Abstract
Background
Each year, approximately one million older adults die in American intensive care units
(ICUs) or survive with significant functional impairment. Inadequate symptom management,
surrogates’ psychological distress and inappropriate healthcare use are major concerns.
Pioneering work by Dr. J. Randall Curtis paved the way for integrating palliative
care (PC) specialists to address these needs, but convincing proof of efficacy has
not yet been demonstrated.
Design
We will conduct a multicenter patient-randomized efficacy trial of integrated specialty
PC (SPC) vs. usual care for 500 high-risk ICU patients over age 60 and their surrogate
decision-makers from five hospitals in Pennsylvania.
Intervention
The intervention will follow recommended best practices for inpatient PC consultation.
Patients will receive care from a multidisciplinary SPC team within 24 hours of enrollment
that continues until hospital discharge or death. SPC clinicians will meet with patients,
families, and the ICU team every weekday. SPC and ICU clinicians will jointly participate
in proactive family meetings according to a predefined schedule. Patients in the control
arm will receive routine ICU care.
Outcomes
Our primary outcome is patient-centeredness of care, measured using the modified Patient
Perceived Patient-Centeredness of Care scale. Secondary outcomes include surrogates’
psychological symptom burden and health resource utilization. Other outcomes include
patient survival, as well as interprofessional collaboration. We will also conduct
prespecified subgroup analyses using variables such as PC needs, measured by the Needs
of Social Nature, Existential Concerns, Symptoms, and Therapeutic Interaction scale.
Conclusions
This trial will provide robust evidence about the impact of integrating SPC with critical
care on patient, family, and health system outcomes.
Key Words
To read this article in full you will need to make a payment
Purchase one-time access:
Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online accessOne-time access price info
- For academic or personal research use, select 'Academic and Personal'
- For corporate R&D use, select 'Corporate R&D Professionals'
Subscribe:
Subscribe to Journal of Pain and Symptom ManagementAlready a print subscriber? Claim online access
Already an online subscriber? Sign in
Register: Create an account
Institutional Access: Sign in to ScienceDirect
References
- Use of intensive care at the end of life in the United States: an epidemiologic study.Crit Care Med. 2004; 32: 638-643
- Critical care delivery in the United States: distribution of services and compliance with Leapfrog recommendations.Crit Care Med. 2006; 34: 1016-1024
- Three-year outcomes for Medicare beneficiaries who survive intensive care.JAMA. 2010; 303: 849-856
- Withdrawing life support and resolution of conflict with families.BMJ. 2002; 325: 1342-1345
- What matters to seriously ill older persons making end-of-life treatment decisions?: a qualitative study.J Palliat Med. 2003; 6: 237-244
- Toward understanding the relationship between prioritized values and preferences for cardiopulmonary resuscitation among seriously Ill adults.J Pain Symptom Manage. 2019; 58 (567-77 e1)
- Is care for the dying improving in the United States?.J Palliat Med. 2015; 18: 662-666
- Site of death, place of care, and health care transitions among us medicare beneficiaries, 2000-2015.JAMA. 2018; 320: 264-271
- Regional variation in use of end-of-life care at hospitals, intensive care units, and hospices among older adults with chronic illness in the US, 2010 to 2016.JAMA Netw Open. 2020; 3e2010810
- How often is end-of-life care in the united states inconsistent with patients' goals of care?.J Palliat Med. 2017; 20: 1400-1404
- Psychological sequelae in family caregivers of critically III intensive care unit patients. A systematic review.Ann Am Thorac Soc. 2019; 16: 894-909
- Informal caregiver burden among survivors of prolonged mechanical ventilation.Am J Respir Crit Care Med. 2007; 175: 167-173
- Half the families of intensive care unit patients experience inadequate communication with physicians.Crit Care Med. 2000; 28
- The long-term outcomes of mechanical ventilation: what are they and how should they be used?.Respir Care. 2002; 47 (discussion -7): 496-505
