Potential Influence of Advance Care Planning and Palliative Care Consultation on ICU Costs for Patients With Chronic and Serious Illness

Refinement of an Emergency Department-Based, Advance Care Planning Intervention for Patients With Cognitive Impairment and Their Caregivers

BACKGROUND AND OBJECTIVES

Advance care planning (ACP) conversations are important to provide goal-concordant care (i.e., the care that matches the patient's previously stated goals) near end of life. While 31% of older adults presenting to the emergency department (ED) have dementia, only 39% have previously had ACP conversations. We refined and piloted an ED-based, motivational interview designed to stimulate ACP conversations (ED GOAL) for patients living with cognitive impairment and their caregivers.

RESEARCH DESIGN AND METHODS

We systematically refined ED GOAL and then conducted an acceptability study in an urban, academic medical center. We prospectively enrolled adults aged 50+ with cognitive impairment and their caregivers. Trained clinicians conducted the intervention. We measured acceptability after the intervention and participants' ACP engagement at baseline and 1-month follow-up.

RESULTS

Specific statements to address both the patient and caregiver were added to the ED GOAL script. Of 60 eligible patient/caregiver dyads approached, 26 participated, and 20 (77%) completed follow-up assessments. Patient mean age was 79 years (SD 8.5); 65% were female, 92.3% were White, 96.2% were non-Hispanic, and 69% had moderate dementia. Most patients/caregivers reported feeling completely heard and understood by the study clinician about their future medical care preferences (58%, 15/26). They also reported that the study clinician was very respectful (96%, 25/26) when eliciting those preferences.

DISCUSSION AND IMPLICATIONS

Patients living with cognitive impairment and their caregivers found our refined ED GOAL acceptable and respectful. Future studies need to examine the effect of ED GOAL on ACP engagement among these dyads in the ED.

The differences in code status conversation approaches reported by emergency medicine and palliative care clinicians: A mixed-method study

BACKGROUND

During acute health deterioration, emergency medicine and palliative care clinicians routinely discuss code status (e.g., shared decision making about mechanical ventilation) with seriously ill patients. Little is known about their approaches. We sought to elucidate how code status conversations are conducted by emergency medicine and palliative care clinicians and why their approaches are different.

METHODS

We conducted a sequential-explanatory, mixed-method study in three large academic medical centers in the Northeastern United States. Attending physicians and advanced practice providers working in emergency medicine and palliative care were eligible. Among the survey respondents, we purposefully sampled the participants for follow-up interviews. We collected clinicians' self-reported approaches in code status conversations and their rationales. A survey with a 5-point Likert scale ("very unlikely" to "very likely") was used to assess the likelihood of asking about medical procedures (procedure based) and patients' values (value based) during code status conversations, followed by semistructured interviews.

RESULTS

Among 272 clinicians approached, 206 completed the survey (a 76% response rate). The reported approaches differed greatly (e.g., 91% of palliative care clinicians reported asking about a patient's acceptable quality of life compared to 59% of emergency medicine clinicians). Of the 206 respondents, 118 (57%) agreed to subsequent interviews; our final number of semistructured interviews included seven emergency medicine clinicians and nine palliative care clinicians. The palliative care clinicians stated that the value-based questions offer insight into patients' goals, which is necessary for formulating a recommendation. In contrast, emergency medicine clinicians stated that while value-based questions are useful, they are vague and necessitate extended discussions, which are inappropriate during emergencies.

CONCLUSIONS

Emergency medicine and palliative care clinicians reported conducting code status conversations differently. The rationales may be shaped by their clinical practices and experiences.

[Precautionary planning at the end of life from the perspective of intensive care medicine]

In recent years, the number of intensive care treatments has increased significantly. About every fourth patient who dies in hospital receives intensive care. Structured prevention planning is important in order to implement the patient's wishes in situations of serious illness in which patients cannot express their wishes themselves. However, the implementation in practice can be problematic since intensive care situations are complex and rarely correspond to the concrete pre-arranged situations. Communication of the prognosis and the prognostic uncertainty is therefore crucial in order to determine the presumed will of the patient, especially in the context of the process of weighing up the benefits and burdens of intensive care therapies. Hospital treatment can be the reason for targeted preventive planning and avoid unnecessary intensive care treatment during the same stay. Documentation templates can help to record the results of preventive care planning clearly and comprehensibly in the medical file.

