Evaluation of automated specialty palliative care in the intensive care unit: A retrospective cohort study

The Real-World Effect of Early Screening for Palliative Care Criteria in a Medical Intensive Care Unit: An Instrumental Variable Analysis

Rationale: Early identification of intensive care unit (ICU) patients likely to benefit from specialist palliative care could reduce the time such patients spend in the ICU receiving care inconsistent with their goals. Objectives: To evaluate the real-world effects of early screening for palliative care criteria in a medical ICU. Methods: We performed a retrospective cohort study in adults admitted to the ICU using a causal inference approach with instrumental variable analysis. The intervention consisted of screening ICU admissions for palliative care trigger conditions and, if present, offering specialist palliative care consultation, which could be accepted or declined by the ICU. We evaluated specialist palliative care use in pre and postimplementation cohorts from the year before and after screening implementation began (October 2022). In the postimplementation cohort, we compared use of specialist palliative care in those who received early screening versus not. We then estimated the effect of early screening on the primary outcome of days to do-not-resuscitate (DNR) code status or ICU discharge, with death without a DNR order placed at the 99th percentile of the days to DNR or ICU discharge distribution. Secondary outcomes included: DNR order, ICU and hospital lengths of stay, hospice discharge, and mortality metrics. To address unmeasured confounding, we used two-stage least-squares instrumental variables analysis. The instrument, which predicts early screening, comprised weekend versus weekday admission and number of patients meeting palliative care criteria on a patient's ICU Days 1 and 2. Results: Among 1,282 postimplementation admissions, 626 (45%) received early screening, and 398 (28%) received specialty palliative consultation. Early receipt of specialist palliative care was higher in patients who received early screening versus not (17% vs. 1%; P < 0.001), and overall use of specialty palliative care was higher after versus before screening implementation (28% vs. 15%; P < 0.001). In the postimplementation cohort, there were no statistically significant effects of early screening on the primary outcome of days to DNR or ICU discharge (15% relative increase; 95% confidence interval, -11% to +48%) or other secondary outcomes. Conclusions: Despite significantly increased specialty palliative care consultation, there was no evidence that early screening for palliative care criteria affected time to DNR/ICU discharge or other secondary outcomes.

Perceptions on Specialist Palliative Care Involvement During and After Cardiopulmonary Resuscitation: A Qualitative Study

IMPORTANCE

Cardiopulmonary resuscitation (CPR) is an exceptional physical situation and may lead to significant psychological, spiritual, and social distress in patients and their next of kin. Furthermore, clinicians might experience distress related to a CPR event. Specialist palliative care (sPC) integration could address these aspects but is not part of routine care.

OBJECTIVES

This study aimed to explore perspectives on sPC integration during and after CPR. A needs assessment for sPC, possible triggers indicating need, and implementation strategies were addressed.

DESIGN SETTING AND PARTICIPANTS

A multiprofessional qualitative semistructured focus group study was conducted in a German urban academic teaching hospital. Participants were clinicians (nursing staff, residents, and consultants) working in the emergency department and ICUs (internal medicine and surgical).

ANALYSIS

The focus groups were recorded and subsequently transcribed. Data material was analyzed using the content-structuring content analysis according to Kuckartz.

RESULTS

Seven focus groups with 18 participants in total were conducted online from July to November 2022. Six main categories (two to five subcategories) were identified: understanding (of palliative care and death), general CPR conditions (e.g., team, debriefing, and strains), prognosis (e.g., preexisting situation, use of extracorporeal support), next of kin (e.g., communication, presence during CPR), treatment plan (patient will and decision-making), and implementation of sPC (e.g., timing, trigger factors).

CONCLUSIONS

Perceptions about the need for sPC to support during and after CPR depend on roles, areas of practice, and individual understanding of sPC. Although some participants perceive CPR itself as a trigger for sPC, others define, for example, pre-CPR-existing multimorbidity or complex family dynamics as possible triggers. Suggestions for implementation are multifaceted, especially communication by sPC is emphasized. Specific challenges of extracorporeal CPR need to be explored further. Overall, the focus groups show that the topic is considered relevant, and studies on outcomes are warranted.

What are the triggers for palliative care referral in burn intensive care units? Results from a qualitative study based on healthcare professionals' views, clinical experiences and practices

BACKGROUND

Burns are a global public health problem, accounting for around 300,000 deaths annually. Burns have significant consequences for patients, families, healthcare teams and systems. Evidence suggests that the integration of palliative care in burn intensive care units improves patients' comfort, decision-making processes and family care. Research is needed on how to optimise palliative care referrals.

AIM

To identify triggers for palliative care referral in critically burned patients based on professionals' views, experiences and practices.

DESIGN

Qualitative study using in-depth interviews.

SETTING/PARTICIPANTS

All five Burn Intensive Care Units reference centres across Portugal were invited; three participated. Inclusion criteria: Professionals with experience/working in these settings. A total of 15 professionals (12 nurses and 3 physicians) participated. Reflexive thematic analysis was performed.

RESULTS

Three main triggers for palliative care referral were identified: (i) Burn severity and extension, (ii) Co-morbidities and (iii) Multiorgan failure. Other triggers were also generated: (i) Rehabilitative palliative care related to patients' suffering and changes in body image, (ii) Family suffering and/or dysfunctional and complex family processes, (iii) Long stay in the burn intensive care unit and (iv) Uncontrolled pain.

