Effect of a palliative care program on trends in intensive care unit utilization
            and do-not-resuscitate orders during terminal hospitalizations. An interrupted time
            series analysis

Ramos, João Gabriel Rosa; Tourinho, Fernanda Correia; Borrione, Patrícia; Azi, Paula; Andrade, Tuanny; Costa, Vanessa Ferreira; Reis, Zan; Batista, Paulo Benígno Pena; Mendes, Ana Verena Almeida

doi:10.5935/0103-507x.20180042

Cited by 7 publications

(6 citation statements)

References 33 publications

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“…This result revealed that the PC policy was not successful in reducing the ICU admission rate of patients. Our results are consistent with the findings of a previous study that found no difference in the ICU admission rate during hospitalisation before and after the implementation of the PC programme 34. Additional investigation is warranted to explore the underlying reason for informing policy planning.…”

Section: Discussionsupporting

confidence: 91%

End-of-life care in cancer and dementia: a nationwide population-based study of palliative care policy changes

Kuo

Lee

Chen

2019

BMJ Support Palliat Care

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ObjectivesThe National Health Insurance programme started providing coverage for inpatient care in palliative care (PC) units of acute care hospitals in 2000; however, initially, only PC provided to patients with terminal cancer was covered. A PC policy that enabled PC reimbursement for patients with dementia was implemented in 2009. However, the association of this PC policy with end-of-life care remains unclear. The study aims to compare the association of the PC policy with end-of-life care between patients with dementia and patients with cancer during the last 6 months of their lives.MethodsWe analysed the claims data of 7396 patients dying with dementia (PDD) and 24 319 patients dying with cancer (PDC) during 1997–2013.ResultsAmong PDC, while the percentage of receiving PC increased from 3.6% in 1999 to 14.2% by the end of 2000 (adjusted OR (aOR)=4.07, 95% CI 2.70 to 6.13) and from 20.9% in 2010 to 41.0% in 2013 (aOR=1.40, 95% CI 1.33 to 1.47), vasopressor use decreased from 71.6% in 1999 to 35.5% in 2001 (aOR=0.90, 95% CI 0.82 to 0.98). Among PDD, PC use increased from 0.2% in 2009 to 4.9% in 2013 (aOR=2.05, 95% CI 1.60 to 2.63) and cardiopulmonary resuscitation use decreased from 17.6% in 2009 to 10.0% in 2013 (aOR=0.83, 95% CI 0.76 to 0.90).ConclusionsImplementation of the PC policy in Taiwan was associated with improved PC utilisation among patients with cancer and dementia, which may reduce unnecessary medical care procedures.

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Section: Discussionsupporting

confidence: 91%

End-of-life care in cancer and dementia: a nationwide population-based study of palliative care policy changes

Kuo

Lee

Chen

2019

BMJ Support Palliat Care

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“…7 The rate of DNR orders prior to death varies from 25% in Brazil to 98% in Australia. [8][9][10][11][12] In addition, the philosophy of the institution, patient involvement, and referral to palliative care play important roles in the DNR rate. A study conducted in both UK and USA demonstrated that at hospitals with an autonomy-focused culture, physicians offered patients the choice of resuscitation regardless of whether they thought resuscitation would be appropriate.…”

Section: Introductionmentioning

confidence: 99%

“…The overall DNR order rates for critically ill patients differ between countries and between institutions, depending on different juridical policies and requirements 7 . The rate of DNR orders prior to death varies from 25% in Brazil to 98% in Australia 8–12 . In addition, the philosophy of the institution, patient involvement, and referral to palliative care play important roles in the DNR rate.…”

Section: Introductionmentioning

confidence: 99%

“Do not resuscitate” order and end‐of‐life treatment in a cohort of deceased in a Norwegian University Hospital

