Symptom distress, interventions, and outcomes of intensive care unit cancer patients referred to a palliative care consult team

Abstract

BACKGROUND:The symptom burden of intensive care unit (ICU) patients who are referred to a palliative care team (PCT) has not been characterized to the authors' knowledge, and the response of these symptoms to the palliative care intervention has not been reported.METHODS:The authors retrospectively reviewed PCT consults for ICU patients who were seen between July 2006 and October 2007. To characterize symptom distress and outcomes in ICU patients who were referred to PCT in a cancer center, information and descriptive statistics about patients' demographics, comorbidities, PCT findings, interventions, and outcomes were obtained. The chi‐square test was used to analyze ICU and PCT mortality, and the signed‐rank test was used to analyze PCT interventions.RESULTS:Of 1637 PCT consults, 88 consults (5%) were from the ICU. The median patient age was 60 years (range, 22‐87 years), and 41 patients (46%) were women. The types of cancers were hematologic (19 patients; 22%), gastrointestinal (19 patients; 22%), lung (18 patients; 20%), and others (24 patients; 26%). Nineteen patients were on mechanical ventilation (MV), and 24 patients were on bilevel positive airway pressure (BIPAP). The findings were delirium (71 patients; 81%), dyspnea (67 patients; 76%), pain (74patients; 84%), fatigue (84 patients; 95%), and anxiety (57 patients; 65%). The interventions used were opioid management (99%), steroids (70%), antipsychotics (76%), and counseling (100%), do not resuscitate conversion (62 of 88 patients; 70%), withdrawal of MV (15 of 19 patients; 79%), and withdrawal of BIPAP (26 of 26 patients; 100%). Improvement was reported in pain (67 patients; 90%), dyspnea (60 patients; 90%), anxiety (51 patients; 80%), and delirium (31 patients; 44%). Thirty‐five patients (40%) were transferred to the palliative care unit (PCU). Fifty‐one ICU/PCT patients (58%) died during admission versus 130 of 1549 (8%) non‐ICU PCT patients (P < .0001). Twenty‐three of 35 patients who were transferred to the PCU (66%) died there versus 212 of 629 patients (34%) who were admitted to the PCU from another service (P < .0001). Thirty‐seven of 88 ICU/PCT patients (42%) were discharged alive.CONCLUSIONS:ICU patients who are referred to the PCT have severe symptom distress. The PCT was able to identify multiple problems and make numerous pharmacologic and nonpharmacologic recommendations that improved these symptoms, including the participation in do not resuscitate conversion and withdrawal of MV and BIPAP. Although many patients in this population died, a significant subset, including those who were transferred to the PCU, survived to discharge. Cancer 2009. © 2009 American Cancer Society.

Access to Palliative Care Among Patients Treated at a Comprehensive Cancer Center

“…Our results are consistent with other studies demonstrating that these patients are more likely to receive aggressive therapy at the end of life [14], to die in an intensive care unit [5], and to have late PC referral [21]. Our finding raises important concerns regarding the quality of end-of-life care for patients with hematologic malignancies.…”

High Burden of Palliative Needs among Older Intensive Care Unit Survivors Transferred to Post–Acute Care Facilities. A Single-Center Study

“…Therefore, we identified characteristics suggestive of physical or psychological symptom distress and/or anticipated poor prognosis that may be compatible with the need for palliative care services on the basis of multidisciplinary input, clinical practice standards, and previous studies. Characteristics suggestive of a high physical symptom burden were chronic wounds (21), supplemental oxygen use (22), use of mechanical ventilation at the time of hospital discharge (5,14,16,22), or prescription of opioids at hospital discharge (23). Characteristics suggestive of psychological symptom distress were consultation with a hospital chaplain during the hospitalization (24); brain dysfunction (delirium or dementia) at discharge (17); or prescription of anxiolytics, tricyclic antidepressants, g-aminobutyric acid analogs, or antipsychotics at discharge (23).…”

“…Characteristics suggestive of a high physical symptom burden were chronic wounds (21), supplemental oxygen use (22), use of mechanical ventilation at the time of hospital discharge (5,14,16,22), or prescription of opioids at hospital discharge (23). Characteristics suggestive of psychological symptom distress were consultation with a hospital chaplain during the hospitalization (24); brain dysfunction (delirium or dementia) at discharge (17); or prescription of anxiolytics, tricyclic antidepressants, g-aminobutyric acid analogs, or antipsychotics at discharge (23). Characteristics suggestive of an anticipated poor prognosis were a diagnosis of active malignancy (22), a "do-not-resuscitate" order at the time of hospital discharge (25), or a designation of "comfort care" as the goal of care at the time of discharge to the post-acute care facility.…”

Clinician Roles in Early Integrated Palliative Care for Patients with Advanced Cancer: A Qualitative Study

“…The evolution of clinician work through the patients' disease trajectory is a key feature of early palliative care in the outpatient setting that differs from inpatient palliative care consultation, which typically focuses on acute symptom control and the care of imminently dying patients. [6][7][8][9][10] For example, in a study of an inpatient palliative care service, the most common symptom for consultation was delirium. 11 These differences suggest that palliative care clinicians caring for patients with advanced cancer earlier in the course of their illness may require specific training.…”