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Utilization and Delivery of Specialty Palliative Care in the ICU: Insights from the Palliative Care Quality Network

  • Allyson Cook Chapman
    Correspondence
    Address correspondence to: Allyson Cook Chapman, MD, FACS, UCSF Division of Palliative Medicine, Box 0125, 521 Parnassus, Floor 05, San Francisco, CA 94143.
    Affiliations
    Division of Palliative Medicine, Department of Medicine (A.C.C., J.A.L., J.L., D.L.O.R., S.Z.P.), University of California San Francisco, San Francisco, California

    Department of Surgery (A.C.C., J.A.L.), University of California San Francisco, San Francisco, California

    Critical Care Medicine, Department of Anesthesia (A.C.C., J.C.), University of California San Francisco, San Francisco, California
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  • Joseph A. Lin
    Affiliations
    Division of Palliative Medicine, Department of Medicine (A.C.C., J.A.L., J.L., D.L.O.R., S.Z.P.), University of California San Francisco, San Francisco, California

    Department of Surgery (A.C.C., J.A.L.), University of California San Francisco, San Francisco, California
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  • Julien Cobert
    Affiliations
    Anesthesia Service (J.C.), San Francisco VA Health Care System, San Francisco, California

    Critical Care Medicine, Department of Anesthesia (A.C.C., J.C.), University of California San Francisco, San Francisco, California
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  • Angela Marks
    Affiliations
    Department of Medicine (A.M.), University of California San Francisco, San Francisco, California
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  • Jessica Lin
    Affiliations
    Division of Palliative Medicine, Department of Medicine (A.C.C., J.A.L., J.L., D.L.O.R., S.Z.P.), University of California San Francisco, San Francisco, California
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  • David L. O'Riordan
    Affiliations
    Division of Palliative Medicine, Department of Medicine (A.C.C., J.A.L., J.L., D.L.O.R., S.Z.P.), University of California San Francisco, San Francisco, California
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  • Steven Z. Pantilat
    Affiliations
    Division of Palliative Medicine, Department of Medicine (A.C.C., J.A.L., J.L., D.L.O.R., S.Z.P.), University of California San Francisco, San Francisco, California
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      Abstract

      Context

      Palliative care (PC) benefits critically ill patients but remains underutilized. Important to developing interventions to overcome barriers to PC in the ICU and address PC needs of ICU patients is to understand how, when, and for which patients PC is provided in the ICU.

      Objectives

      Compare characteristics of specialty PC consultations in the ICU to those on medical-surgical wards.

      Methods

      Retrospective analysis of national Palliative Care Quality Network data for hospitalized patients receiving specialty PC consultation January 1, 2013 to December 31, 2019 in ICU or medical-surgical setting. 98 inpatient PC teams in 16 states contributed data. Measures and outcomes included patient characteristics, consultation features, process metrics and patient outcomes. Mixed effects multivariable logistic regression was used to compare ICU and medical-surgical units.

      Results

      Of 102,597 patients 63,082 were in medical-surgical units and 39,515 ICU. ICU patients were younger and more likely to have non-cancer diagnoses (all P < 0.001). While fewer ICU patients were able to report symptoms, most patients in both groups reported improved symptoms. ICU patients were more likely to have consultation requests for GOC, comfort care, and withdrawal of interventions and less likely for pain and/or symptoms (OR-all P < 0.001). ICU patients were less often discharged alive.

      Conclusion

      ICU patients receiving PC consultation are more likely to have non-cancer diagnoses and less likely able to communicate. Although symptom management and GOC are standard parts of ICU care, specialty PC in the ICU is often engaged for these issues and results in improved symptoms, suggesting routine interventions and consultation targeting these needs could improve care.

      Key Words

      Introduction

      Palliative care (PC) is an interprofessional specialty focused on improving the quality of life (QOL) and care for seriously ill patients and their families, regardless of their disease trajectory.
      • Kelley AS
      • Morrison RS.
      Palliative care for the seriously Ill.
      In the intensive care unit (ICU), many PC needs are apparent including: communication of prognosis and diagnosis; complex patient, family and surrogate interactions; difficult decision making and goals-of-care (GOC) conversations; complex symptom management; and end-of-life (EOL) care often involving withdrawal of interventions.

      Aslakson RA, Curtis JR, Nelson JE. The changing role of palliative care in the ICU. Crit Care Med 2014;42:2418–2428.

