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Lessons Learned from an Embedded Palliative Care Model in the Medical Intensive Care Unit

  • Ankita Mehta
    Correspondence
    Address correspondence to Ankita Mehta, MD; Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1070, New York, NY, USA. (P.O. Box 10029)
    Affiliations
    Brookdale Department of Geriatrics and Palliative Medicine (A.M., P.K., E.C., J.L., A.N., L.Z., L.P.G.), Icahn School of Medicine at Mount Sinai, New York, NY, USA
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  • Priya Krishnasamy
    Affiliations
    Brookdale Department of Geriatrics and Palliative Medicine (A.M., P.K., E.C., J.L., A.N., L.Z., L.P.G.), Icahn School of Medicine at Mount Sinai, New York, NY, USA
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  • Emily Chai
    Affiliations
    Brookdale Department of Geriatrics and Palliative Medicine (A.M., P.K., E.C., J.L., A.N., L.Z., L.P.G.), Icahn School of Medicine at Mount Sinai, New York, NY, USA
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  • Samuel Acquah
    Affiliations
    Division of Pulmonary (S.A.), Critical Care, and Sleep Medicine, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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  • Joshua Lasseigne
    Affiliations
    Brookdale Department of Geriatrics and Palliative Medicine (A.M., P.K., E.C., J.L., A.N., L.Z., L.P.G.), Icahn School of Medicine at Mount Sinai, New York, NY, USA
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  • Amy Newman
    Affiliations
    Brookdale Department of Geriatrics and Palliative Medicine (A.M., P.K., E.C., J.L., A.N., L.Z., L.P.G.), Icahn School of Medicine at Mount Sinai, New York, NY, USA
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  • Li Zeng
    Affiliations
    Brookdale Department of Geriatrics and Palliative Medicine (A.M., P.K., E.C., J.L., A.N., L.Z., L.P.G.), Icahn School of Medicine at Mount Sinai, New York, NY, USA
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  • Laura P. Gelfman
    Affiliations
    Brookdale Department of Geriatrics and Palliative Medicine (A.M., P.K., E.C., J.L., A.N., L.Z., L.P.G.), Icahn School of Medicine at Mount Sinai, New York, NY, USA

    Geriatric Research Education and Clinical Center (L.P.G.), James J. Peters VA Medical Center, Bronx, NY, USA
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      Abstract

      Objective

      To describe a physician (MD) and registered nurse (RN) led palliative care consultation team embedded in the medical intensive care unit (MICU). To compare patterns of palliative care consultation, and rates of goals of care documentation and in-ICU mortality before and after the implementation of the embedded team.

      Context

      By embedding MD/RN palliative care team in the MICU, more critically ill patients with unmet palliative care needs could receive an earlier palliative care consultation.

      Methods

      In a retrospective cohort study of patients admitted to the MICU who received a palliative care consultation, we compared sociodemographic and clinical characteristics of patients who received a referral-based consultation (01/01/2019-06/30/2019) and those who received an embedded MD/RN consult (09/01/2019-02/28/2020). Using the electronic health record data, we compared palliative care consultation characteristics, rates of documentation of medical decision-maker and goals of care, and percentage of in-ICU mortality between the referral group and the embedded group.

      Results

      In a six-month period, 169 MICU patients received an embedded consultation, as compared to 52 MICU patients who received a referral-based consultation. As compared to the referral-based period, those patients who received an embedded consult were seen significantly earlier in hospitalization (median number of days from hospital admission to consult: 10 days [pre] vs. 3 days [embedded], P<0.001), more likely to have documentation of medical decision-makers (40% [pre] vs. 66% [embedded], P=0.002) and goals of care (37% [pre] vs. 71% [embedded], P<0.001) and less likely to die in the hospital (75% [pre] vs. 44% [embedded], P<0.001).

      Conclusions

      After embedding a palliative care MD/RN team into the MICU, patients received earlier palliative care consultation, were more likely to have medical decision-maker and goals of care documented, and less likely to die in the hospital. Future work will examine how to adapt this model to other ICUs to improve palliative care access for critically ill patients broadly.