Benefits of Early Utilization of Palliative Care Consultation in Trauma Patients

OBJECTIVES

To determine the effects of palliative care consultation if performed within 72 hours of admission on length of stay (LOS), mortality, and invasive procedures.

DESIGN

Retrospective observational study.

SETTING

Single-center level 1 trauma center.

PATIENTS

Trauma patients, admitted to ICU with palliative care consultation.

INTERVENTION

None.

MEASUREMENTS AND MAIN RESULTS

The ICU LOS was decreased in the early palliative care (EPC) group compared with the late palliative care (LPC) group, by 6 days versus 12 days, respectively. Similarly, the hospital LOS was also shorter in the EPC group by 8 days versus 17 days in the LPC group. In addition, the EPC group had lower rates of tracheostomy (4% vs 14%) and percutaneous gastrostomy tubes (4% vs 15%) compared with the LPC group. There was no difference in mortality or discharge disposition between patients in the EPC versus LPC groups. It is noteworthy that the patients who received EPC were slightly older, but there were no other significant differences in demographics.

CONCLUSIONS

EPC is associated with fewer procedures and a shorter amount of time spent in the hospital, with no immediate effect on mortality. These outcomes are consistent with studies that show patients' preferences toward the end of life, which typically involve less time in the hospital and fewer invasive procedures.

Barriers to Effective Communication about Advance Care Planning and Palliative Care: A Qualitative Study

Purpose

The purpose of this study was to identify barriers to effective conversations about advance care planning (ACP) and palliative care reported by health care and community-based service providers in Massachusetts, USA.

Methods

This qualitative research analyzed open-ended responses to two survey questions, inquiring about perceived barriers to having conversations about ACP and palliative care with patients and consumers. Data were collected between November 2017 and June 2019 from nine organizations in Massachusetts, including health care provider organizations, health insurers, community-based organizations, and a nursing education institution. Two researchers reviewed and coded the responses and identified common themes inductively.

Results

Across 142 responses, primary barriers to ACP included hesitation and lack of understanding and knowledge, discomfort and resistance among service providers, lack of staff knowledge, difficulties with follow-up, and differences in ACP policies across regions. Common barriers to palliative care were misconceptions about palliative care and lack of knowledge, service providers' lack of preparedness, and limited policy support and availability. Challenges relevant to both ACP and palliative care were fear and discomfort around serious illness discussions, lack of knowledge and awareness, discussions that occur too late, and cultural and language barriers.

Conclusion

Health care practitioners and community-based professionals reported consumer-, service provider-, and system-level barriers to facilitating conversations about ACP and palliative care with patients experiencing serious illness. There is a need for more tools and support to strengthen service providers' ACP and palliative care competencies and to promote a structured approach to health care planning conversations.

An emergency department nurse led intervention to facilitate serious illness conversations among seriously ill older adults: A feasibility study

BACKGROUND

Serious illness conversations may lead to care consistent with patients' goals near the end of life. The emergency department could serve as an important time and location for these conversations.

AIM

To determine the feasibility of an emergency department-based, brief motivational interview to stimulate serious illness conversations among seriously ill older adults by trained nurses.

DESIGN

A pre-/post-intervention study.

SETTINGS/PARTICIPANTS

In an urban, tertiary care, academic medical center and a community hospital from January 2021 to January 2022, we prospectively enrolled adults ⩾50 years of age with serious illness and an expected prognosis <1 year. We measured feasibility outcomes using the standardized framework for feasibility studies. In addition, we also collected the validated 4-item Advance Care Planning Engagement Survey (a 5-point Likert scale) at baseline and 4-week follow-up and reviewing the electronic medical record for documentation related to newly completed serious illness conversations.

RESULTS

Among 116 eligible patients who were willing and able to participate, 76 enrolled (65% recruitment rate), and 68 completed the follow-up (91% retention rate). Mean patient age was 64.4 years (SD 8.4), 49% were female, and 58% had metastatic cancer. In all, 16 nurses conducted the intervention, and all participants completed the intervention with a median duration of 27 min. Self-reported Advance Care Planning Engagement increased from 2.78 pre to 3.31 post intervention (readiness to "talk to doctors about end-of-life wishes," p < 0.008). Documentation of health care proxy forms increased (62-70%) as did Medical Order for Life Sustaining Treatment (1-11%) during the 6 months after the emergency department visit.