      ,
      • Cook AC
      • Aslakson RA.
      Palliative and End-of-Life Care in the Intensive Care Unit.
      Despite estimates that a large subset of ICU patients would benefit from PC consultation,
      • Hua MS
      • Li G
      • Blinderman CD
      • et al.
      Estimates of the need for palliative care consultation across united states intensive care units using a trigger-based model.
      specialty PC remains underutilized in the ICU setting overall
      • Seamen JB
      • Barnato AE
      • Sereika SM
      • et al.
      Patterns of palliative care service consultation in a sample of critically ill ICU patients at high risk of dying.
      and for the subset of patients who die in the ICU.
      • Decato TW
      • Engelberg RA
      • Downey L
      • et al.
      Hospital variation and temporal trends in palliative and end-of-life care in the ICU.
      PC interventions in the critically ill have been associated with reduced subsequent ICU admissions and reduced ICU length of stay.
      • Aslakson R
      • Cheng J
      • Vollenweider D
      • et al.
      Evidence-based palliative care in the intensive care unit: a systematic review of interventions.
      Barriers to PC integration and utilization in the ICU include unrealistic expectations of ICU interventions by patients and families, barriers related to ICU culture as well as cultural attributes of patients and families, insufficient training in PC principles for ICU clinicians, PC workforce shortages, and inability of patients to participate in treatment discussions.
      • Nelson JE.
      Identifying and overcoming the barriers to high-quality palliative care in the intensive care unit.
      ,
      • Beckstrand RL
      • Kirchhoff KT.
      Providing end-of-life care to patients: critical care nurses’ perceived obstacles and supportive behaviors.
      Overcoming these barriers and assessing patient and provider needs for specialty PC depends on the availability and capabilities of PC services at the institutional level, the bandwidth of providers and characteristics of the patient population. While patients from medical-surgical units and those in the ICU setting are distinct populations with differing presentations, acuity, and likely prognosis, comparison of PC delivery in these different populations including reasons for consultation and issues addressed by the PC team can help guide PC resource allocation and PC education needs for providers. Hence, an important step in developing interventions to overcome these barriers and address PC needs for ICU patients is to better understand how, when, and for which patients PC is currently provided in the ICU and how it compares to medical-surgical units.
      Palliative Care in the ICU cannot be discussed without highlighting the groundbreaking research of Dr. J. Randall Curtis, MD. His body of work has not only taught us the state of palliative care provision in the ICU, but also what skills are needed to provide quality care. Dr. Curtis and colleagues demonstrated early on the challenges with goals of care conversations and family meetings in the ICU. Subsequently he developed tools to teach these skills and evaluated their effectiveness. Dr. Curtis’ work also helped to measure quality of care and quality of communication in end-of-life care identifying factors that contribute to quality and allowing others to assess interventions to improve care.
      • Patrick DL
      • Curtis JR
      • Engelberg RA
      • et al.
      Measuring and improving the quality of dying and death.
      • Patrick DL
      • Engelberg RA
      • Curtis JR.
      Evaluating the quality of dying and death.
      • Curtis JR
      • Patrick DL
      • Engelberg RA
      • et al.
      A measure of the quality of dying and death: initial validation using after-death interviews with family members.
      • Downey L
      • Curtis JR
      • Lafferty WE
      • et al.
      The Quality of Dying and Death (QODD) Questionnaire: Empirical Domains and Theoretical Perspectives.
      • Engelberg RA
      • Downey L
      • Wenrich MD
      • et al.
      Measuring the quality of end-of-life care.
      • Engelberg R
      • Downey L
      • Curtis JR.
      Psychometric characteristics of a quality of communication questionnaire assessing communication about end-of-life care.
      His focus on the patient and family and improving care for the critically ill provided the foundation for integration and evaluation of PC in the ICU as well as a roadmap for future research in this space. Through his large body of research that made the case for the importance, relevance, and need for palliative care in the ICU, Dr. Curtis also paved the way for clinicians interested not just in research but also clinical practice and education at this intersection. In fact, three authors of this work (ACC, JAL, and JC) have careers made possible through the pioneering work of Dr. Curtis. We cite his groundbreaking research throughout this paper in gratitude and admiration of his work and because they are essential to understanding and improving palliative care in the ICU.

      Methods

      Study Population

      The PCQN is a national quality improvement collaborative of specialty PC teams that collect standardized data on processes of care and patient-level outcomes.
      • Pantilat SZ
      • Marks AK
      • Bischoff KE
      • et al.
      The Palliative Care Quality Network: Improving the Quality of Caring.
      As of December 2019, there were 98 inpatient PC teams in the PCQN from hospitals across 16 states. Teams in the PCQN vary in composition and work in a broad range of hospitals (Table 1).
      Table 1Characteristics of Hospitals and Palliative Care Teams Contributing Data to the PCQN Dataset.
      CharacteristicsFrequency % (n)
      State:N = 98
       California59.0 (58)
       Arizona4.1 (4)
       Hawaii1.0 (1)
       Kentucky2.0 (2)
       Louisiana4.1 (4)
       Massachusetts3.1 (3)
       Michigan5.1 (5)
       Missouri1.0 (1)
       Montana1.0 (1)
       New Mexico1.0 (1)
       Oregon4.1 (4)
       South Carolina1.0 (1)
       Texas8.2 (8)
       Washington4.1 (4)
       Wisconsin1.0 (1)
      Size:N = 73
       Mean348
       Median286
       Range:26 – 1,120
      N = 73
       1 – 149 beds10 (13.7)
       150 – 299 beds27 (37.0)
       300 – 499 beds19 (26.0)
       500+ beds17 (23.3)
      Hospital StatusN = 97
       Not for profit68.1 (66)
       Academic17.5 (17)
       Public11.3 (11)
       For profit1.0 (1)
       Other2.1 (2)
      Team composition
      Percentage of teams with each discipline.
      :
      % (n)
       Nurse (NP/RN)92.2 (83/90)
       Physician98.8 (84/85)
       Social Worker87.1 (74/85)
       Chaplain69.9 (58/83)
      Number of members in the team:N = 90
       13.3 (3)
       212.2 (11)
       333.3 (30)
       451.1 (46)
      Credentialed
      Credentialling includes American Board of Hospice and Palliative Nursing certification for nurses, Amercian Board of Medical Specialties certification for physicians; Advanced Palliative Hospice and Social Work Certification credentialling for Social Workers and Palliative Care & Hospice Advanced Certification or Hospice and Palliative Care Specialty Certification credentialling for Chaplains.
      :
       Registered Nurse44.3 (27/61)
       Nurse Practitioner57.7 (41/71)
       Physician94.7 (72/76)
       Social Worker33.3 (21/63)
       Chaplain18.6 (11/59)
      a Percentage of teams with each discipline.
      b Credentialling includes American Board of Hospice and Palliative Nursing certification for nurses, Amercian Board of Medical Specialties certification for physicians; Advanced Palliative Hospice and Social Work Certification credentialling for Social Workers and Palliative Care & Hospice Advanced Certification or Hospice and Palliative Care Specialty Certification credentialling for Chaplains.
      Patients who received a PC consultation between January 1, 2013 and December 31, 2019 in the ICU or medical-surgical setting were included. Though patients in medical-surgical units differ from those in the ICU, we chose them as a comparator because they represent a large cohort of patients seen by PC teams. While medical-surgical patients have a similar breadth of diagnoses, patient characteristics, and access to PC consultation resources, their PC needs likely differ. This comparison helps elucidate the differences in reasons for PC consultation and issues addressed by PC teams that could guide PC team processes, operations, and resource allocation tailored to each setting.

