Early Palliative Care Intervention Reduces Icu Readmissions in High-Risk Patients

Abstract

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.

The utility of the surprise question: A useful tool for identifying patients nearing the last phase of life? A systematic review and meta-analysis

“…79,80 Eight studies were excluded since the author was not able to not provide extra data. 81–88 Seven studies were excluded since the corresponding author did not respond after various attempts. 89–95 For eight other potential relevant studies (all non-peer reviewed), no contact details were available nor could these be obtained after extensive searching.…”