Integrating Palliative Care on an Adult Trauma Service

Schockett, Erica; Prather, Christina; Benjenk, Ivy; Estroff, Jordan

doi:10.1089/jpm.2020.0378

Cited by 7 publications

(14 citation statements)

References 10 publications

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“…Highlights include mandatory annual critical care fellow rotations with the inpatient palliative consult service, ICU grand rounds presentations on palliative topics, critical care providers’ participation in serious illness communication workshops, and the successful integration of palliative care on the hospital's trauma service. 31 The mixed model of palliative and ICU collaboration allows critical care faculty to role model the integration of primary palliative skills into daily practice. It has been shown that this multidisciplinary approach between families, nursing, and providers fosters EOL discussion through a multitude of factors.…”

Section: Discussionmentioning

confidence: 99%

“…[25][26][27] Recent studies describe the limiting or withdrawal of lifesustaining therapies in nearly half of ICU deaths. [28][29][30][31] ETHICUS-2, a large European study suggested a change in EOL care in their ICUs from 1999 to 2000 to 2015 to 2016 with more limitations in life-prolonging therapies and fewer deaths without treatment limitations. 32 Differences in EOL practices between the US and other countries is complex, related to ethical, philosophical, and legal issues.…”

Section: Introductionmentioning

confidence: 99%

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The Growth of Palliative Practice and End of Life Care in an Academic Teaching Intensive Care Unit

King

Schockett

Rizvi

et al. 2022

J Intensive Care Med

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Objective Dying in the intensive care unit (ICU) has changed over the last twenty years due to increased utilization of palliative care. We sought to examine how palliative medicine (PM) integration into critical care medicine has changed outcomes in end of life including the utilization of do not resuscitate (no cardiopulmonary resuscitation but continue treatment) and comfort care orders (No resuscitation, only comfort medication). Design: Retrospective observational review of critical care patients who died during admission between two decades, 2008 to 09 and 2018 to 19. Setting: Single urban tertiary care academic medical center in Washington, D.C. Patients: Adult patients who were treated in any ICU during the admission which they died. Interventions and Measurements We sought to measure PM involvement across the two decades and its association with end of life care including do not resuscitate (DNR) and comfort care (CC) orders. Main Results: 571 cases were analyzed. Mean age was 65 ± 15, 46% were female. In univariate analysis significantly more patients received PM in 2018 to 19 (40% vs. 27%, p = .002). DNR status increased significantly over time (74% to 84%, p = .002) and was significantly more common in patients who were receiving PM (96% vs. 72%, p < 0.001). CC also increased over time (56% to 70%, p = <0.001), and was more common in PM patients (87% vs. 53%, p < 0.001). Death in the ICU decreased significantly over time (94% to 86%, p = .002) and was significantly lower in PM patients (76% vs. 96%, p < 0.001). The adjusted odds of getting CC for those receiving versus those not receiving PM were 14.51 (5.49-38.36, p < 0.001) in 2008 to 09 versus 3.89 (2.27-6.68, p < 0.001) in 2018 to 19. Conclusion: PM involvement increased significantly across a decade in our ICU and was significantly associated with incidence of DNR and CC orders as well as the decreased incidence of dying in the ICU. The increase in DNR and CC orders independent of PM over the past decade reflect intensivists delivering PM services.

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

The Growth of Palliative Practice and End of Life Care in an Academic Teaching Intensive Care Unit

King

Schockett

Rizvi

et al. 2022

J Intensive Care Med

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“…7 Several small studies show promising feasibility and efficacy of primary and specialist PC educational interventions in trauma care. For example, embedding a PC clinician in trauma rounds and providing didactics for trauma clinicians led to clinician-perceived improvements in serious illness communication and documentation, 50 though the scalability of this approach is limited given the national scarcity of PC specialists. 51 Results from a single center pre-post study of a primary PC intervention among trauma clinicians suggest that early family support and goals of care communication may lead to earlier consensus on goals of care and decreased ICU length of stay among dying trauma patients without increasing overall mortality rates.…”