      Dataset

      The PCQN dataset has been previously described in detail.
      • Pantilat SZ
      • Marks AK
      • Bischoff KE
      • et al.
      The Palliative Care Quality Network: Improving the Quality of Caring.
      PCQN teams prospectively collect a standardized set of 23 data elements in real time capturing patient characteristics, processes and outcomes data for all patients seen by a specialty PC team. Patient characteristics at time of referral include age, gender, and referral location. Processes of care metrics include date of PC consultation, number of family meetings, number of PC team assessments, and reason(s) for consultation for which the team can record as many as are appropriate. Initial PC team assessment of advance care planning (ACP) includes surrogate decision-maker designation, code status, and presence in the electronic health record of a Physician's Orders for Life-Sustaining Treatment (POLST)

      POLST: Portable medical orders for seriously ill or frail individuals. [cited 2021 Jan 11]. Available at: https://polst.org. Accessed April 3, 2022.

      form and/or an advance directive (AD). Teams also collect patient-reported outcomes including Palliative Performance Scale (PPS), a 0%–100% measure of functional status, with higher scores reflecting greater function at the first visit and symptom severity at each visit with the patient (pain, dyspnea, nausea, and anxiety rated none, mild, moderate, and severe, and patient unable to rate).
      • Anderson F
      • Downing GM
      • Hill J
      • et al.
      Palliative Performance Scale (PPS): a new tool.
      Treatment outcomes include code status after consultation (Full Code, Do-not-resuscitate and/or Do-not-intubate (DNR/DNI), or Partial code), ACP documentation completed, discharge disposition, discharge location, and services provided. The study was reviewed and approved by the University of California, San Francisco Institutional Review Board (16-18596).

      Statistical Analysis

      Continuous variables were summarized using means (95% confidence intervals [CI]) medians (with range). Frequencies were calculated for categorical variables. We used chi-squared tests (χ2) to examine bivariate associations between categorical variables and analysis of variance (ANOVA) to examine associations between categorical and continuous variables. Change in reported symptom scores from initial assessment to second assessment and to last assessment were calculated with a change of one category (±1) considered clinically meaningful.
      • Bischoff KE
      • O'Riordan DL
      • Fazzalaro K
      • et al.
      Identifying opportunities to improve pain among patients with serious illness.
      • Dworkin RH
      • Turk DC
      • Wyrwich KW
      • et al.
      Interpreting the Clinical Importance of Treatment Outcomes in Chronic Pain Clinical Trials: IMMPACT Recommendations.
      • Suzuki H
      • Aono S
      • Inoue S
      • et al.
      Clinically significant changes in pain along the Pain Intensity Numerical Rating Scale in patients with chronic low back pain.
      We used mixed effects multivariable logistic regression models to study the association of ICU vs. medical-surgical units with both processes of care and treatment outcomes. For each of the binary outcomes we examined, we included age, gender, and primary diagnosis as fixed effects and PC team as a random effect to account for intra-team correlation of patient measures. For each of the outcome models, we report the OR and 95% CI for the primary predictor (ICU vs. Medical-surgical).
      There was no adjustment or imputation for missing covariate or outcome values. Analyses were performed only for patients for whom both covariate and specific outcome data were available, resulting in different n values for each analysis. We used a 2 sided alpha of 0.01. We used SPSS, version 27 for MAC (SPSS Inc).