- Recommendations for end-of-life care in the intensive care unit: the Ethics Committee of the Society of Critical Care Medicine.Crit Care Med. 2001; 29: 2332-2348
- Consensus guidelines on analgesia and sedation in dying intensive care unit patients.BMC Med Ethics. 2002; 3: 3
- Guidelines for family-centered care in the neonatal, pediatric, and adult ICU.Crit Care Med. 2017; 45: 103-128
- Managing death in the ICU: The transition from cure to comfort.Managing death in the ICU: The transition from cure to comfort. Oxford University Press, New York2000
- Studying communication about end-of-life care during the ICU family conference: development of a framework.J Crit Care. 2002; 17: 147-160
- Family satisfaction with family conferences about end-of-life care in the intensive care unit: increased proportion of family speech is associated with increased satisfaction.Crit Care Med. 2004; 32: 1484-1488
- Missed opportunities during family conferences about end-of-life care in the intensive care unit.Am J Respir Crit Care Med. 2005; 171: 844-849
- Quality indicators for end-of-life care in the intensive care unit.Crit Care Med. 2003; 31: 2255-2262
- A measure of the quality of dying and death: initial validation using after-death interviews with family members.J Pain Symptom Manage. 2002; 24: 17-31
- Measuring and improving the quality of dying and death.Ann Intern Med. 2003; 139: 410-415
- Psychometric characteristics of a quality of communication questionnaire assessing communication about end-of-life care.J Palliat Med. 2006; 9: 1086-1098
- Randomized trial of communication facilitators to reduce family distress and intensity of end-of-life care.Am J Respir Crit Care Med. 2016; 193: 154-162
- A randomized trial of a family-support intervention in intensive care units.N Engl J Med. 2018; 378: 2365-2375
- Effect of a quality-improvement intervention on end-of-life care in the intensive care unit: a randomized trial.Am J Respir Crit Care Med. 2011; 183: 348-355
- Effects of a personalized web-based decision aid for surrogate decision makers of patients with prolonged mechanical ventilation: a randomized clinical trial.Ann Intern Med. 2019; 170: 285-297
- Effect of palliative care-led meetings for families of patients with chronic critical illness: a randomized clinical trial.JAMA. 2016; 316: 51-62
- Seeking worldwide professional consensus on the principles of end-of-life care for the critically ill. The Consensus for Worldwide End-of-Life Practice for Patients in Intensive Care Units (WELPICUS) study.Am J Respir Crit Care Med. 2014; 190: 855-866
- Impact of palliative care screening and consultation in the ICU: a multihospital quality improvement project.J Pain Symptom Manage. 2017; 53 (e3): 5-12
- Impact of a proactive approach to improve end-of-life care in a medical ICU.Chest. 2003; 123: 266-271
- A proactive approach to improve end-of-life care in a medical intensive care unit for patients with terminal dementia.Crit Care Med. 2004; 32: 1839-1843
- Proactive palliative care in the medical intensive care unit: effects on length of stay for selected high-risk patients.Crit Care Med. 2007; 35: 1530-1535
- Palliative care interventions in intensive care unit patients.Intensive Care Med. 2021; 47: 1415-1425
- Developing a research agenda for integrating palliative care into critical care and pulmonary practice to improve patient and family outcomes.J Palliat Med. 2017; 20: 329-343
- Developing triggers for the surgical intensive care unit for palliative care integration.J Crit Care. 2016; 35: 7-11
- Estimates of the need for palliative care consultation across united states intensive care units using a trigger-based model.Am J Respir Crit Care Med. 2014; 189: 428-436
- Derivation of data-driven triggers for palliative care consultation in critically ill patients.J Crit Care. 2018; 46: 79-83
- Early palliative care consultation in the medical ICU: a cluster randomized crossover trial.Crit Care Med. 2019; 47: 1707-1715
- Evaluation of screening criteria for palliative care consultation in the MICU: a multihospital analysis.BMJ Support Palliat Care. 2014; 4: 254-262
- Association between frailty and short- and long-term outcomes among critically ill patients: a multicentre prospective cohort study.CMAJ. 2014; 186: E95-102
