To determine whether a process of early palliative care intervention prompted by a patient-specific estimate of poor prognosis leads to a self-fulfilling prophecy of increased death in intervention patients in the medical intensive care unit (ICU). METHODS: We conducted a prospective two-phase study including usual care (UC) (N¼53) and usual care plus targeted proactive palliative care intervention (PC) (N¼51) (either by specialist palliative care consultants or shared decision making discussion by the intensivists), each lasting four months on consecutive patients admitted to the ICU who survived $48 hours. For both phases, we identified patients predicted to be at high risk ($40% 6-month mortality) using our validated integrated prognostic model1 [Surprise question "No" response-Would you be surprised if this patient died in the next six months?-, APACHE IV score, and Charlson Comorbidity Index (CCI) score].

To determine whether a process of early palliative care intervention prompted by a patient-specific estimate of poor prognosis leads to improved patient outcomes in the medical intensive care unit (ICU). METHODS: We conducted a prospective two-phase study including usual care (UC) (N¼53) and usual care plus targeted proactive palliative care intervention (PC) (N¼51) (either by consulting supportive care services or shared decision making discussion by the intensivists), each lasting four months on consecutive patients admitted to the ICU who survived $48 hours. For both phases, patients predicted to be at high risk ($40% 6-month mortality) were identified using our validated integrated prognostic model1 [Surprise question "No" response-Would you be surprised if this patient died in the next six months?-, APACHE IV score, and Charlson Comorbidity Index (CCI) score]. RESULTS: Compared to UC, the pro-active PC intervention phase showed significant reduction in ICU readmissions (35.8% vs 16%, p¼0.022) and increased identification of the patient's legal decision maker (98% vs 83%, p¼0.009). There were no differences in means between groups (UC vs PC) for age (67.9 vs 68.1 years, p¼.938), CCI score (6.6 vs 6.1, p¼.489), and mortality prediction model score (51.6 vs 54.3, p¼.141). Intervention-arm patients had higher BMI (34.0 vs 28.3 kg/m2, p¼0.005) and APACHE IV scores (65.3 vs 55.8, p¼0.019), suggestive of a sicker critically ill patient population. There was no significant difference between groups (UC vs PC) in mean length of stay in ICU (5.5 vs 6.2 days, p¼.454) or in hospital (13.0 vs 14.7 days, p¼.466). There was no difference between groups (UC vs PC) in death at hospital discharge (60% vs 48%, p¼.208). CONCLUSIONS: This pilot study demonstrates feasibility and improved patient-specific outcomes of end-of-life care. CLINICAL IMPLICATIONS: Systematic identification of high-risk ICU patients using the integrated mortality prediction model and pro-active primary palliative care intervention improves shared-decision making with the appropriate legal decision-maker and ICU readmission rates. This study promotes the role of family engagement and empowerment which is in compliance with Society of Critical Care Medicine (SCCM) ICU liberation bundle (A-F). These findings provide support for a large, multisite trial to see if they can be confirmed and if this approach represents a way to improve ICU patient care.