Association Between the Implementation of Hospital-Based Palliative Care and Use of Intensive Care During Terminal Hospitalizations

Abstract

IMPORTANCE The use of intensive care at the end of life continues to be common. Although the provision of palliative care has been advocated as a way to mitigate the use of high-intensity care, it is unknown whether implementation of hospital-based palliative care services is associated with reduced use of intensive care at the end of life. OBJECTIVE To determine whether implementation of hospital-based palliative care services is associated with decreased intensive care unit (ICU) use during terminal hospitalizations. DESIGN, SETTING, AND PARTICIPANTS This cohort study included 51 hospitals in New York State that either did or did not implement a palliative care program between 2008 and 2014. Hospitals that consistently had a palliative care program during the study period were excluded. Participants were adult patients who died during hospitalization. Data analysis was performed between January 2018 and July 2019. EXPOSURE Implementation of a palliative care program. MAIN OUTCOMES AND MEASURES The primary outcome was ICU use. A difference-indifferences analysis was performed using multilevel regression to assess the association between implementing a palliative care program and ICU use during terminal hospitalizations while adjusting for patient and hospital characteristics and time trends. RESULTS During the study period, 73 370 patients (mean [SD] age, 76.5 [14.1] years; 38 467 [52.4%] women) died during hospitalization, of whom 37 628 (51.3%) received care in hospitals that implemented palliative care services and 35 742 (48.7%) received care in a hospital without palliative care implementation. Patients who received care in hospitals after implementation of palliative care services were less likely to receive intensive care than patients admitted to the same hospitals before implementation (49.3% vs 52.8%; difference 3.5%; 95% CI, 2.5%-4.5%; P < .001). Compared with hospitals that never had a palliative care program, the implementation of palliative care was associated with a 10% reduction in ICU use during terminal hospitalizations (adjusted relative risk, 0.90; 95% CI, 0.85-0.95; P < .001). CONCLUSIONS AND RELEVANCE The implementation of hospital-based palliative care services in New York State was associated with a modest reduction in ICU use during terminal hospitalizations.

Asian American Medicare Beneficiaries Disproportionately Receive Invasive Mechanical Ventilation When Hospitalized at the End-of-Life

“…This pattern of healthcare utilization may relate to differential engagement with palliative care services. 3 quality and lower intensity EOL care, [51][52][53][54][55] few have investigated the impact of palliative care on Asian Americans. 56 What is known is that Asian Americans continue to face many barriers in accessing palliative care services, including underreporting of symptoms, low engagement with advance care planning, low knowledge of available end-of-life services (e.g., hospice), and significant communication barriers (e.g., language discordance).…”

Antibiotic use during end-of-life care: A systematic literature review and meta-analysis

“…89,90 A recently published study indicated that implementing palliative care programs were associated with a modest decrease in the use of intensive care during terminal hospitalizations and that the association may also differ according to hospital characteristics. 91 Prior studies have also reported that people generally prioritize quality over quantity of life, and specifically in settings of a poor prognosis, patients choose care focused on comfort and physicians prefer nonaggressive care at the end of life. [92][93][94] However, Wunsch et al 95 showed that physicians were not more likely to die at home compared with similar nonphysicians and even had greater use of both intensive care and palliative care services in the 6 months before death.…”

“…A growing number of US hospitals are rethinking intensive care measures principally for patients under palliative care. 91 During 2013-2017, there has been a trend toward the creation of more palliative care consultation services in acute-care hospitals. 5 Highquality studies are needed, particularly in noncancer populations during EOL, so that we can accurately determine how palliative care consultation can best collaborate with antimicrobial stewardship goals and teams.…”

Implementation of Specialist Palliative Care and Outcomes for Hospitalized Patients with Dementia

“…In comparison to patients who received care in hospitals without palliative care, patients with dementia who received care in hospitals after the implementation of palliative care were more 35% likely to be discharged to hospice (adjusted odds ratio (aOR) = 1. 35 (1.19-1.51), P < .001). No meaningful differences in secondary outcomes were observed.…”