CONCLUSION

A novel, emergency department-based, nurse-led brief motivational interview to stimulate serious illness conversations is feasible and may improve advance care planning engagement and documentation in seriously ill older adults.

Emergency department-based, nurse-initiated, serious illness conversation intervention for older adults: a protocol for a randomized controlled trial

BACKGROUND

Visits to the emergency department (ED) are inflection points in patients' illness trajectories and are an underutilized setting to engage seriously ill patients in conversations about their goals of care. We developed an intervention (ED GOAL) that primes seriously ill patients to discuss their goals of care with their outpatient clinicians after leaving the ED. The aims of this study are (i) to test the impact of ED GOAL administered by trained nurses on self-reported, advance care planning (ACP) engagement after leaving the ED and (ii) to evaluate whether ED GOAL increases self-reported completion of serious illness conversation and other patient-centered outcomes.

METHODS

This is a two-armed, parallel-design, single-blinded, randomized controlled trial of 120 seriously ill older adults in two academic and one community EDs in Boston, MA. Participants are English-speaking adults 50 years and older with a serious life-limiting illness with a recent ED visit. Patients with a valid MOLST (medical order for life-sustaining treatment) form or other documented goals of care within the last 3 months are excluded. We enroll the caregivers of patients with cognitive impairment. Patients are assigned to the intervention or control group using block randomization. A blinded research team member will perform outcome assessments. We will assess (i) changes in ACP engagement within 6 months and (ii) qualitative assessments of the effect of ED GOAL.

DISCUSSION

In seriously ill older adults arriving in the ED, this randomized controlled trial will test the effects of ED GOAL on patients' self-reported ACP engagement, EMR documentation of new serious illness conversations, and improving patient-centered outcomes.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT05209880.

Anticipating need for intensive care in the healthcare trajectory of patients with chronic disease: A qualitative study among specialists

Introduction

We investigated the reflections and perceptions of non-ICU physicians about anticipating the need for ICU admission in case of acute decompensation in patients with chronic disease.

Methods

We performed a qualitative multicentre study using semi-structured interviews among non-ICU specialist physicians. The interview guide, developed in advance, focused on 3 questions: (1) What is your perception of ICU care? (2) How do you think advance directives can be integrated into the patient’s healthcare goals? and (3) How can the possibility of a need for ICU admission be integrated into the patient’s healthcare goals? Interviews were recorded, transcribed and analysed by thematic analysis. Interviews were performed until theoretical saturation was reached.

Results

In total, 16 physicians (8 women, 8 men) were interviewed. The main themes related to intensive care being viewed as a distinct specialty, dispensing very technical care, and with major human and ethical challenges, especially regarding end-of-life issues. The participants also mentioned the difficulty in anticipating an acute decompensation, and the choices that might have to be made in such situations. The timing of discussions about potential decompensation of the patient, the medical culture and the presence of advance directives are issues that arise when attempting to anticipate the question of ICU admission in the patient’s healthcare goals or wishes.

Conclusion

This study describes the perceptions that physicians treating patients with chronic disease have of intensive care, notably that it is a distinct and technical specialty that presents challenging medical and ethical situations. Our study also opens perspectives for actions that could promote a pluridisciplinary approach to anticipating acute decompensation and ICU requirements in patients with chronic disease.

Improving Outcomes Measurement in Palliative Care: The Lasting Impact of Randy Curtis and his Collaborators

Palliative care research is deeply challenging for many reasons, not the least of which is the conceptual and operational difficulty of measuring outcomes within a seriously ill population such as critically ill patients and their family members. This manuscript describes how Randy Curtis and his network of collaborators successfully confronted some of the most vexing outcomes measurement problems in the field, and by so doing, have enhanced clinical care and research alike. Beginning with a discussion of the clinical challenges of measurement in palliative care, we then discuss a selection of the novel measures developed by Randy and his collaborators and conclude with a look toward the future evolution of these concepts. Randy and his foundational work, including both successes as well as the occasional near miss, have enriched and advanced the field as well as (immeasurably) impacted the work of so many others-including this manuscript's authors.

