Palliative Care Services in the NeuroICU: Opportunities and Persisting Barriers

Abstract

Background: End-of-life (EOL) supportive care, including palliative and hospice services, is an area of increasing importance in critical care. Neurointensivists face unique challenges in providing timely supportive care to terminally ill patients expected to expire in the NeuroICU. Objective: This study explored the extent of effective utilization of, and recorded barriers to, palliative and hospice services in a dedicated 30-bed NeuroICU at a large academic medical center. Design: A retrospective chart review of patients who expired in the NeuroICU was conducted. The timeline from patient admission to arrival of palliative care services was traced. Qualitative review of chart notes was used to identify barriers to provision of palliative services. Setting: A total of 330 patients expired in the NeuroICU during the study period, including 176 from the neurology and 154 from the neurosurgical service. Results: Across services, 146 expired patients were never referred to palliative care or hospice services. Of those referred, over one-third were referred more than 4 days past admission to the NeuroICU. On average, patients were referred with less than 1 day before expiration. Common barriers to referral for supportive services were documented (e.g., patient expected to expire, family declined service). Conclusions: Despite benefits of palliative care and an in-hospital hospice opportunity, we identified lack of referral, and particularly delays in referral to services as significant barriers. Our study highlights these as missed opportunities for patients and families to receive maximum benefits from these services. Future research should solidify triggers for EOL services in this setting.

Palliative Care and End-of-Life Issues in Patients with Brain Cancer Admitted to ICU

“…From a total of 915 records retrieved, after duplicate exclusion and screening from abstracts, 363 relevant articles were screened from full text; of those, 15 articles [ 6 , 7 , 8 , 9 , 10 , 11 , 12 , 13 , 14 , 15 , 16 , 17 , 18 , 19 , 20 ] were adjudicated relevant for inclusion in this review and provided the basis for data and discussion presented on the topic ( Table 1 ). Twelve studies were conducted in a single center, and only three were multicentric studies.…”

“…Indeed, palliative care needs in patients admitted to neuro-ICUs are often unmet or met late. A retrospective study based on a chart review of patients who died in neuro-ICU found that 44% of expired patients never received palliative care referral, and that patients were, on average, referred only 1 day before death [ 8 ]. On the other hand, evidence exists for a high prevalence of palliative care needs in a neuro-ICU (62%), which may be detected if systematically screened [ 13 ].…”

Neurocritical Care for Patients With Ischemic Stroke

“…Goals of care discussions and treatment decisions were the overwhelming reason for palliative care involvement 124 . A lack of referrals and delays in referral impede patient access to palliative care, 125 so inclusion of this team in the care of patients with stroke due to LVO should be considered as appropriate.…”

Making Family-Centered Care for Adults in the ICU a Reality

“…They also can have difficulties engaging family members in evidence- and value-informed decision-making due to the physical, psychological, and cognitive (e.g., difficulties synthesizing vast amounts of information) challenges of having a family member in the ICU; any history of personal or family conflicts; or previous experiences with healthcare systems ( 16 ). Additional, consultations often are not sought at all or in a timely fashion or are unavailable due to resource constraints ( 24 ).…”