Effective integration of palliative care is essential for critically ill patients with advanced disease and life-threatening illnesses. Interventions such as proactive palliative care consultations, trigger-based consultations, and intensive multidisciplinary communication have been shown to improve patient care and reduce intensive care unit (ICU) length of stay (LOS).[1, 3, 4, 5, 7] Different ICUs use distinct approaches to palliative care integration or consultation, and thus, individual ICUs must find the approach which is most effective. In order to improve the quality of palliative care provided to ICU patients, we started by examining our medical ICU (MICU) approach to goals of care discussions and palliative care consultations in patients who meet established triggers for palliative care involvement.
Baseline data were obtained by a resident quality team who reviewed new admissions to the Mount Sinai St. Luke’s MICU during a 2-week period (10/23/2018-11/5/2018). Patient records were reviewed to identify triggers for palliative care, as defined in the literature (Table 1). [6, 8] Events such as goals of care discussions by the MICU team, placement of advance directive and palliative care consultation were identified. Patients were followed for a 2-week period or until transfer out of ICU. At the end of the follow-up period, the quality team met with the MICU team to obtain information as to why patients who met triggers did not have a palliative care consultation.
|Prolonged (>2 weeks) ventilator dependence and consideration of tracheostomy|
|Multiorgan failure with documented poor prognosis|
|Advanced dementia (bed-bound and non-verbal)|
|Stage IV malignancy|
|Coma due to any cause with poor neurologic prognosis|
|Cardiac arrest with neurologic sequelae and poor neurologic prognosis|
|Poor prognosis (<6 months) based on disease process|
|Unrealistic expectations of the patient or family|
|Assistance to family in transitioning goals of care|
|Family request for palliative care or hospice|
During the 2-week period, 27 patients were admitted to the MICU (Table 2). Of these patients, 12 (44%) met at least one criterion for palliative care consultation. Palliative care consultation was obtained in 6 of these 12 patients (50%). Patients who received palliative care consultation were older (median age of 82.5 years (IQR 5.25) versus 62 years (IQR 25.50)). The most commonly met criteria were advanced dementia, poor prognosis (< 6 months) and multiorgan failure. During the study period, 8 patients (30%) expired. Six of those patients (75%) met trigger criteria but only 2 received palliative care services. However, every patient that expired had a goals of care discussion by the MICU team despite not being seen by palliative care. Barriers to palliative care consultation included perceived proficiency of ICU clinicians in managing palliative care situations, rapid deterioration or expected improvement of the patient, ongoing aggressive treatment measures and resistance from family members or surrogate decision-makers. These results are consistent with those from a larger study from Mount Sinai Beth Israel .
|Variable||All Patients (n = 27)||Patients Who Met Trigger Criteria (n = 12)||No Palliative Care (n = 6)||Palliative Care (n = 6)|
|Median Age in Years (IQR)||63 (25.5)||76.5 (26.5)||62 (25.5)||82.5 (5.25)|
|Female||16 (59)||5 (42)||4 (66)||1 (17)|
|Male||11 (41)||7 (58)||2 (33)||5 (83)|
|Expired during ICU Stay (%)||8 (30)||6 (50)||4 (67)||2 (33)|
Our small baseline analysis of MICU patients demonstrates that half of our critically ill patients meeting trigger-based criteria do not receive palliative care consultative services. The MICU team does effectively address goals of care, particularly in patients who are rapidly deteriorating. We identified opportunities for palliative care consultation in patients who are expected to survive their ICU stay but who remain at risk of mortality. Examining our own MICU experience allows us to customize an approach to patients who may benefit from palliative care consultation. This has led us to initiate weekly screening assessment for palliative care consultative services in the MICU and palliative care referral for selected patients who are expected to be transferred out of the MICU.
Aslakson R, Cheng J, Vollenweider D, Galusca D, Smith TJ and Pronovost PJ. Evidence-based palliative care in the intensive care unit: a systematic review of interventions. J Palliat Med. 2014; 17: 219–35. DOI: https://doi.org/10.1089/jpm.2013.0409
Butner J, Silverberg M and Hayes E. 874: Identifying Palliative Care Triggers & Reasons for Not Consulting Specialist in Critical Care Setting. Critical Care Medicine. 2014; 42: A1570–A1571. DOI: https://doi.org/10.1097/01.ccm.0000458371.66468.e6
Campbell ML and Guzman JA. A proactive approach to improve end-of-life care in a medical intensive care unit for patients with terminal dementia. Crit Care Med. 2004; 32: 1839–43. DOI: https://doi.org/10.1097/01.CCM.0000138560.56577.88
Holloran SD, Starkey GW, Burke PA, Steele G, Jr. and Forse RA. An educational intervention in the surgical intensive care unit to improve ethical decisions. Surgery. 1995; 118: 294–8; discussion 298–9. DOI: https://doi.org/10.1016/S0039-6060(05)80337-X
Lilly CM, Sonna LA, Haley KJ and Massaro AF. Intensive communication: four-year follow-up from a clinical practice study. Crit Care Med. 2003; 31: S394–9. DOI: https://doi.org/10.1097/01.CCM.0000065279.77449.B4
Nelson JE, Curtis JR, Mulkerin C, Campbell M, Lustbader DR, Mosenthal AC, Puntillo K, Ray DE, Bassett R, Boss RD, Brasel KJ, Frontera JA, Hays RM and Weissman DE. Choosing and using screening criteria for palliative care consultation in the ICU: a report from the Improving Palliative Care in the ICU (IPAL-ICU) Advisory Board. Crit Care Med. 2013; 41: 2318–27. DOI: https://doi.org/10.1097/CCM.0b013e31828cf12c
Norton SA, Hogan LA, Holloway RG, Temkin-Greener H, Buckley MJ and Quill TE. Proactive palliative care in the medical intensive care unit: effects on length of stay for selected high-risk patients. Crit Care Med. 2007; 35: 1530–5. DOI: https://doi.org/10.1097/01.CCM.0000266533.06543.0C
Wysham NG, Hua M, Hough CL, Gundel S, Docherty SL, Jones DM, Reagan O, Goucher H, McFarlin J and Cox CE. Improving ICU-Based Palliative Care Delivery: A Multicenter, Multidisciplinary Survey of Critical Care Clinician Attitudes and Beliefs. Critical Care Medicine. 2017; 45: e372–e378. DOI: https://doi.org/10.1097/CCM.0000000000002099