Early Palliative Care Consults Reduce Patients' Length of Stay and Overall Hospital Costs

Background: Palliative care improves health outcomes and satisfaction and supports decision-making for patients and families during challenging times in their lives. Earlier referral for consults has demonstrated increased costs savings.Hypothesis: Education proposing physicians order a palliative care consult within 3 days of patient hospital admission will decrease patient length of stay (LOS) and overall costs as well as expedite the transition to next level of care.Design/Method: A descriptive retrospective cohort study was completed using de-identified data originally captured for a system-wide initiative at a large acute care hospital in Illinois. Hospitalists were selected as the pilot group and received education encouraging physicians to order palliative care consults within 3 days of patient admission. Non-hospitalists (control group) did not receive the education. All results were compared to a 3-month baseline period.Results: A total of 711 patients were included in this study (367 baseline, 138 pilot, 206 controls). The baseline pre-consult LOS of 4.8 days was reduced to 3.7 days in the pilot group, representing a > 1 day decrease in the timing of palliative consult. The pilot demonstrated a direct cost savings of 26% over the 3-months pilot period. Additionally, a 2-day reduction in overall LOS was demonstrated in the pilot group compared to both the baseline and control groups.Conclusions: This pilot demonstrated an ability to change the timing of new palliative care consults, resulting in direct cost savings and LOS reduction. These results demonstrated the need for a larger study to confirm these findings.

Transitioning end-of-life care from hospital to the community: case report

Palliative/end-of-life care is an integral part of the district nursing service. There is increasing demand for palliative care to be delivered in the community setting. Therefore, there is a need for excellent collaboration between staff in primary and secondary care settings to achieve optimum care for patients. This article critically analyses the care delivered for a palliative patient in the hospital setting and his subsequent transition to the community setting. The importance of effective communication, holistic assessment in palliative care, advance care planning, organisational structures and the socio-cultural aspects of caring for patients at the end of life are discussed. Additionally, the article highlights the impact of substandard assessment and communication and the consequent effect on patients and families.

Efficacy of an Online Curriculum for Perioperative Goals of Care and Code Status Discussions: A Randomized Controlled Trial

BACKGROUND

Preoperative goals of care (GOC) and code status (CS) discussions are important in achieving an in-depth understanding of the patient's care goals in the setting of a serious illness, enabling the clinician to ensure patient autonomy and shared decision making. Past studies have shown that anesthesiologists are not formally trained in leading these discussions and may lack the necessary skill set. We created an innovative online video curriculum designed to teach these skills. This curriculum was compared to a traditional method of learning from reading the medical literature.

METHODS

In this bi-institutional randomized controlled trial at 2 major academic medical centers, 60 anesthesiology trainees were randomized to receive the educational content in 1 of 2 formats: (1) the novel video curriculum (video group) or (2) journal articles (reading group). Thirty residents were assigned to the experimental video curriculum group, and 30 were assigned to the reading group. The content incorporated into the 2 formats focused on general preoperative evaluation of patients and communication strategies pertaining to GOC and CS discussions. Residents in both groups underwent a pre- and postintervention objective structured clinical examination (OSCE) with standardized patients. Both OSCEs were scored using the same 24-point rubric. Score changes between the 2 OSCEs were examined using linear regression, and interrater reliability was assessed using weighted Cohen's kappa.

RESULTS

Residents receiving the video curriculum performed significantly better overall on the OSCE encounter, with a mean score of 4.19 compared to 3.79 in the reading group. The video curriculum group also demonstrated statistically significant increased scores on 8 of 24 rubric categories when compared to the reading group.

CONCLUSIONS

Our novel video curriculum led to significant increases in resident performance during simulated GOC discussions and modest increases during CS discussions. Further development and refinement of this curriculum are warranted.

Individual, interpersonal, and health care factors associated with informal and formal advance care planning in a nationally-representative sample of midlife and older adults

OBJECTIVE

Assess correlates of advance care planning (ACP) among midlife and older adults in the United States, with attention to informal planning (e.g., conversations) and formal planning (e.g., legal documentation such as a living will).

