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Ma J, Chi S, Buettner B, et al. Early Palliative Care Consultation in the Medical ICU: A Cluster Randomized Crossover Trial. Crit Care Med. 2019 Dec;47(12):1707-1715. doi: 10.1097/CCM.0000000000004016. (Original study)
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.

Ratings
Discipline Area Score
Hospital Doctor/Hospitalists 6 / 7
Internal Medicine 6 / 7
Intensivist/Critical Care 6 / 7
Comments from MORE raters

Intensivist/Critical Care rater

Very important study showing the impact of palliative care medicine on outcomes in critically ill patients. Although the hard outcomes were no different, equally important outcomes such as resource utilization and over-treatment was significantly lower in this population.

Intensivist/Critical Care rater

This shows that early palliative care consultation in ICU patients results in more DNR and less ICU resource utilization, but no difference in ICU length of stay. This is highly relevant and while these outcomes (as well as reduced LOS) are suspected by clinicians, this study demonstrates the effects of early palliative care consultation.

Intensivist/Critical Care rater

Important article. Small numbers but demonstrable benefit of early palliative consultation in ICU.

Internal Medicine rater

At my practice site, we have had integrated palliative care for years. It always astounds me when I visit other institutions that do not. This kind of intervention is really crucial for right-sizing care and patient/family expectations.

Internal Medicine rater

The need for families to understand the severity of disease and likelihood that a patient will not survive despite ICU care is vital for both family and ICU staff. Adding the help of a palliative care team makes great sense. It will allow for better communication that often fails because of scheduling problems and ICU staff frustration. I would have liked to know the satisfaction gained by families using the early intervention and the overall benefit to the ICU staff by having the palliative team helping with communication and family support. The cost savings with the intervention demonstrates that families better understood the limited benefit of the intervention in patients with virtually no chance of recovery. Using the model could allow funding for more preventive medicine and less for expensive and futile end-of-life interventions.
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