Section: Discussionmentioning

confidence: 99%

Opportunities to Improve Palliative Care Delivery in Trauma Critical Illness

Haines

Wang

Harhay

et al. 2021

Am J Hosp Palliat Care

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Background: Despite recommendations to integrate palliative care (PC) into care for critically ill trauma patients, little is known about current PC practices in trauma care to inform opportunities for improvement. Objective: Describe patterns of PC delivery among a large, critically ill trauma cohort. Setting/Subjects: Retrospective cohort study of adult (≥18 years) trauma patients admitted to an intensive care unit (ICU) at an urban, level one trauma center in the United States from March 1, 2017 to March 1, 2019. Methods: We linked the electronic medical record with the institutional trauma registry. PC process measures included a PC consult order, advance care planning (ACP) note, and hospice use. Unadjusted results are reported for the total population, decedents, and subgroups at risk for poor outcomes (age ≥55 years, Black race ≥1 pre-existing comorbidity, and severe injury) after trauma. Results: Among 1309 eligible admissions, 902 (68.9%) were male, 640 (48.9%) were Black, and 654 (50.0%) were ≥55 years old. Eighty-one (6.2%) patients received a PC consult order, 66 (5.0%) had an ACP note, and 13 (1.1%) were discharged to hospice. Among decedents (N = 91; 7%), 28 (30.8%) received a PC consult order and 36 (39.6%) had an ACP note. For high-risk subgroups, PC consult orders and ACP note rates ranged from 4.5-12.8% and 4.5-11.8%, respectively. Conclusion: PC delivery was rare among this cohort, including those at high risk for poor outcomes. Urgent efforts are needed to identify barriers to and develop targeted interventions for high quality PC delivery in trauma ICU care.

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“…The risk of bias of four included studies was classified as moderate, 2,6,17,19 and all eighteen remaining studies were classified as low (eTable 2 and eTable 3: Supplemental File). 3,5,[10][11][12]18,[20][21][22][23][24][25][26][27][28][29][30][31] Among crosssectional studies classified as moderate risk of bias, common concerns included lack of identification of possible confounding factors and lack of strategies to account for confounders.…”

Section: Risk Of Biasmentioning

confidence: 99%

“…We identified 6 studies that evaluated integrated palliative care approaches. [22][23][24][25]27,30 Several of these studies account for the implementation of American College of Surgeons (ACS) Trauma Quality Improvement Program (TQIP) guidelines at a particular institution. Key components of the ACS TQIP guidelines that were evaluated within these studies include developing an interdisciplinary care team, discussing goals of care, planning for end-of-life care, and establishing a framework to promote palliative care discussion.…”

Section: Consultation Trigger Systemmentioning

confidence: 99%

Palliative Care in the Trauma and Surgical Critical Care Settings: A Narrative Review

Newsome

Sauder

Spardy

et al. 2022

The American Surgeon™

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Background We aimed to conduct a narrative review of available literature to understand the use of palliative care in the trauma and surgical critical care setting. Methods PubMed, EMBASE, and Google Scholar databases were searched for studies investigating the use of palliative care in the trauma and surgical critical care setting. The search included all studies published through January 9th, 2022. The risk of bias of included studies was assessed using the Joanna Briggs Institute Critical Appraisal Checklist tools. Outcomes were summarized in tables and synthesized qualitatively. Results A total of 22 studies were included in this review. Key elements of successful palliative care include communication, shared decision-making, family involvement, pain control, establishing a patient’s prognosis, and end-of-life management. Approaches to implementation based upon these key elements include best-case/worst-case scenarios, consultation trigger systems, and integrated institutional palliative care programs. Palliative care may reduce hospital length of stay, improve symptom management, and increase patient satisfaction, but the impact on mortality is unclear. Conclusion The core elements of palliative care have been identified and palliative care has been shown to improve outcomes in trauma and surgical critical care. However, the approaches for implementation still require development. The underutilization of palliative care for trauma patients reveals the need for refining criteria for use of palliative care and improvement in the education of surgical critical care teams to provide primary palliative care services.

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Integrating Palliative Care on an Adult Trauma Service

Cited by 7 publications

References 10 publications

The Growth of Palliative Practice and End of Life Care in an Academic Teaching Intensive Care Unit

The Growth of Palliative Practice and End of Life Care in an Academic Teaching Intensive Care Unit

Opportunities to Improve Palliative Care Delivery in Trauma Critical Illness

Palliative Care in the Trauma and Surgical Critical Care Settings: A Narrative Review

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