      Results

      Patient Characteristics

      A total of 102,597 patients were seen and evaluated by a PC team; 39% (n = 39,515) received a PC consult in the ICU and 61% (n = 63,082) in a medical-surgical unit. ICU patients referred to PC were younger 68.43 vs. 72.04, P < 0.0001), less likely to be female (45.4% vs. 52.0%, P < 0.0001), more likely to have a primary diagnosis other than cancer (cancer diagnosis 15.0% vs. 40.9%, P < 0.0001) and had poorer functional status (PPS 25.7; 95%CI: 25.5, 25.9 vs. 41.6; 95%CI: 41.5, 41.8, P < 0.0001) (Table 2). PC referrals from the ICU were more likely to be for GOC and ACP and less likely to be for pain or other symptom management (80.6% vs. 75.0% for goals of care and/or ACP and 6.1%vs. 21.8% for pain management, P < 0.0001). ICU patients were significantly less likely to have a POLST (7.7% vs. 13.5%, P < 0.0001) or advance directive (19.1% vs. 25.4%, P < 0.0001, and were significantly more likely to have full or partial code (for example: DNR but intubation within goals) status (71.1% vs. 58.2%, P < 0.0001). The time from admission to consultation request was longer for ICU patients. Overall, 38.1% (n = 39,090) of patients received a referral request for PC within 24 hours of admission, with medical-surgical patients more likely to have a referral in this timeframe than ICU patients (39.5%; n = 25,075 vs. 35.5%, n = 14,015; P ≤ 0.0001).
      Table 2Patient Characteristics at Time of Palliative Care Consultation.
      Patient CharacteristicsReferral LocationP-value
      ICUMed/Surg
      N = 39,462N = 63,056
      Mean (95%CI)Mean (95%CI)
      Age (Years)68.43(68.27,68.59)72.04 (71.91,72.17)<0.001
       Median (SD)70.0 (16.0)74.0 (16.3)
      %(n)%(n)
      N = 39,501N = 63,047
      Gender (Female)45.4 (17,919)52.0 (32,815)<0.001
      Primary Diagnosis:N = 38,750N = 62,012
       Cancer15.0 (5,819)40.9 (25,355)<0.001
       Cardiovascular20.3 (7,864)7.2 (4,483)
       Pulmonary16.5 (6,405)7.2 (4,439)
       Neurologic/Stroke15.9 (6,146)7.6 (4,713)
       Other32.3 (12,516)37.1 (23,022)
      Reason for referral:N = 39,012N = 62,590
       GoC/ACP80.6 (31,434)75.0 (46,913)<0.001
       Pain management6.1 (2,393)21.8 (13,665)<0.001
       Other symptom management9.0 (3,500)15.1 (9,472)<0.001
       Hospice referral/discussion9.8 (3,806)17.7 (11,059)<0.001
       Comfort care9.7 (3,780)5.1 (3,172)<0.001
       Withdrawal of interventions7.7 (3,014)1.3 (787)<0.001
       Support for patient/family36.6 (14,271)25.9 (16,189)<0.001
      N = 34,321N = 54,558
      Mean (95%CI)Mean (95%CI)
      PPS score25.7 (25.5,25.9)41.6 (41.5,41.8)<0.001
       Median (SD)20.0 (17.5)40.0 (18.3)
      %(n)%(n)
      Code Status:N = 38,366N = 61,543
       Full64.4 (24,720)55.9 (34,402)<0.0001
       Partial6.7 (2,564)2.3 (1,441)
       DNR/DNI28.9 (11,082)41.8 (25,700)
      N = 39,496N = 63,025
      Mean (95%CI)Mean (95%CI)
      Time between admission and PC consult in days5.90 (5.73,6.07)

      Median (SD)

      3.0 (17.1)
      5.04 (4.87,5.20)

      Median (SD)