CONCLUSIONS

This study identifies triggers for palliative care in burn intensive care units based on professionals' views, clinical experiences and practices. The systematisation and use of triggers could help streamline referral pathways and strengthen the integration of palliative care in burn intensive care units. Research is needed on the use of these triggers in clinical practice to enhance decision-making processes, early and high-quality integrated palliative care and proportionate patient and family centred care.

Clinical outcomes of a joint ICU and palliative care multidisciplinary rounding model: A retrospective cohort study

OBJECTIVES

This retrospective cohort study assessed whether implementation of a joint inpatient palliative care (IPC) and ICU multidisciplinary rounding model affected clinical outcomes including ICU length of stay (LOS).

METHODS

Beginning in October of 2018, an IPC physician joined the pre-existing ICU multidisciplinary rounds. Data were collected for ICU patients admitted during a 6-month period before this intervention and a 6-month period after the intervention. Data were extracted from an integrated electronic medical records (EMR) data system and compared by Wilcoxon and chi-square test for continuous and categorical variables respectively. Negative binomial regression was used to analyze the primary outcome measure, ICU LOS.

RESULTS

Patients in the intervention group spent fewer days in the ICU (3.7 vs. 3.9 days, p = 0.05; RR 0.82, 95% CI 0.70-0.97, p = 0.02) and in the hospital (7.5 vs. 7.8 days, p<0.01) compared to the pre-intervention group. The rate of CPR was lower in the intervention group, but the difference was not statistically significant [13(3.1%) vs. 23(5.3%), p = 0.10]. The groups did not differ significantly in rate of hospital mortality, number of days connected to mechanical ventilation via endotracheal tube, or bounceback to the ED or hospital. Multivariable analysis of the primary outcome demonstrated that patients with prior palliative care involvement had longer ICU LOS (RR 1.46, 95% CI 1.04-2.06, p = 0.03) when controlling for other variables.

CONCLUSION

The presented joint IPC-ICU multidisciplinary rounding model was associated with a statistically significant reduction in ICU and hospital LOS, but the clinical significance of this reduction is unclear.

Across race, ethnicity, and language: An intervention to improve advance care planning documentation unmasks health disparities

BACKGROUND

Racial and ethnic minority groups are less likely to have advance directives and living wills, despite the importance of advanced care planning (ACP) in end-of-life care. We aimed to understand the impact of an intervention to improve ACP documentation across race, ethnicity, and language on hospitalized patients at our institution.

METHODS

We launched an intervention to improve the rates of ACP documentation for hospitalized patients aged >75 or with advanced illness defined by the International Classification of Diseases 10th Revision codes. We analyzed ACP completion rates, preintervention, and intervention, and used interrupted time-series analyses to measure the differential impact of the intervention across race, ethnicity, and language.

KEY RESULTS

A total of 10,220 patients met the inclusion criteria. Overall rates of ACP documentation improved from 13.9% to 43.7% in the intervention period, with a 2.47% monthly increase in ACP documentation compared to baseline (p < .001). During the intervention period, the rate of ACP documentation increased by 2.72% per month for non-Hispanic White patients (p < .001), by 1.84% per month for Latinx patients (p < .001), and by 1.9% per month for Black patients (p < .001). Differences in the intervention trends between non-Hispanic White and Latinx patients (p = .04) and Black patients (p = .04) were significant.

CONCLUSIONS

An intervention designed to improve ACP documentation in hospitalized patients widened a disparity across race and ethnicity with Latinx and Black patients having lower rates of improvement. Our findings reinforce the need to measure the impact of quality improvement interventions on existing health disparities and to implement specific strategies to prevent worsening disparities.

Palliative care phenotypes among critically ill patients and family members: intensive care unit prospective cohort study

OBJECTIVE

Because the heterogeneity of patients in intensive care units (ICUs) and family members represents a challenge to palliative care delivery, we aimed to determine if distinct phenotypes of palliative care needs exist.

METHODS

Prospective cohort study conducted among family members of adult patients undergoing mechanical ventilation in six medical and surgical ICUs. The primary outcome was palliative care need measured by the Needs at the End-of-Life Screening Tool (NEST, range from 0 (no need) to 130 (highest need)) completed 3 days after ICU admission. We also assessed quality of communication, clinician-family relationship and patient centredness of care. Latent class analysis of the NEST's 13 items was used to identify groups with similar patterns of serious palliative care needs.

RESULTS

Among 257 family members, latent class analysis yielded a four-class model including complex communication needs (n=26, 10%; median NEST score 68.0), family spiritual and cultural needs (n=21, 8%; 40.0) and patient and family stress needs (n=43, 31%; 31.0), as well as a fourth group with fewer serious needs (n=167, 65%; 14.0). Interclass differences existed in quality of communication (median range 4.0-10.0, p<0.001), favourable clinician-family relationship (range 34.6%-98.2%, p<0.001) and both the patient centredness of care Eliciting Concerns (median range 4.0-5.0, p<0.001) and Decision-Making (median range 2.3-4.5, p<0.001) scales.

CONCLUSIONS

Four novel phenotypes of palliative care need were identified among ICU family members with distinct differences in the severity of needs and perceived quality of the clinician-family interaction. Knowledge of need class may help to inform the development of more person-centred models of ICU-based palliative care.