Preliminary report of the integration of a palliative care team into an intensive care unit

Abstract

Nearly half of Americans who die in hospitals spend time in the intensive care unit (ICU) in the last 3 days of life. Minority patients who die in the ICU are less likely to formalize advance directives and surviving family members report lower satisfaction with the provision of information and sensitivity to their cultural traditions at the end-of-life. This is a descriptive report of a convenience sample of 157 consecutive patients served by a palliative care team which was integrated into the operations of an ICU at Montefiore Medical Center in the Bronx, New York, from August 2005 until August 2007. The team included an advance practice nurse (APN) and social worker. A separate case-control study was conducted comparing the length of hospital stay for persons who died in the ICU during the final 6 months of the project, prior to and post-palliative care consultation for 22 patients at the hospital campus where the project team was located versus 24 patients at the other campus. Pharmaco-economic data were evaluated for 22 persons who died with and 43 who died without a palliative care consultation at the intervention campus ICU to evaluate whether the project intervention was associated with an increase in the use of pain medications or alterations in the use of potentially non-beneficial life-prolonging treatments in persons dying in the ICU. Data was abstracted from the medical record with a standardized chart abstraction instrument by an unblinded research assistant. Interviews were conducted with a sample of family members and ICU nurses rating the quality of end-of-life care in the ICU with the Quality of Dying and Death in the ICU instrument (ICUQODD), and a family focus group was also conducted. Forty percent of patients were Caucasian, 35% were African American or Afro-Caribbean, 22% Hispanic and 3% were Asian or other. Exploration of the patients' and families' needs identified significant spiritual needs in 62.4% of cases. Education on the death process was provided to 85% of families by the project team. Twenty-nine percent of patients were disconnected from mechanical ventilators following consultation with the Palliative Care Service (PCS), 15.9% of patients discontinued the use of inotropic support, 15.3% stopped artificial nutrition, 6.4% stopped dialysis and 2.5% discontinued artificial hydration. Recommendations on pain management were made for 51% of the project's patients and symptom management for 52% of patients. The project was associated with an increase in the rate of the formalization of advance directives. Thirty-three percent of the patients who received PCS consultations had 'do not resuscitate' orders in place prior to consultation and 83.4% had 'do not resuscitate' orders after the intervention. The project team referred 80 (51%) of the project patients to hospice and 55 (35%) patients were enrolled on hospice, primarily at the medical center. The mean time from admission to palliative care consultation at the project site was 2.8 days versus 15.5 days at the other campus (p = 0....

Intervention to Improve Care at Life’s End in Inpatient Settings: The BEACON Trial

“…This may be due to recent patientcentered practice changes in ICU settings, 22,58,59 including permitting longer and more frequent family presence. Transfer to other settings may be advisable in fewer cases, as it may move the patient away from providers who know them well.…”

“…[15][16][17][18] During this time, palliative care treatment plans can be implemented, in place of or in addition to existing care plans, to reduce suffering and improve end-of-life care. 12,19,20 Despite the benefits of palliative care [18][19][20][21][22][23][24][25] and its growth in recent years, 20,25,27 it is not always available for inpatients, partly because the subspecialty palliative care workforce is not currently sufficient to reach all patients dying in hospital settings and partly because practitioners do not recognize shifts in patient trajectory indicating the need for palliative care consultation. [26][27][28][29][30][31][32] In an environment focusing on "cure," transition away from disease-modifying treatments to symptom control can seem counterintuitive.…”

Content Validation of a Novel Screening Tool to Identify Emergency Department Patients With Significant Palliative Care Needs

“…Unlike previously published PC screening tools, this one should not require a provider to perform an additional patient interview, nor should it require a PC specialist or case manager for completion. 15,69,70,72 Ultimately, for this screening tool to increase rates of PC consultation as well as decrease the long latency between hospital admission and PC consultation, the results of the screening tool must be put to use. Multiple interventions based on this screening tool are conceivable.…”

“…Many high-quality studies, including several randomized trials, [6][7][8] have examined the benefits of PC and shown it leads to significant improvements in patient quality of life and mood, 9 increased patient and caregiver satisfaction, 3,10,11 reduction in health care costs, [12][13][14] decreased intensive care unit (ICU) days, [15][16][17][18] hospital length of stay, physical symptomatology, and improved resource usage. 19 Despite the clear benefits of PC, the vast majority of patients who could benefit from PC are never identified or referred at any point during the course of their illness.…”

Palliative Care auf der Intensivstation

“…So waren beinahe 50 % der Menschen, die in den USA im Krankenhaus verstarben, in ihren letzten 3 Tagen auf einer Intensivstation [9]. Die zunehmenden intensivmedizinischen Möglichkeiten durch Einsatz neuer apparativer, interventioneller, chirurgischerund medikamentöserMaßnah-men haben einen großen Fortschritt ge- …”