      2.0 (20.9)
      <0.001
      %(n)%(n)
      N = 39,496N = 63,025
      PC referral within 24 hours of admission:35.5 (14,015)39.8 (25,075)<0.001
      Symptoms at time of consult:
      Pain:N = 32,762N = 53,209
       Able to report42.8 (14,048)73.8 (39,266)<0.001
      N = 14,048N = 39,266
       Severity – Mod./Severe
      Of patients that were able to report symptoms. Abbreviations: ICU = intensive care unit; CI = confidence interval; PC = palliative care; PPS = palliative performance scale; GoC = goals of care; ACP = advance care planning, SD = standard deviation.
      18.0 (2,527)31.5 (12,364)<0.001
      Anxiety:N = 32,666N = 53,049
       Able to report40.0 (13,066)68.5 (36,342)<0.001
      N = 13,066N = 36,342
       Severity – Mod./Severe
      Of patients that were able to report symptoms. Abbreviations: ICU = intensive care unit; CI = confidence interval; PC = palliative care; PPS = palliative performance scale; GoC = goals of care; ACP = advance care planning, SD = standard deviation.
      11.8 (1,537)11.6 (4,214)0.61
      Nausea:N = 32,692N = 53,059
       Able to report41.2 (13,465)72.0 (38,215)<0.001
      N = 13,465N = 38,215
       Severity – Mod./Severe
      Of patients that were able to report symptoms. Abbreviations: ICU = intensive care unit; CI = confidence interval; PC = palliative care; PPS = palliative performance scale; GoC = goals of care; ACP = advance care planning, SD = standard deviation.
      2.3 (310)5.7 (2,185)<0.001
      Dyspnea:N = 32,685N = 52,951
       Able to report41.5 (13,571)72.4 (38,335)<0.001
      N = 13,571N = 38,335
       Severity – Mod./Severe
      Of patients that were able to report symptoms. Abbreviations: ICU = intensive care unit; CI = confidence interval; PC = palliative care; PPS = palliative performance scale; GoC = goals of care; ACP = advance care planning, SD = standard deviation.
      16.8 (2,276)7.8 (3,002)<0.001
      a Of patients that were able to report symptoms.Abbreviations: ICU = intensive care unit; CI = confidence interval; PC = palliative care; PPS = palliative performance scale; GoC = goals of care; ACP = advance care planning, SD = standard deviation.
      Patients referred from the ICU were less likely to be able to report pain, anxiety, nausea, and dyspnea at time of PC consultation than their medical-surgical counterparts. Of those able to report, ICU patients were less likely to have moderate and/or severe pain and nausea and more likely to have moderate and/or severe dyspnea. There were no differences between the 2 patient populations in prevalence of anxiety.
      After adjusting for confounders, ICU patients had higher adjusted odds ratios (OR) of consultation requests for GOC/ACP (OR = 1.70, 95%CI: 1.64, 1.77), comfort care (OR = 1.82, 95%CI: 1.72, 1.92), withdrawal of interventions (OR = 6.47, 95%CI: 5.91, 7.08), and patient or family support (OR = 1.56, 95%CI: 1.51, 1.62; P < 0.001)(Table 3). Consistent with the lower reported symptom burden in ICU patients referred to PC, they were significantly less likely than medical-surgical patients to receive consultation for pain (OR = 0.26, 95%CI: 0.24, 0.27; P < 0.001) or other symptoms (OR = 0.57, 95%CI: 0.54, 0.60; P < 0.001.
      Table 3Multivariate Regression of Processes of Care for Patients Referred for PC from ICU vs. Medical/Surgical Units with Medical/Surgical Unit Patients as the Reference Group.
      Processes of CareOR 95%CI
      All mixed effect multivariate logistic regression models include PC team clustering as a random effect, and age, gender, and primary diagnosis as fixed effects.
      P-value
      Reason for referralN = 64,682
       GoC/ACP1.70 (1.64,1.77)<0.001
       Pain management0.26 (0.24,0.27)<0.001
       Other symptom management0.57 (0.54,0.60)<0.001
       Hospice referral/discussion0.59 (0.56,0.61)<0.001
       Comfort care1.82 (1.72,1.92)<0.001
       Withdrawal of interventions6.47 (5.91,7.08)<0.001
       Support for patient/family1.56 (1.51,1.62)<0.001
      N = 61,528
      POLST at time of consult0.66 (0.62,0.69)<0.001
      N = 62,599
      Advance Directives documented at time of consult0.87 (0.84,0.91)<0.001
      Code status at time of consult:N = 63,932
       Full1.0
       Partial3.01 (2.79,3.25)<0.001
       DNR/DNI0.71 (0.69,0.74)<0.001
      N = 65,121
      PC referral within 24 hours of admission:0.88 (0.84, 0.91)<0.001
      PPS by tertile
      N = 57,050
       70% – 100%1.0
       40% – 60%2.02 (1.87,2.19)<0.001
       10% – 30%8.90 (8.20,9.65)<0.001
      Symptoms at time of consult
      Pain:N = 55,586
       Able to report0.27 (0.26,0.28)<0.001
      N = 35,962
       Severity – Mod./Severe
      Of patients that were able to report symptoms. Abbreviations: PC = palliative care; ICU = intensive care unit; OR = odds ratio; GoC = goals of care; ACP = advance care planning; POLST = Physician Order for Life-Sustaining Treatments; DNR = do-not-resuscitate; DNI = do-not-intubate; PPS = Palliative Performance Scale; Mod = moderate.
      0.53 (0.50,0.56)<0.001
      Anxiety:N = 55,378
       Able to report0.29 (0.28,0.30)<0.001
      N = 33,399
       Severity – Mod./Severe
      Of patients that were able to report symptoms. Abbreviations: PC = palliative care; ICU = intensive care unit; OR = odds ratio; GoC = goals of care; ACP = advance care planning; POLST = Physician Order for Life-Sustaining Treatments; DNR = do-not-resuscitate; DNI = do-not-intubate; PPS = Palliative Performance Scale; Mod = moderate.
      0.96 (0.89,1.03)0.26
      Nausea:N = 55,425
       Able to report0.27 (0.25,0.28)<0.001
      N = 34,968
       Severity – Mod./Severe
      Of patients that were able to report symptoms. Abbreviations: PC = palliative care; ICU = intensive care unit; OR = odds ratio; GoC = goals of care; ACP = advance care planning; POLST = Physician Order for Life-Sustaining Treatments; DNR = do-not-resuscitate; DNI = do-not-intubate; PPS = Palliative Performance Scale; Mod = moderate.
      0.53 (0.47,0.61)<0.001
      Dyspnea:N = 55,370
       Able to report0.27 (0.26,0.28)<0.001
      N = 35,085
       Severity – Mod./Severe
      Of patients that were able to report symptoms. Abbreviations: PC = palliative care; ICU = intensive care unit; OR = odds ratio; GoC = goals of care; ACP = advance care planning; POLST = Physician Order for Life-Sustaining Treatments; DNR = do-not-resuscitate; DNI = do-not-intubate; PPS = Palliative Performance Scale; Mod = moderate.
      1.98 (1.85,2.13)<0.001
      a All mixed effect multivariate logistic regression models include PC team clustering as a random effect, and age, gender, and primary diagnosis as fixed effects.
      b Of patients that were able to report symptoms.Abbreviations: PC = palliative care; ICU = intensive care unit; OR = odds ratio; GoC = goals of care; ACP = advance care planning; POLST = Physician Order for Life-Sustaining Treatments; DNR = do-not-resuscitate; DNI = do-not-intubate; PPS = Palliative Performance Scale; Mod = moderate.