METHODS

Data were collected from a nationally-representative U.S. sample of adults ages 55-74.

RESULTS

Informal ACP was positively associated with greater confidence, history of life-threatening illness, designation as health care decision maker for someone else, knowing at least one negative end-of-life (EOL) story in one's personal network, a desire to ease surrogates' decision making, and having a health care provider who had broached ACP. Formal ACP was positively associated with greater confidence, designation as a health care decision maker, having a provider who had broached ACP, and primarily receiving medical care from a doctor's office, and marginally negatively associated with health worry.

CONCLUSIONS

There are relevant correlates of advance care planning at the individual, interpersonal, and health care levels, with implications for increasing uptake of ACP.

PRACTICE IMPLICATIONS

A desire to mitigate proxies' decision-making burden was a significant motivator for ACP conversations. Awareness of negative EOL experiences may also motivate these conversations. Health care providers have a powerful role in formal and informal ACP uptake.

What Surrogates Understand (and Don't Understand) About Patients' Wishes After Engaging Advance Care Planning: A Qualitative Analysis

BACKGROUND

The goal of advance care planning (ACP) is to improve end-of-life decision-making for patients and their spokespersons, but multiple studies have failed to show substantial or consistent benefit from ACP. Understanding how and why ACP under-performs in the setting of complex medical decision-making is key to optimizing current, or designing new, ACP interventions.

AIM

To explore how ACP did or did not contribute to a spokespersons' understanding of patient wishes after engaging in ACP.

DESIGN

Thematic analysis of 200 purposively sampled interviews from a randomized control trial of an ACP decision aid.

SETTING/PARTICIPANTS

200 dyads consisting of patients 18 years or older with advanced serious illness and their spokesperson at 2 tertiary care centers in Hershey, PA and Boston, MA. Participants were interviewed 1 month after completing ACP.

RESULTS

ACP helped participants: 1) express clear end-of-life wishes, 2) clarify values, and 3) recognize challenges associated with applying those wishes in complex situations. Shortcomings of ACP included 1) unknown prognostic information or quality-of-life outcomes to inform decision-making, 2) skepticism about patients' wishes, and 3) complicated emotions impacting end-of-life discussions.

CONCLUSIONS

Helping patients and their spokespersons better anticipate decision-making in the face of prognostic and informational uncertainty as well as the emotional complexities of making medical decisions may improve the efficacy of ACP interventions.

The Cost-Effectiveness of Palliative Care: Insights from the PAL-HF Trial

BACKGROUND

In a randomized control trial, Palliative Care in Heart Failure (PAL-HF) improved heart failure-related quality of life, though cost-effectiveness remains unknown. The aim of this study was to evaluate the cost-effectiveness of the PAL-HF trial, which provided outpatient palliative care to patients with advanced heart failure.

METHODS AND RESULTS

Outcomes for usual care and PAL-HF strategies were compared using a Markov cohort model over 36 months from a payer perspective. The model parameters were informed by PAL-HF trial data and supplemented with meta-analyses and Medicare administrative data. Outcomes included hospitalization, place of death, Medicare expenditures, quality-adjusted life years (QALYs), and incremental cost-effectiveness ratios. Simulated mortality rates were the same for PAL-HF and usual care cohorts, at 89.7% at 36 months. In the base case analysis, the PAL-HF intervention resulted in an incremental gain of 0.03 QALYs and an incremental cost of $964 per patient for an incremental cost-effectiveness ratio of $29,041 per QALY. In 1-way sensitivity analyses, an intervention cost of up to $140 per month is cost effective at $50,000 per QALY. Of 1000 simulations, the PC intervention had a 66.1% probability of being cost effective at a $50,000 willingness-to-pay threshold assuming no decrease in hospitalization. In a scenario analysis, PAL-HF decreased payer spending through reductions in noncardiovascular hospitalizations.

CONCLUSIONS

These results from this single-center trial are encouraging that palliative care for advanced heart failure is an economically attractive intervention. Confirmation of these findings in larger multicenter trials will be an important part of developing the evidence to support more widespread implementation of the PAL-HF palliative care intervention.

