Early Palliative Care Consultation in the Medical ICU: A Cluster Randomized Crossover Trial

Abstract

Objectives: To assess the impact of early triggered palliative care consultation on the outcomes of high-risk ICU patients. Design: Single-center cluster randomized crossover trial. Setting: Two medical ICUs at Barnes Jewish Hospital. Patients: Patients (n = 199) admitted to the medical ICUs from August 2017 to May 2018 with a positive palliative care screen indicating high risk for morbidity or mortality. Interventions: The medical ICUs were randomized to intervention or usual care followed by washout and crossover, with independent assignment of patients to each ICU at admission. Intervention arm patients received a palliative care consultation from an interprofessional team led by board-certified palliative care providers within 48 hours of ICU admission. Measurements and Main Results: Ninety-seven patients (48.7%) were assigned to the intervention and 102 (51.3%) to usual care. Transition to do-not-resuscitate/do-not-intubate occurred earlier and significantly more often in the intervention group than the control group (50.5% vs 23.4%; p < 0.0001). The intervention group had significantly more transfers to hospice care (18.6% vs 4.9%; p < 0.01) with fewer ventilator days (median 4 vs 6 d; p < 0.05), tracheostomies performed (1% vs 7.8%; p < 0.05), and postdischarge emergency department visits and/or readmissions (17.3% vs 38.9%; p < 0.01). Although total operating cost was not significantly different, medical ICU (p < 0.01) and pharmacy (p < 0.05) operating costs were significantly lower in the intervention group. There was no significant difference in ICU length of stay (median 5 vs 5.5 d), hospital length of stay (median 10 vs 11 d), in-hospital mortality (22.6% vs 29.4%), or 30-day mortality between groups (35.1% vs 36.3%) (p > 0.05). Conclusions: Early triggered palliative care consultation was associated with greater transition to do-not-resuscitate/do-not-intubate and to hospice care, as well as decreased ICU and post-ICU healthcare resource utilization. Our study suggests that routine palliative care consultation may positively impact the care of high risk, critically ill patients.

Why palliative care is the answer to the serious illness question in payment reform

“…To understand the impact at a more granular level, consider the results of Ma et al's randomized, controlled trial of formal specialist consultations, which showed a substantial increase in code status changes and in transfers to hospice, along with reductions in ventilator days, number of tracheostomies performed, and rates of postdischarge emergency department visits or readmissions. 16 Taken together, these study results suggest that palliative consultations uncover patient-or surrogate-driven desires to limit aggressive therapies-desires that otherwise may go unrealized. Indeed, it is largely through this improved communication regarding expectations, prognosis, preferences, and resources that palliative medicine programs have been able to reliably boost levels of patient and family satisfaction.…”

Reduction in antimicrobial use among medical intensive care unit patients during a cluster randomized crossover trial of palliative care consultation

“…In the original trial, 242 patients were enrolled, but only 199 were eligible for the primary outcome. 6 Of these patients, only 132 survived to hospital discharge and had not been on suppressive antimicrobials or active treatment for a previous infection at the time of hospital admission. Of 132 patients, 36 patients (27.3%) changed their code status to do not resuscitate/do not intubate.…”

“…The details of the trial have recently been described. 6 Briefly, the trial was a single-center cluster randomized crossover trial (August 2017-May 2018) at Barnes-Jewish Hospital (1,250 beds). The study included a 6-week washout period halfway through the study, followed by crossing over to intervention or usual care of the 2 medical ICUs.…”

“…All patients admitted on weekdays that were ≥18 years of age and at high risk for morbidity and mortality based on predetermined palliativecare screening criteria could be enrolled as long as they did not meet exclusion criteria. 6 Patients in the intervention arm received palliative-care consultation within 48 hours of ICU admission, and the control arm received standard of care with palliative-care consultation at the discretion of the treating physicians.…”

“…2,3 Patients at the end of life are often cared for in ICUs and frequently receive antimicrobials 4 with uncertain benefits. 5 We recently conducted a cluster randomized crossover trial of early palliative care consultation in our medical ICUs, 6 with the goal of determining the impact of early palliative care interventions on outcomes of medical ICU patients. The purpose of the current investigation was to determine whether palliative-care consultation in our medical ICU resulted in reduced antimicrobial use at the end of life.…”