      Key Words

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      References

        • Angus DC
        • Barnato AE
        • Linde-Zwirble WT
        • et al.
        Use of intensive care at the end of life in the United States: an epidemiologic study.
        Crit Care Med. Mar 2004; 32: 638-643https://doi.org/10.1097/01.ccm.0000114816.62331.08
        • White Douglas B.
        • Luce John M.
        Palliative care in the intensive care unit: barriers, advances, and unmet needs.
        Crit Care Clin. 2004; 20.3: 329-343
        • Nelson M.J.E.
        • Azoulay P.E.
        • Curtis J.R.
        • et al.
        Palliative care in the ICU.
        J Palliat Med. 2012; 15: 168-174
        • Dzeng E.
        • Bein T.
        • Curtis J.R.
        The role of policy and law in shaping the ethics and quality of end-of-life care in intensive care.
        Intensive Care Med. 2022; 48: 352-354
        • Puntillo KA
        • Arai S
        • Cohen NH
        • et al.
        Symptoms experienced by intensive care unit patients at high risk of dying.
        Crit Care Med. Nov 2010; 38: 2155-2160https://doi.org/10.1097/CCM.0b013e3181f267ee
        • Nelson JE
        • Meier DE
        • Litke A
        • et al.
        The symptom burden of chronic critical illness.
        Crit Care Med. Jul 2004; 32: 1527-1534https://doi.org/10.1097/01.ccm.0000129485.08835.5a
        • Aslakson RA
        • Curtis JR
        • Nelson JE.
        The changing role of palliative care in the ICU.
        Crit Care Med. Nov 2014; 42: 2418-2428https://doi.org/10.1097/ccm.0000000000000573
        • Truog RD
        • Campbell ML
        • Curtis JR
        • et al.
        Recommendations for end-of-life care in the intensive care unit: a consensus statement by the American College [corrected] of Critical Care Medicine.
        Crit Care Med. Mar 2008; 36: 953-963https://doi.org/10.1097/ccm.0b013e3181659096
        • Sullivan DR
        • Iyer AS
        • Enguidanos S
        • et al.
        Palliative Care Early in the Care Continuum among patients with serious respiratory illness: an official ATS/AAHPM/HPNA/SWHPN policy statement.
        Am J Respirat Crit Care Med. 2022; 206: e44-e69
        • Aslakson R
        • Cheng J
        • Vollenweider D
        Evidence-based palliative care in the intensive care unit: a systematic review of interventions.
        J Palliat Med. Feb 2014; 17: 219-235https://doi.org/10.1089/jpm.2013.0409
        • Einstein DJ
        • DeSanto-Madeya S
        • Gregas M
        • et al.
        Improving end-of-life care: palliative care embedded in an oncology clinic specializing in targeted and immune-based therapies.
        J Oncol Pract. 2017; 13: e729-e737https://doi.org/10.1200/jop.2016.020396
        • Post KE
        • Heuer LB
        • Kamal AH
        • et al.
        Study protocol for a randomised trial evaluating the non-inferiority of stepped palliative care versus early integrated palliative care for patients with advanced lung cancer.
        BMJ open. 2022; 12e057591
        • Temel J.S.
        • Greer J.A.
        • El-Jawahri A.
        • et al.
        Effects of early integrated palliative care in patients with lung and GI cancer: a randomized clinical trial.
        J Clinical Oncol. 2017; 35.8: 834
        • O'Mahony S
        • McHenry J
        • Blank AE
        • et al.
        Preliminary report of the integration of a palliative care team into an intensive care unit.
        Palliat Med. 2010; 24: 154-165
        • O'Mahony S
        • Johnson TJ
        • Amer S
        • et al.
        Integration of palliative care advanced practice nurses into intensive care unit teams.
        Am J Hosp Palliat Care. May 2017; 34: 330-334https://doi.org/10.1177/1049909115627425
        • Mun E
        • Umbarger L
        • Ceria-Ulep C
        • Nakatsuka C.
        Palliative care processes embedded in the ICU workflow may reserve palliative care teams for refractory cases.
        Am J Hosp Palliat Care. Jan 2018; 35: 60-65https://doi.org/10.1177/1049909116684821
        • Jacobson M
        • May P
        • Morrison RS
        Improving care of people with serious medical illness—an economic research agenda for palliative care.
        JAMA Health Forum. 2022; 3 (No. 1. American Medical Association. e214464)
        • Swidler RN.
        The family healthcare decisions act: a summary of key provisions.
        NYSBA Health Law J. 2010; 15: 32-35
        • Gelfman LP
        • Morrison RS
        • Moreno J
        • Chai E
        • et al.
        Palliative care as essential to a hospital system’s pandemic preparedness planning: how to get ready for the next wave.
        J Palliat Med. 2021; 24: 656-658
        • Kelley AS
        • Ferreira KB
        • Bollens-Lund E
        • et al.
        Identifying older adults with serious illness: transitioning from ICD-9 to ICD-10.
        J Pain Symptom Manage. 2019; 57 (Epub 2019 Mar 12): 1137-1142https://doi.org/10.1016/j.jpainsymman.2019.03.006
        • Kelley AS
        • Ferreira Katelyn B
        • Bollens-Lund Evan
        • et al.
        Identifying older adults with serious illness: transitioning from ICD-9 to ICD-10.
        J Pain Symptom Manage. 2019; 57: 1137-1142
        • Péus D
        • Newcomb N
        • Hofer S
        Appraisal of the Karnofsky Performance Status and proposal of a simple algorithmic system for its evaluation.
        BMC Med Inform Decis Mak. 2013; 13.1: 1-7
        • Anne E
        • Claudia S
        • Robert Harris D
        • et al.
        Comorbidity measures for use with administrative data.
        Med Care. 1998; : 8-27
        • February 11, 2020
        Update on hospital mortality measures and their implications.
        Cent Adv Palliat Care. 2020; (Available at:)
        • Farrell TW
        • Ferrante LE
        • Brown T
        • et al.
        AGS position statement: resource allocation strategies and age-related considerations in the COVID-19 era and beyond.
        J Am Geriatrics Soc. 2020; 68: 1136-1142
      1. Parker, J. (2021, August 13). Hospices feel strain of GIP audits as inpatient care days dwindle. Retrieved November 28, 2022, fromhttps://hospicenews.com/2021/08/13/hospices-feel-strain-of-gip-audits-as-inpatient-care-days-dwindle/.