      Treatment Outcomes

      Patients referred from ICU were more likely to receive their second visit within 72 hours of their first (11.6% vs. 6.8%. P < 0.001) (Tables 4 and 5). The vast majority of patients in both groups reported improvements in symptoms by the second PC visit and those in the ICU were more likely to report improvements in pain (72.9% vs. 67.0%, P < 0.001) and nausea (83.0% vs. 76.6%, P < 0.05). Although ICU consultations were more likely for ACP and GOC, POLSTs and ADs were significantly less likely to be completed in the ICU. Specialty PC teams held more family meetings for ICU patients and both groups had high rates of surrogate decision-maker designation.
      Table 4Treatment Outcomes of Medical-Surgical and ICU Patients Referred to Palliative Care.
      Treatment OutcomesReferral LocationP-value
      ICUMed/Surg
      %(n)%(n)
      N = 19,588N = 31,203
      2nd PC assessment within 72 hours after 1st assessment11.6 (2,268)6.8 (2,136)<0.001
      Symptom improvement from 1st to 2nd assessment
      Of patients reporting moderate to severe symptom distress at initial assessment. Abbreviations: PC = palliative care; ICU = intensive care unit; GoC = goals of care; ACP = advance care planning; POLST = Physician Order for Life-Sustaining Treatments; DNR = do-not-resuscitate; DNI = do-not-intubate; PPS = Palliative Performance Scale; Mod = moderate.
      N = 1,634N = 9,086
       Pain72.9 (1,191)67.0 (6,087)<0.001
      N = 947N = 2,812
       Anxiety72.3 (685)69.3 (1,949)0.08
      N = 182N = 1,624
       Nausea83.0 (151)76.6 (1,244)0.05
      N = 1,312N = 1,831
       Dyspnea63.4 (832)64.7 (1,184)0.47
      N = 36,266N = 58,027
      Mean (95%CI)Mean (95%CI)
      Mean number of family meetings1.67 (1.65,1.68)1.23 (1.22,1.24)<0.001
       Median (SD)1.0 (1.6)1.0 (1.3
      %(n)%(n)
      Surrogate decision maker at time of discharge:N = 24,420N = 40,290
       Not Identified3.7 (907)4.9 (1,994)<0.001
       Identified92.0 (22,471)88.0 (35,456)
       Not Addressed4.3 (1,042)7.0 (2,840)
      Code status at discharge:N = 27,293N = 42,821
       Full30.5 (8,336)32.8 (14,050)<0.001
       Partial5.6 (1,517)2.1 (886)
       DNR/DNI63.9 (17,440)65.1 (27,885)
      N = 35,452N = 56,087
      POLST Completed during PC consultation8.5 (3,002)16.9 (9,487)<0.001
      N = 35,665N = 56,545
      Advanced directives completed during PC consultation3.4 (1,199)4.3 (2,454)<0.001
      N = 38,919N = 61,904
      Mean (95%CI)Mean (95%CI)
      Mean days followed by the PC Team6.85 (6.70-7.01)5.57 (5.40-5.74)<0.001
       Median (SD)4.0 (15.7)3.0 (21.1)
      %(n)%(n)
      Discharge Disposition:N = 39,001N = 62,355
       Discharged alive56.7 (22,112)87.1 (54,283)<0.001
      Discharge Location:N = 21,728N = 53,468
       Home31.2 (6,774)49.5 (26,471)<0.001
       Inpatient34.6 (7,524)17.8 (9,516)
       Non-Hospital Facility29.4 (6,387)29.5 (15,791)
       Other4.8 (1,043)3.2 (1,690)
      Service provided if discharged:N = 19,009N = 49,124
       None44.2 (8,395)34.1 (16,764)<0.001
      N = 19,004N = 49,075
       Nursing Home12.2 (2,315)15.8 (7,755)<0.001
      N = 18,995N = 49,061
       Clinic-based PC1.4 (274)6.0 (2,930)<0.001
      N = 18,995N = 49,061
       Home-based PC3.1 (588)6.7 (3,270)<0.001
      N = 19,009N = 49,124
       Hospice31.6 (5,998)35.3 (17,355)<0.001
      a Of patients reporting moderate to severe symptom distress at initial assessment.Abbreviations: PC = palliative care; ICU = intensive care unit; GoC = goals of care; ACP = advance care planning; POLST = Physician Order for Life-Sustaining Treatments; DNR = do-not-resuscitate; DNI = do-not-intubate; PPS = Palliative Performance Scale; Mod = moderate.
      Table 5Multivariate Regression of Palliative Care Treatment Outcomes for ICU Patients Compared to Medical-Surgical Patients With Medical/Surgical Patients as the Reference Group.
      Treatment OutcomesOR (95%CI)
      All mixed effects multivariate logistic regression models include PC team clustering as a random effect, and age, gender, and primary diagnosis as fixed effects.
      P-value
      N = 33,880
      Patients receiving 2nd PC assessment 72 hours after 1st assessment1.62 (1.51,1.75)<0.001
      Symptom improvement from 1st to 2nd assessment
      Of patients reporting moderate to severe symptom distress at initial assessment. Abbreviations: PC = palliative care; ICU = intensive care unit; OR = odds ratio; POLST = Physician Order for Life-Sustaining Treatments; DNR = do-not-resuscitate; DNI = do-not-intubate.
      N = 7,818
       Pain1.13 (0.99,1.30)0.06
      N = 2,784
       Anxiety1.11 (0.91,1.35)0.32
      N = 1,468
       Nausea1.37 (0.86,2.17)0.19
      N = 2,638
       Dyspnea0.96 (0.81, 1.14)0.68
      Surrogate decision maker at time of discharge:N = 41,614
       Not Identified1.0
       Identified1.35 (1.23,1.48)<0.001
       Not Addressed0.79 (0.70,0.89)<0.001
      Code status at discharge:N = 44,932
       Full1.0
       Partial3.62 (3.27,4.01)<0.001
       DNR/DNI1.44 (1.38,1.50)<0.001
      N = 58,777
      POLST Completed during PC consultation0.61 (0.58,0.64)<0.001
      N = 59,220
      Advance directives completed during PC consultation0.80 (0.73,0.87)<0.001
      Discharge Disposition:N = 64,464
       Discharged alive0.19 (0.18,0.20)<0.001
      Discharge LocationN = 47,323
       Home0.48 (0.46,0.50)<0.001
       Inpatient2.4 (2.32,2.53)<0.001
       Non-Hospital Facility1.0 (0.96,1.05)0.85
      Service provided if dischargedN = 43,219
       None1.24 (1.19,1.30)<0.001
      N = 43,180
       Nursing Home0.65 (0.62,0.69)<0.001
      N = 43,162
       Clinic-based PC0.41 (0.36,0.47)<0.001
      N = 43,162
       Home-based PC0.48 (0.44,0.54)<0.001
      N = 43,219
       Hospice1.07 (1.03,1.12)0.001
      a All mixed effects multivariate logistic regression models include PC team clustering as a random effect, and age, gender, and primary diagnosis as fixed effects.
      b Of patients reporting moderate to severe symptom distress at initial assessment.Abbreviations: PC = palliative care; ICU = intensive care unit; OR = odds ratio; POLST = Physician Order for Life-Sustaining Treatments; DNR = do-not-resuscitate; DNI = do-not-intubate.
      In both cohorts, nearly two-thirds of patients had a code status of DNR/DNI after PC consultation (Table 4). ICU patients referred to PC were significantly less likely to be discharged alive compared to those on medical-surgical units, and of those discharged, ICU patients were less likely to be discharged to home. Hospice was provided at discharge in about one third of cases in both cohorts. Non-hospice outpatient PC services were infrequently provided in both groups.

