Assessment of Clinical Palliative Care Trigger Status vs Actual Needs Among Critically Ill Patients and Their Family Members

Abstract

IMPORTANCEPalliative care consultations in intensive care units (ICUs) are increasingly prompted by clinical characteristics associated with mortality or resource utilization. However, it is not known whether these triggers reflect actual palliative care needs. OBJECTIVE To compare unmet needs by clinical palliative care trigger status (present vs absent). DESIGN, SETTING, AND PARTICIPANTS This prospective cohort study was conducted in 6 adult medical and surgical ICUs in academic and community hospitals in North Carolina between January 2019 and September 2020. Participants were consecutive patients receiving mechanical ventilation and their family members. EXPOSURE Presence of any of 9 common clinical palliative care triggers. MAIN OUTCOMES AND MEASURESThe primary outcome was the Needs at the End-of-Life Screening Tool (NEST) score (range, 0-130, with higher scores reflecting greater need), which was completed after 3 days of ICU care. Trigger status performance in identifying serious need (NEST score Ն30) was assessed using sensitivity, specificity, positive and negative likelihood ratios, and C statistics. RESULTSSurveys were completed by 257 of 360 family members of patients (71.4% of the potentially eligible patient-family member dyads approached) with a median age of 54.0 years (IQR, 44-62 years); 197 family members (76.7%) were female, and 83 (32.3%) were Black. The median age of patients was 58.0 years (IQR, 46-68 years); 126 patients (49.0%) were female, and 88 (33.5%) were Black. There was no difference in median NEST score between participants with a trigger present (45%) and those with a trigger absent (55%) (21.

Trajectories of Palliative Care Needs in the ICU and Long-Term Psychological Distress Symptoms*

“…We observed that palliative care needs reported by ICU patients’ family members were common, complex, and persistent, with one-third still experiencing serious overall needs after a week of ICU care. These results are compelling because while palliative care needs are common (8, 25), it has generally been assumed that they improve over time in ICU settings.…”

“…As such, this metric could potentially play a useful role in future trials of ICU-based interventions. Last, knowledge of need severity and type could be used to inform future models of ICU-based palliative care delivery focused on efficiently aligning the skills of the ideal provider (e.g., nurse, chaplain, social worker, physician) with the needs of greatest importance (8, 36).…”

Palliative care phenotypes among critically ill patients and family members: intensive care unit prospective cohort study

“…Patients in ICUs and family members have substantial heterogeneity in sociodemographic and clinical characteristics, none of which appear to adequately reflect the presence, type and severity of palliative care needs present 12. This represents a challenge to aligning the appropriate type of care with the specific unmet needs.…”

“…A key clinical challenge in ICU settings is identifying those who possess serious unmet needs with accuracy and efficiency, and then aligning the most appropriate provider with the patient and family member. We recently found that clinical factors such as common clinical palliative care triggers and illness severity performed no better than chance at identifying family members with serious palliative care needs in ICU settings 12. As such, if the goal is to address unmet palliative care needs, they must be ascertained directly from patients and family members—a task that is feasible,34 though more challenging than building an electronic health record system-informed screening algorithm.…”

“…Family members are similarly diverse in age, relationship to the patient and health literacy. Furthermore, we recently found that the presence, type or severity of self-reported palliative care needs among ICU family members could not be inferred by any of a variety of common sociodemographic and clinical characteristics 12…”