End-of-life care in the cardiac intensive care unit: a contemporary view from the Critical Care Cardiology Trials Network (CCCTN) Registry

AIMS

Increases in life expectancy, comorbidities, and survival with complex cardiovascular conditions have changed the clinical profile of the patients in cardiac intensive care units (CICUs). In this environment, palliative care (PC) services are increasingly important. However, scarce information is available about the delivery of PC in CICUs.

METHODS AND RESULTS

The Critical Care Cardiology Trials Network (CCCTN) Registry is a network of tertiary care CICUs in North America. Between 2017 and 2020, up to 26 centres contributed an annual 2-month snapshot of all consecutive medical CICU admissions. We captured code status at admission and the decision for comfort measures only (CMO) before all deaths in the CICU. Of 13 422 patients, 10% died in the CICU and 2.6% were discharged to palliative hospice. Of patients who died in the CICU, 68% were CMO at death. In the CMO group, only 13% were do not resuscitate/do not intubate at admission. The median time from CICU admission to CMO decision was 3.4 days (25th-75th percentiles: 1.2-7.7) and ≥7 days in 27%. Time from CMO decision to death was <24 h in 88%, with a median of 3.8 h (25th-75th 1.0-10.3). Before a CMO decision, 78% received mechanical ventilation and 26% mechanical circulatory support. A PC provider team participated in the care of 41% of patients who died.

CONCLUSIONS

In a contemporary CICU registry, comfort measures preceded death in two-thirds of cases, frequently without PC involvement. The high utilization of advanced intensive care unit therapies and lengthy times to a CMO decision highlight a potential opportunity for early engagement of PC teams in CICU.

Comfort Measures Orders and Hospital Transfers: Insights From the OPTIMISTIC Demonstration Project

CONTEXT

Nursing facility residents and their families may identify "comfort measures" as their overall goal of care, yet some hospital transfers still occur.

OBJECTIVES

Describe nursing facility residents with comfort measures and their hospital transfers.

METHODS

Mixed methods, including root cause analyses of transfers by registered nurses and interviews with a subset of health care providers and family members involved in transfers. Participants were residents in 19 central Indiana facilities with comfort measures orders who experienced unplanned transfers to the hospital between January 1, 2015 and June 30, 2016. Project demographic and clinical characteristics of the residents were obtained from the Minimum Data Set 3.0. Interviews were conducted with stakeholders involved in transfer decisions. Participants were prompted to reflect on reasons for the transfer and outcomes. Interviews were transcribed and coded using qualitative descriptive methods.

RESULTS

Residents with comfort measures orders (n = 177) experienced 204 transfers. Most events were assessed as unavoidable (77%). Communication among staff, or between staff and the resident/family, primary care provider, or hospital was the most frequently noted area needing improvement (59.5%). In interviews, participants (n = 11) highlighted multiple issues, including judgments about whether decisions were "good" or "bad," and factors that were important to decision-making, including communication, nursing facility capabilities, clinical situation, and goals of care.

CONCLUSION

Most transfers of residents with comfort measures orders were considered unavoidable. Nonetheless, we identified several opportunities for improving care processes, including communication and addressing acute changes in status.

Transitioning to Comfort-Focused Care at the End of Life

Shared decision making requires the exchange of information from the patient and the surgeon (and ideally involves the expertise of the entire multidisciplinary team) to determine the medical and/or surgical treatment that best aligns with the patient's goals and values. Should the surgical patient wish to transition to end-of-life care, the transition to comfort-focused care is within the scope of practice for surgeons. Incorporating the expertise of other health care professionals is an important consideration for whole-patient care. Integrating primary palliative care into surgical practice can help mitigate unnecessary suffering and allow a smoother transition to comfort-focused care.