Nurses' Perceptions of Facilitating Advance Care Planning Conversations in the Emergency Department

Background: Nurses are well positioned to initiate advance care planning (ACP) conversations because of their unique strength in communication and central patient-facing role in the interdisciplinary team. Nurse-led ACP conversations have demonstrated promising results in settings outside of the emergency department (ED). Understanding ED nurses' perspectives regarding ACP conversations is needed before implementing similar practices in the ED.

Objective: To explore ED nurses' perception of facilitating ACP conversations.

Design: We conducted a cross-sectional survey to assess ED nurses' perceptions of facilitating ACP conversations in the ED.

Setting: ED nurses at one academic hospital and one community hospital located within the northeastern region of the United States.

Results: Seventy-seven (53.1%) out of 145 eligible ED nurses completed the survey. All participants perceived ACP conversations in the ED as at least somewhat important. Forty (51.9%) felt somewhat comfortable in facilitating these conversations. The majority of participants (77.9%) agreed that a specially trained nurse consultation model might be helpful in the ED. We found a correlation between total clinical experience and interest in facilitating ACP conversations in the ED (p = 0.045).

Conclusion: ED nurses are well positioned to help patients clarify their goals-of-care and end-of-life care preferences. They perceived ACP conversations to be important and felt comfortable to facilitate them in the ED. Additional studies are needed to empirically test its implementation.

Use of an Online Palliative Care Clinical Curriculum to Train U.S. Hospital Staff: 2015-2019

Background: Most clinicians in the United States do not receive pre-professional education in pain and symptom management, communication skills, and caregiver support. The use of these skills by clinicians improves the quality of care for persons living with serious illness and enables the specialty-trained palliative care workforce to focus on patients whose needs are most complex. Objective: To review current trends in hospital use of the Center to Advance Palliative Care (CAPC) online clinical training curriculum. Description: Launched in 2015, CAPC clinical curriculum educates clinicians in the knowledge and skills necessary to improve care for patients with serious illness. CAPC currently offers 43 clinical courses and 4 Designations in recognition of successful completion of training by topic. Results: From January 15, 2015, to August 31, 2019, 26,535 clinicians working in hospitals completed 172,684 clinical courses. Registered nurses represented half of learners, and advanced practice providers were most likely to seek Designation. Physicians made up 22% of all learners; 85% of physician learners came from specialties beyond palliative care. Two of every five U.S. hospitals with more than 300 beds had at least one learner. In post-course evaluations, 84% reported that they will make practice changes as a result, and 70% reported that the content was new. Conclusions: The CAPC clinical curriculum is a widely used and valued method for education in clinical skills specific to the care of people living with serious illness. Findings suggest that an increasing number of hospital leaders recognize the importance of these skills in caring for patients with serious illness and support the necessary training.

Case Discussions in Advanced Care Planning

BACKGROUND

Advanced care planning (ACP) provides an opportunity for individuals to explore and document their values concerning medical care decisions prior to an acute event. This manuscript explores the value of ACP and compares and contrasts 2 ACP models currently in practice.

METHODS

This hypothetical case describes an elderly, frail patient with end-stage chronic obstructive pulmonary disease who is also a high user of health care resources. A new palliative care-led outpatient ACP clinic model is described using this example.

RESULTS

Using the ACP clinic model in this case reveals how different a patient's end of life experience may be when proper, proactive planning measures are in place. With proper education and discussion around this patient and family's wishes pertaining to the end of his life, this man was able to change his plan of care from aggressive resuscitation treatment in hospital to a peaceful palliative experience at home.

CONCLUSIONS

In this case description, the valuable role of ACP in preserving quality of life for patients, increasing satisfaction with care, and decreasing distress among family members during a medical event is demonstrated.

Patient Risk Factor Profiles Associated With the Timing of Goals-of-Care Consultation Before Death: A Classification and Regression Tree Analysis

Background:

Early palliative care consultation (“PCC”) to discuss goals-of-care benefits seriously ill patients. Risk factor profiles associated with the timing of conversations in hospitals, where late conversations most likely occur, are needed.

Objective:

To identify risk factor patient profiles associated with PCC timing before death.

