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ProPACC: Protocol for a Trial of Integrated Specialty Palliative Care for Critically Ill Older Adults

  • Sarah K. Andersen
    Affiliations
    Program on Ethics and Decision Making, The Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine (S.K.A., G.V., R.A.B., E.H.P.B., D.M., S.K., R.O., J.S., D.B.W.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
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  • Grace Vincent
    Affiliations
    Program on Ethics and Decision Making, The Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine (S.K.A., G.V., R.A.B., E.H.P.B., D.M., S.K., R.O., J.S., D.B.W.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
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  • Rachel A. Butler
    Affiliations
    Program on Ethics and Decision Making, The Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine (S.K.A., G.V., R.A.B., E.H.P.B., D.M., S.K., R.O., J.S., D.B.W.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA

    Palliative Research Center (PaRC) (R.A.B., J.R., K.B.B., A.T., L.A.K., J.S., R.A., Y.S., D.B.W.), University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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  • Elke H.P. Brown
    Affiliations
    Program on Ethics and Decision Making, The Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine (S.K.A., G.V., R.A.B., E.H.P.B., D.M., S.K., R.O., J.S., D.B.W.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
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  • Dave Maloney
    Affiliations
    Program on Ethics and Decision Making, The Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine (S.K.A., G.V., R.A.B., E.H.P.B., D.M., S.K., R.O., J.S., D.B.W.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
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  • Sana Khalid
    Affiliations
    Program on Ethics and Decision Making, The Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine (S.K.A., G.V., R.A.B., E.H.P.B., D.M., S.K., R.O., J.S., D.B.W.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
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  • Rae Oanesa
    Affiliations
    Program on Ethics and Decision Making, The Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine (S.K.A., G.V., R.A.B., E.H.P.B., D.M., S.K., R.O., J.S., D.B.W.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
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  • James Yun
    Affiliations
    The CRISMA Center, Department of Critical Care Medicine (I.B., C.-C.H.C.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
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  • Carrie Pidro
    Affiliations
    The CRISMA Center, Department of Critical Care Medicine (I.B., C.-C.H.C.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
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  • Valerie N. Davis
    Affiliations
    The CRISMA Center, Department of Critical Care Medicine (I.B., C.-C.H.C.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
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  • Judith Resick
    Affiliations
    Palliative Research Center (PaRC) (R.A.B., J.R., K.B.B., A.T., L.A.K., J.S., R.A., Y.S., D.B.W.), University of Pittsburgh, Pittsburgh, Pennsylvania, USA

    Department of Medicine, Division of General Internal Medicine, Section of Palliative Care and Medical Ethics (J.R., K.B.B., R.A., Y.S.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
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  • Aaron Richardson
    Affiliations
    The CRISMA Center, Department of Critical Care Medicine (I.B., C.-C.H.C.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
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  • Kimberly Rak
    Affiliations
    The CRISMA Center, Department of Critical Care Medicine (I.B., C.-C.H.C.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
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  • Jackie Barnes
    Affiliations
    The CRISMA Center, Department of Critical Care Medicine (I.B., C.-C.H.C.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
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  • Karl B. Bezak
    Affiliations
    Palliative Research Center (PaRC) (R.A.B., J.R., K.B.B., A.T., L.A.K., J.S., R.A., Y.S., D.B.W.), University of Pittsburgh, Pittsburgh, Pennsylvania, USA

    Department of Medicine, Division of General Internal Medicine, Section of Palliative Care and Medical Ethics (J.R., K.B.B., R.A., Y.S.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
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  • Andrew Thurston
    Affiliations
    Palliative Research Center (PaRC) (R.A.B., J.R., K.B.B., A.T., L.A.K., J.S., R.A., Y.S., D.B.W.), University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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  • Eva Reitschuler-Cross
    Affiliations
    Department of Medicine, Division of General Internal Medicine (E.R.-C., C.-C.H.C.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
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  • Linda A. King
    Affiliations
    Palliative Research Center (PaRC) (R.A.B., J.R., K.B.B., A.T., L.A.K., J.S., R.A., Y.S., D.B.W.), University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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  • Ian Barbash
    Affiliations
    Department of Critical Care Medicine (I.B., A.-K., E.B., J.B.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA

    Department of Medicine, Division of Pulmonary, Allergy and Critical Care (I.B., J.M.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA

    The CRISMA Center, Department of Critical Care Medicine (I.B., C.-C.H.C.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
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  • Ali Al-Khafaji
    Affiliations
    Department of Critical Care Medicine (I.B., A.-K., E.B., J.B.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
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  • Emily Brant
    Affiliations
    Department of Critical Care Medicine (I.B., A.-K., E.B., J.B.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
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  • Jonathan Bishop
    Affiliations
    Department of Critical Care Medicine (I.B., A.-K., E.B., J.B.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
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  • Jennifer McComb
    Affiliations
    Department of Medicine, Division of Pulmonary, Allergy and Critical Care (I.B., J.M.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
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  • Chung-Chou H. Chang
    Affiliations
    Department of Medicine, Division of General Internal Medicine (E.R.-C., C.-C.H.C.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA

    The CRISMA Center, Department of Critical Care Medicine (I.B., C.-C.H.C.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
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  • Jennifer Seaman
    Affiliations
    Program on Ethics and Decision Making, The Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine (S.K.A., G.V., R.A.B., E.H.P.B., D.M., S.K., R.O., J.S., D.B.W.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA

    Palliative Research Center (PaRC) (R.A.B., J.R., K.B.B., A.T., L.A.K., J.S., R.A., Y.S., D.B.W.), University of Pittsburgh, Pittsburgh, Pennsylvania, USA

    Department of Acute and Tertiary Care (J.S.), University of Pittsburgh School of Nursing, Pittsburgh, Pennsylvania, USA
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  • Jennifer S. Temel
    Affiliations
    Division of Hematology/Oncology, Massachusetts General Hospital, Boston (J.S.T.), Massachusetts, USA
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  • Derek C. Angus
    Affiliations
    The CRISMA Center, Department of Critical Care Medicine (I.B., C.-C.H.C.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
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  • Robert Arnold
    Affiliations
    Palliative Research Center (PaRC) (R.A.B., J.R., K.B.B., A.T., L.A.K., J.S., R.A., Y.S., D.B.W.), University of Pittsburgh, Pittsburgh, Pennsylvania, USA

    The CRISMA Center, Department of Critical Care Medicine (I.B., C.-C.H.C.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
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  • Author Footnotes
    a Denotes equal contribution as senior author.
    Yael Schenker
    Footnotes
    a Denotes equal contribution as senior author.
    Affiliations
    Palliative Research Center (PaRC) (R.A.B., J.R., K.B.B., A.T., L.A.K., J.S., R.A., Y.S., D.B.W.), University of Pittsburgh, Pittsburgh, Pennsylvania, USA

    Department of Medicine, Division of General Internal Medicine, Section of Palliative Care and Medical Ethics (J.R., K.B.B., R.A., Y.S.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
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  • Author Footnotes
    a Denotes equal contribution as senior author.
    Douglas B. White
    Correspondence
    Address correspondence to: Douglas B. White, MD, MAS, Program on Ethics and Decision Making in Critical Illness, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, 3550 Terrace St. Scaife Hall, Room 608, HPU010604, Pittsburgh, PA 15261, USA.
    Footnotes
    a Denotes equal contribution as senior author.
    Affiliations
    Program on Ethics and Decision Making, The Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine (S.K.A., G.V., R.A.B., E.H.P.B., D.M., S.K., R.O., J.S., D.B.W.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA

    Palliative Research Center (PaRC) (R.A.B., J.R., K.B.B., A.T., L.A.K., J.S., R.A., Y.S., D.B.W.), University of Pittsburgh, Pittsburgh, Pennsylvania, USA
    Search for articles by this author
  • Author Footnotes
    a Denotes equal contribution as senior author.

      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

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