      Discussion

      Using a large, national, prospectively collected database of PC consultation characteristics and outcomes, we found that the vast majority of ICU referrals for PC were for ACP and GOC in contrast to a more diverse utilization of PC consultation in medical-surgical patients. While ICU patients were sicker and more likely to die before discharge, their PC consultations were requested on average one day later in the hospitalization. Our findings describe the current state of PC delivery in the ICU and what PC specialists are being asked to do, highlighting the differing needs of patients and teams from these two settings.
      Our results reveal a high prevalence of unmet PC needs in ICU patients. Even though 40% of ICU patients were able to report symptoms, compared to 70% of medical-surgical patients, and a significant percentage reported moderate-severe symptoms, specialty PC was rarely sought for pain and symptom management (6% and 9%, respectively). Similar to other studies, we found that ICU patients report the presence of symptoms such as pain and dyspnea
      • Puntillo KA
      • Arai S
      • Cohen NH
      • et al.
      Symptoms experienced by intensive care unit patients at high risk of dying.
      • Clukey L
      • Weyant RA
      • Roberts M
      • et al.
      Discovery of unexpected pain in intubated and sedated patients.
      • Gentzler ER
      • Derry H
      • Ouyang DJ
      • et al.
      Underdetection and undertreatment of dyspnea in critically ill patients.
      and that PC team involvement was associated with improvements in pain (73%) and dyspnea (63%) though given the observational design of all of these studies, we cannot infer causality.
      • Wysham NG
      • Hochman MJ
      • Wolf SP
      • et al.
      Performance of consultative palliative care model in achieving quality metrics in the ICU.
      • Delgado-Guay MO
      • Parsons HA
      • Palmer JL
      • et al.
      Symptom distress, interventions, and outcomes of intensive care unit (ICU) cancer patients referred to a palliative care consult team (PCT).
      • O'Mahony S
      • McHenry J
      • Blank AE
      • et al.
      Preliminary report of the integration of a palliative care team into an intensive care unit.
      Given that symptom control is correlated with quality of life at the end of life,
      • Downey L
      • Curtis JR
      • Lafferty WE
      • et al.
      The Quality of Dying and Death (QODD) Questionnaire: Empirical Domains and Theoretical Perspectives.
      our results demonstrate the need for improved symptom identification and treatment and a potential role for specialty PC in symptom management.
      We found that most ICU patients have a Full Code status at time of consultation and that withdrawal of interventions is a common reason for consultation, suggesting specialty PC in the ICU is commonly utilized when more invasive strategies are not working. This idea of a ‘time-limited trial’ of ICU care
      • Chang DW
      • Neville TH
      • Parrish J
      • et al.
      Evaluation of time-limited trials among critically ill patients with advanced medical illnesses and reduction of nonbeneficial ICU treatments.
      and the ‘culture of rescue’ by which aggressive care is employed to save patients, is also supported by the longer length of stay prior to PC consultation in the ICU and may delay PC involvement.
      • Hetzler PT
      • LS Dugdale
      How Do Medicalization and Rescue Fantasy Prevent Healthy Dying?.
      ,
      • Vink EE
      • Azoulay E
      • Caplan A
      • et al.
      Time-limited trial of intensive care treatment: an overview of current literature.
      PC consultations may represent a means to de-escalate care during new or severe exacerbations of serious illness, as Ma and colleagues described, with early PC consultation associated with de-escalation of care and increased utilization of hospice.
      • Ma J
      • Chi S
      • Buettner B
      • et al.
      Early palliative care consultation in the medical ICU: a cluster randomized crossover trial.
      That these consultations happen on average six days into hospitalization and nearly a full day later than for patients in medical-surgical units, suggests an opportunity to engage patients in GOC conversations sooner, potentially allowing more patients to participate in these discussions. Prior research has found that among patients who die in the hospital, the families of those cared for in the ICU reported higher rating of quality care at the end of life than those cared for on the wards
      • Rolnick JA
      • Ersek M
      • Wachterman MW
      • et al.
      The quality of end-of-life care among ICU versus ward decedents.
      and our results suggest that earlier or routine involvement of specialty PC teams with ICU patients may further improve quality of care. We found that PC teams consulting in the ICU were more likely to follow up within 72 hours, had more family meetings on average, and also reported support for families and symptom management, suggesting that they provided a longitudinal, comprehensive, specialty PC consultation in the ICU that includes and extends beyond GOC.
      In addition to specialty PC consultation, other approaches to PC delivery have been described, including by ICU teams such as focusing on the family conference as a means to improve communication between teams and families at the EOL
      • Curtis JR
      • Patrick DL
      • Shannon SE
      • et al.
      The family conference as a focus to improve communication about end-of-life care in the intensive care unit: opportunities for improvement.
      ,
      • McDonagh JR
      • Elliott TB
      • Engelberg RA
      • et al.
      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.
      and a communication facilitator intervention developed by Dr. J. Randall Curtis, MD and his team showing reduced costs, length of stay, and intensity of EOL care.
      • Curtis JR
      • Treece PD
      • Nielsen EL
      • et al.
      Randomized trial of communication facilitators to reduce family distress and intensity of end-of-life care.
      Other ICU based interventions including an ICU led Family Support intervention resulted in improvements in quality of communication and reduction in length of stay.
      • White DB
      • Angus DC
      • Shields A-M
      • et al.
      A Randomized Trial of a Family-Support Intervention in Intensive Care Units.
      Many ICU clinicians express that PC may be within their own knowledge domain
      • Gatta B
      • Turnbull J.
      Providing Palliative Care in the Medical ICU: a qualitative study of MICU Physicians’ Beliefs and Practices.