Werff

Michelet

Fredheim

et al. 2022

Acta Anaesthesiol Scand

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Background: A "Do not resuscitate" (DNR) order implies that cardiopulmonary resuscitation will not be started. Absent or delayed DNR orders in advanced chronic disease may indicate suboptimal communication about disease stage, prognosis, and treatment goals. The study objective was to determine clinical practice and patient involvement regarding DNR and the prevalence of life-prolonging treatment in the last week of life.Methods: A cross-sectional observational study was made of a cohort of 315 deceased from a large general hospital in Norway. Data on DNR and other treatment limitations, life-prolonging treatment in the last week of life, and cause of death were obtained from medical records.Results: A DNR order was documented for 287 (91%) patients. Almost half the DNR orders, 142 (49%), were made during the last 7 days of life. The main causes of death were cancer (31%), infectious diseases (31%), and cardiovascular diseases (19%). The most frequent life-prolonging treatments during the last week of life were intravenous fluids in 221 patients (70%) and antibiotics in 198 (63%). During the last week of life, 103 (36%) patients received ICU treatment. Death by cancer (odds ratio 2.5, 95% confidence interval 1.24-5.65) and DNR decision made by a palliative care physician (odds ratio 3.4, 95% CI 1.21-3.88) were predictors of not receiving lifeprolonging treatment. Conclusion:The findings of a high prevalence of life-prolonging treatment in the last week of life and DNR orders being made close to the time of death indicate that decisions about limiting life-prolonging treatment are often postponed until the patient's death is imminent."Do not resuscitate" orders, end-of-life care, palliative medicine, treatment limitations

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“…By using multiple previously published data on MICU patient satisfaction, a total sample size of 95 patients would be required to detect a meaningful difference with an 80% power and a type 1 error of 5%. 8,[14][15][16]29,30 MICU patient satisfaction (primary outcome) caregiver satisfaction scores (secondary outcome) were compared between the two groups using the Wilcoxon rank-sum test. The differences in median scores and corresponding 95% confidence intervals were estimated using 1000 bootstrap resamples.…”

Section: Discussionmentioning

confidence: 99%

Early Versus Usual Palliative Care Consultation in the Intensive Care Unit

Helgeson

Burnside

Robinson

et al. 2022

Am J Hosp Palliat Care

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Objectives Palliative Medicine involvement in MICU patients have improved length of stay and mortality, but with varying effects on specific patient decision outcomes, such as, advance care planning. These studies have utilized Palliative Medicine later in the hospital or ICU course, with some evidence showing that earlier involvement resulted in better results. The purpose of this study was to evaluate the benefits of early (within 24 hours) palliative care consultation in medical ICU (MICU) patients to clinical and satisfaction outcomes. Methods An unblinded randomized study performed in the MICU in one academic hospital in the USA. Ninety-one adult patients admitted to MICU received a Palliative care medicine consultation within 24 hours as the intervention. Measurements and results Ninety-one patients admitted to the MICU underwent randomization with 50 patients randomly assigned to receive Palliative Medicine consultation and 41 patients randomly assigned to receive standard-of-care based on predefined criteria. The median satisfaction score was 23 points higher for the patients in the intervention group (P < .001). The median length of MICU stay was 5 days shorter in the intervention group compared to the control group (95% CI; 1 day to 18 days, P = .018). Advance care planning was completed in the hospital for 34% of patients in the intervention arm and 12% of patients in the controls arm (absolute risk difference 22%, 95% CI 4% to 37%, P = .016). Conclusion Early Palliative Medicine consultation within 24 hours of MICU admission showed significant benefits to patients by improving satisfaction and decreasing length of stay. This study provides evidence that Palliative Medicine involvement earlier in the course of severe disease is important. Further studies in other types of intensive care units (neurological and Cardiovascular) are necessary to determine their impact.

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Effect of a palliative care program on trends in intensive care unit utilization and do-not-resuscitate orders during terminal hospitalizations. An interrupted time series analysis

Cited by 7 publications

References 33 publications

End-of-life care in cancer and dementia: a nationwide population-based study of palliative care policy changes

End-of-life care in cancer and dementia: a nationwide population-based study of palliative care policy changes

“Do not resuscitate” order and end‐of‐life treatment in a cohort of deceased in a Norwegian University Hospital

Early Versus Usual Palliative Care Consultation in the Intensive Care Unit

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