- A new method of classifying prognostic comorbidity in longitudinal studies: development and validation.J Chronic Dis. 1987; 40: 373-383
- Validation of the pittsburgh cardiac arrest category illness severity score.Resuscitation. 2015; 89: 86-92
- Cumulative prognostic score predicting mortality in patients older than 80 years admitted to the ICU.J Am Geriatr Soc. 2019; 67: 1263-1267
- Serial evaluation of the SOFA score to predict outcome in critically ill patients.JAMA. 2001; 286: 1754-1758
- Triggers in advanced neurological conditions: prediction and management of the terminal phase.BMJ Support Palliat Care. 2014; 4: 30-37
- The role of illness acuity on the association between frailty and mortality in emergency department patients referred to internal medicine.Age Ageing. 2020; 49: 1071-1079
- The right time for palliative care in heart failure: a review of critical moments for palliative care intervention.Rev Esp Cardiol (Engl Ed). 2020; 73: 78-83
- Medical guidelines for determining prognosis in selected non-cancer diseases. the National Hospice Organization.Hosp J. 1996; 11: 47-63
- Cluster randomised trials.Cluster Randomised Trials: Second Edition. CRC Press, Boca Raton2017
- National consensus project clinical practice guidelines for quality palliative care guidelines, 4th Edition.J Palliat Med. 2018; 21: 1684-1689
- Enhancing treatment fidelity in health behavior change studies: best practices and recommendations from the NIH Behavior Change Consortium.Health Psychol. 2004; 23: 443-451
- Protocol and fidelity monitoring plan for four supports. A multicenter trial of an intervention to support surrogate decision makers in intensive care units.Ann Am Thorac Soc. 2018; 15: 1083-1091
- Measuring patients' perceptions of patient-centered care: a systematic review of tools for family medicine.Ann Fam Med. 2011; 9: 155-164
- Patient-centered medicine: Transforming the clinical method.3rd ed. CRC Press, 2013
- The hospital anxiety and depression scale.Acta Psychiatr Scand. 1983; 67: 361-370
- Measurement of change with the hospital anxiety and depression scale (HADS): sensitivity and reliability of change.Psychother Psychosom Med Psychol. 2009; 59: 394-400
- Impact of event scale: psychometric properties.Br J Psychiatry. 2002; 180: 205-209
- Refinement, scoring, and validation of the Family Satisfaction in the Intensive Care Unit (FS-ICU) survey.Crit Care Med. 2007; 35: 271-279
- Feasibility and effectiveness of the NEST13+ as a screening tool for advanced illness care needs.J Palliat Med. 2010; 13: 161-169
- Validation of a decisional conflict scale.Med Decis Making. 1995; 15: 25-30
- An evaluation of the Decisional Conflict Scale for measuring the quality of end-of-life decision making.Patient Educ Couns. 2006; 61: 397-404
- Development and pilot testing of a decision aid for surrogates of patients with prolonged mechanical ventilation.Crit Care Med. 2012; 40: 2327-2334
- Validation of toolkit after-death bereaved family member interview.J Pain Symptom Manage. 2001; 22: 752-758
- Concordance of end-of-life care with end-of-life wishes in an integrated health care system.JAMA Netw Open. 2021; 4e213053
- Understanding economic outcomes in critical care.Curr Opin Crit Care. 2006; 12: 399-404
- Studies of illness in the aged: the index of ADL: a standardized measure of biological and psychosocial function.JAMA. 1963; 185: 914-919
- Measuring success of interventions to improve the quality of end-of-life care in the intensive care unit.Crit Care Med. 2006; 34: S341-S347
- Choosing and using screening criteria for palliative care consultation in the ICU: a report from the Improving Palliative Care in the ICU (IPAL-ICU) Advisory Board.Crit Care Med. 2013; 41: 2318-2327
- Models for structuring a clinical initiative to enhance palliative care in the intensive care unit: a report from the IPAL-ICU Project (improving palliative care in the ICU).Crit Care Med. 2010; 38: 1765-1772
- Preliminary report of the integration of a palliative care team into an intensive care unit.Palliat Med. 2009; 24: 154-165
- Merging cultures: palliative care specialists in the medical intensive care unit.Crit Care Med. 2006; 34: S388-S393
Article Info
Publication History
Accepted:
February 24,
2022
Identification
Copyright
© 2022 American Academy of Hospice and Palliative Medicine. Published by Elsevier Inc. All rights reserved.