      and as a result, may be less inclined to consult PC. The dual roles of primary and specialty palliative care in the care of critically ill patients is evident and challenging to quantify and has been an ongoing topic of evaluation for Dr. Curtis and the Cambia Palliative Care Center for Excellence. Unfortunately, the PCQN dataset does not capture primary PC delivery and we agree that documenting this care is a target of future research to better understand the overall delivery of PC in and out of the ICU. The fact that unmet PC needs are identified and that specialty PC consultation impacts symptom and care planning outcomes, suggests that there remain important gaps in PC delivery in the ICU. Triggers for PC consultation could help engage PC teams earlier and more routinely in an ICU stay, though novel trigger development is necessary to improve sensitivity of these tools.
      • Hua MS
      • Ma X
      • Li G
      • et al.
      Derivation of data-driven triggers for palliative care consultation in critically ill patients.
      Patients in the ICU were less likely to have a POLST or AD documented. A POLST or similar document is often used to limit interventions, not to express preferences for full treatment, and thus the lower incidence was expected in the ICU. Of note, Lee et al. found that while having a treatment limiting POLST was associated with a lower rate of admission to the ICU in the last six months of life when compared to patients with full treatment POLSTs, they also highlight that 38% of patients with treatment limiting POLSTs received intensive care that may have been discordant with their POLST.
      • Lee RY
      • Brumback LC
      • Sathitratanacheewin S
      • et al.
      Association of physician orders for life-sustaining treatment with ICU admission among patients hospitalized near the end of life.
      The lack of ACP documents among patients in the ICU may suggest unanticipated serious illness, highlighted by the lower likelihood of cancer being the primary diagnosis. However, acute exacerbations necessitating ICU admission for people with heart and lung disease, among other illnesses, are common and can be anticipated.
      • Desai AS
      • Stevenson LW.
      Rehospitalization for heart failure: Predict or prevent?.
      These findings highlight an opportunity for PC consultation and ACP earlier in the disease trajectory and for a broader range of diagnoses.
      There are limitations in this study. First, given the variables gathered and retrospective nature of the study, there may be unmeasured confounding, including different ICU types and characteristics of referring providers. Additionally, we use registry data collected by clinicians during routine practice, and while this allowed for a large sample reflective of actual practice, to feasibly collect this data, the PCQN is intentionally focused and collection is not always complete for each data element. Separately, there may be biases related to local practices and referral patterns by PC teams and referring providers in each institution and setting.
      • Lee JD
      • Jennerich AL
      • Engelberg RA
      • Downey L
      • Curtis JR
      • Khandelwal N.
      The type of intensive care unit matters: variations in palliative care for critically ill patients with chronic, life-limiting illness.
      The inclusion of a large number of teams from many different institutions and controlling for patient clustering by PC team in our analyses mitigates this issue. Other factors known to influence PC consultations in the ICU, such as provider training, knowledge, and available PC staffing and models, could not be controlled for. The PCQN database does not provide data on prior hospitalizations or link to PC in the outpatient setting, which limits our understanding of previous ACP, changes in goals over time, and resources available to patients prior to admission. Finally, while we would also like to compare patients in the ICU that received PC consultation to patients who did not, the PCQN dataset includes data only on patients seen by PC teams. Nonetheless, these data provide a detailed picture of the current state of PC consultation across a wide range of institutions in the US.
      In summary, our study highlights that patients receiving PC consultation in the ICU are sicker, more likely to die, and less likely to be able to communicate than those on medical surgical units. The majority of PC consults in the ICU are for GOC and ACP support though specialty PC teams also improve pain and dyspnea. PC teams provide longitudinal care and address a broad range of PC needs for ICU patients. Routine involvement of PC for patients with serious life-limiting conditions on admission to the ICU could allow more patients to participate in GOC conversations, earlier implementation of care decisions, and more effective management of symptoms. Rigorous follow up evaluation of these approaches, including patient, family and clinician perspectives on patient centered outcomes and goal-concordant care initiatives,
      • Sanders JJ
      • Curtis JR
      • Tulsky JA.
      Achieving goal-concordant care: a conceptual model and approach to measuring serious illness communication and its impact.
      as well as iteration of the optimal balance of primary and specialty PC interventions in the ICU based on these data could further improve care.
      • Mosenthal AC
      • Weissman DE
      • Curtis JR
      • et al.
      Integrating palliative care in the surgical and trauma intensive care unit: a report from the Improving Palliative Care in the Intensive Care Unit (IPAL-ICU) Project Advisory Board and the Center to Advance Palliative Care.
      ,
      • Aslakson RA
      • Reinke LF
      • Cox C
      • et al.
      Developing a research agenda for integrating palliative care into critical care and pulmonary practice to improve patient and family outcomes.

      Disclosures and Acknowledgments

      We thank Randy Curtis, MD, MPH for his pioneering work integrating palliative and intensive care that makes this work and the careers of the authors possible.
      We would like to thank all of the PCQN teams across the country for their care and data collection. We also woud like to thank the UniHealth Foundation, Archstone Foundation, Stupski Foundation, and California Healthcare Foundation for their support of this work.
      This study was supported by the Stupski Foundation, grant 16-01-06 from the Archstone Foundation, grant 19625 from the California HealthCare Foundation, and grant 2911p from the UniHealth Foundation (Drs Pantilat and O'Riordan).
      This project was supported in part by the National Institutes of Health Grant Number T32CA25107001. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health (Dr. Lin).
      The sponsors had no role in the development of the research or the manuscript.
      The authors have no conflicts of interest.

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