687492e311">Inpatient PC consultation meets a common and important need, but there remains opportunity for improvement. </p> </div><div class="section"> <a class="named-anchor" id="ab-ioi170107-4"> <!-- named anchor --> </a> <h5 class="section-title" id="d1687492e315">Importance</h5> <p id="d1687492e317">Care planning is a critical function of palliative care teams, but the impact of advance care planning and goals of care discussions by palliative care teams has not been well characterized. </p> </div><div class="section"> <a class="named-anchor" id="ab-ioi170107-5"> <!-- named anchor --> </a> <h5 class="section-title" id="d1687492e320">Objective</h5> <p id="d1687492e322">To describe the population of patients referred to inpatient palliative care consultation teams for care planning, the needs identified by palliative care clinicians, the care planning activities that occur, and the results of these activities. </p> </div><div class="section"> <a class="named-anchor" id="ab-ioi170107-6"> <!-- named anchor --> </a> <h5 class="section-title" id="d1687492e325">Design, Setting, and Participants</h5> <p id="d1687492e327">This was a prospective cohort study conducted between January 1, 2013, and December 31, 2016. Seventy-eight inpatient palliative care teams from diverse US hospitals in the Palliative Care Quality Network, a national quality improvement collaborative. Standardized data were submitted for 73 145 patients. </p> </div><div class="section"> <a class="named-anchor" id="ab-ioi170107-7"> <!-- named anchor --> </a> <h5 class="section-title" id="d1687492e330">Exposures</h5> <p id="d1687492e332">Inpatient palliative care consultation.</p> </div><div class="section"> <a class="named-anchor" id="ab-ioi170107-8"> <!-- named anchor --> </a> <h5 class="section-title" id="d1687492e335">Results</h5> <p id="d1687492e337">Overall, 52 571 of 73 145 patients (71.9%) referred to inpatient palliative care were referred for care planning (range among teams, 27.5%-99.4% of patients). Patients referred for care planning were older (73.3 vs 67.9 years; <i>F</i> statistic, 1546.0; <i>P &lt; </i>.001), less likely to have cancer (30.0% vs 41.1%; <i>P</i> &lt; .001), and slightly more often had a clinical order of full code at the time of referral (54.6% vs 52.1%; <i>P</i> &lt; .001). Palliative care teams identified care planning needs in 52 825 of 73 145 patients (72.2%) overall, including 42 467 of 49 713 patients (85.4%) referred for care planning and in 10 054 of 17 475 patients (57.5%) referred for other reasons. Through care planning conversations, surrogates were identified for 10 571 of 11 149 patients (94.8%) and 9026 patients (37.4%) elected to change their code status. Substantially more patients indicated that a status of do not resuscitate/do not intubate was consistent with their goals (7006 [32.1%] preconsultation to 13 773 [63.1%] postconsultation). However, an advance directive was completed for just 2160 of 67 955 patients (3.2%) and a Physicians Orders for Life-Sustaining Treatment form was completed for 8359 of 67 955 patients (12.3%) seen by palliative care teams. </p> </div><div class="section"> <a class="named-anchor" id="ab-ioi170107-9"> <!-- named anchor --> </a> <h5 class="section-title" id="d1687492e352">Conclusions and Relevance</h5> <p id="d1687492e354">Care planning was the most common reason for inpatient palliative care consultation, and care planning needs were often found even when the consultation was for other reasons. Surrogates were consistently identified, and patients’ preferences regarding life-sustaining treatments were frequently updated. However, a minority of patients completed legal forms to document their care preferences, highlighting an area in need of improvement. </p> </div><p class="first" id="d1687492e357">This cohort study describes the population of patients referred to inpatient palliative care consultation teams for care planning, the needs identified by palliative care clinicians, and the care planning activities that occur. </p>