End-of-Life Care Patterns at a Community Hospital: The Rest of the Story

Abstract

We undertook a retrospective review of a subset of expired patients at our community hospital to evaluate end-of-life care patterns and the use of advanced care planning tools among patients who died in the hospital. These 162 expired patients fell into 1 of the 3 diagnosis-related groups of cardiac, respiratory, or infectious disease. Seventy-nine percent of patients arrived to the hospital with no requested limitations in the extent of resuscitative efforts, even though 98% of all patients had major or extreme severity of illness and risk of mortality scores. The presence of an advance directive requesting a limitation of resuscitative efforts modestly impacted resources and procedures, even though utilization in this group was high. Among the 21% of patients with preexisting limits, 21% requested more aggressive support during their course. Critical care unit utilization was seen in 69% of patients for a median of 48 hours. A request for palliative care consultation was received in 44% of patients but only occurred in 30% of all patients due to the short period between the consultation request and patient death (median 37 hours). Among this group of dying patients, engagement of the palliative care team came too late in the course of many patients, suggesting that automated tools embedded in the electronic medical record might be helpful in the identification of appropriate patients earlier.

Advanced Care Planning for Hospitalized Patients Following Clinician Notification of Patient Mortality by a Machine Learning Algorithm

“…In these studies, multiple barriers have been identified, including lack of clinician engagement, alert fatigue, restricted or biased prediction models, and limited practice capacity for serious illness conversations . Our study offers an example of how these challenges can be partially attenuated while also demonstrating that mortality risk-based predictions can be applied in a community setting, which has been previously highlighted as a need . Clinician fatigue was mitigated by a combination of manual medical record review to ensure the appropriate patient selection and targeted messages in lieu of pop-up or click-through alerts.…”

“…[40][41][42] Our study offers an example of how these challenges can be partially attenuated while also demonstrating that mortality risk-based predictions can be applied in a community setting, which has been previously highlighted as a need. 43 Clinician fatigue was mitigated by a combination of manual medical record review to ensure the appropriate patient selection and targeted messages in lieu of pop-up or click-through alerts. Our mortality model was shown to apply broadly to all inpatients, even in the modern COVID-19 era, and our palliative care team was closely involved in our implementation to ensure sufficient resources were readily available.…”

Potentially Avoidable Surgical Intensive Care Unit Admissions and Disposition Delays

“…Palliative care screening has been proposed to ameliorate this issue. 32 Zalenski et al 33 suggest that hospitals can decrease ICU LOS and reduce costs when all patients in the ICU undergo palliative care screening with subsequent consultation. Preintervention analysis in our study revealed that many of our patients who required EOL discussions came from the liver transplant surgical service; thus, communication between this service and the SICU team helped identify specific patients who warranted supportive care consultations.…”

“…This finding suggests some degree of inconsistency between a patient’s status and how the prognosis is perceived by clinicians, family members, or both. Palliative care screening has been proposed to ameliorate this issue . Zalenski et al suggest that hospitals can decrease ICU LOS and reduce costs when all patients in the ICU undergo palliative care screening with subsequent consultation.…”

Quality of End-of-Life Care during the COVID-19 Pandemic at a Comprehensive Cancer Center

“…The American Society of Clinical Oncology, National Comprehensive Cancer Network, European Society of Medical Oncology, and other national and international guidelines recommend timely referral to palliative care to optimize patient-centered and goal-concordant care as early as at the time of diagnosis through survivorship or the end-of-life [ 12 , 13 , 14 ]. Despite these recommendations, referrals to palliative care are commonly deferred until patients are profoundly symptomatic when treatment options become limited at the end of life or not considered at all [ 15 , 16 , 17 , 18 , 19 , 20 ].…”