Methods:

Secondary analysis of an observational study was conducted at an urban, academic medical center. Patients aged 18 years and older admitted to the medical center, who had PCC, and died July 1, 2014 to October 31, 2016, were included. Patients admitted for childbirth or rehabilitationand patients whose date of death was unknown were excluded. Classification and Regression Tree modeling was employed using demographic and clinical variables.

Results:

Of 1141 patients, 54% had PCC “close to death” (0-14 days before death); 26% had PCC 15 to 60 days before death; 21% had PCC >60 days before death (median 13 days before death). Variables associated with receiving PCC close to death included being Hispanic or “Other” race/ethnicity intensive care patients with extreme illness severity (85%), with age <46 or >75 increasing this probability (98%). Intensive care patients with extreme illness severity were also likely to receive PCC close to death (64%) as were 50% of intensive care patients with less than extreme illness severity.

Conclusions:

A majority of patients received PCC close to death. A complex set of variable interactions were associated with PCC timing. A systematic process for engaging patients with PCC earlier in the care continuum, and in intensive care regardless of illness severity, is needed.

The Critical Care Nurse Communicator Program: An Integrated Primary Palliative Care Intervention

Twenty percent of Americans die in an intensive care unit (ICU), often incapacitated or requiring assisted decision making. Surrogates are often required to make urgent, complex, high-stakes decisions. Communication among patients, families, and clinicians is often delayed and inefficient with frequent missed opportunities to support the emotional and psychological needs of surrogates, particularly at the end of life. The Critical Care Nurse Communicator program is a nurse-led, primary palliative care intervention designed to improve the quality and consistency of communication in the ICU and address the informational, psychological, and emotional needs of surrogate decision-makers through the shared decision-making process.

A Review of the Literature on Native Hawaiian End-of-Life Care: Implications for Research and Practice

The need for cultural understanding is particularly important in end-of-life (EOL) care planning as the use of EOL care in minority populations is disproportionately lower than those who identify as Caucasian. Data regarding the use of EOL care services by Native Hawaiians in Hawai'i and the United States is limited but expected to be similarly disproportionate as other minorities. In a population with a lower life expectancy and higher prevalence of deaths related to chronic diseases such as cardiovascular disease, diabetes, and obesity, as compared to the state of Hawai'i as a whole, our objective was to review the current literature to understand the usage and perceptions of EOL care planning in the Native Hawaiian population. We searched ten electronic databases and after additional screening, seven articles were relevant to our research purpose. We concluded that limited data exists regarding EOL care use specifically in Native Hawaiians. The available literature highlighted the importance of understanding family and religion influences, educating staff on culturally appropriate EOL care communication, and the need for more research on the topic. The paucity of data in EOL care and decision-making in Native Hawaiians is concerning and it is evident this topic needs more study. From national statistics it looks as though this is another health disparate area that needs to be addressed and is especially relevant when considering the rapid increase in seniors in our population.

Estimating the Impact of Words Used by Physicians in Advance Care Planning Discussions: The "Do You Want Everything Done?" Effect

Supplemental Digital Content is available in the text.

To estimate the probability of a substitute decision maker choosing to withdraw life-sustaining therapy after hearing an affirmative patient response to the phrase “Do you want everything done?”

Association of Emergency Clinicians' Assessment of Mortality Risk With Actual 1-Month Mortality Among Older Adults Admitted to the Hospital

IMPORTANCE

The accuracy of mortality assessment by emergency clinicians is unknown and may affect subsequent medical decision-making.

OBJECTIVE

To determine the association of the question, "Would you be surprised if your patient died in the next one month?" (known as the surprise question) asked of emergency clinicians with actual 1-month mortality among undifferentiated older adults who visited the emergency department (ED).

DESIGN, SETTING, AND PARTICIPANTS

This prospective cohort study at a single academic medical center in Portland, Maine, included consecutive patients 65 years or older who received care in the ED and were subsequently admitted to the hospital from January 1, 2014, to December 31, 2015. Data analyses were conducted from January 2018 to March 2019.

EXPOSURES

Treating emergency clinicians were required to answer the surprise question, "Would you be surprised if your patient died in the next one month?" in the electronic medical record when placing a bed request for all patients who were being admitted to the hospital.

MAIN OUTCOMES AND MEASURES

The primary outcome was mortality at 1 month, assessed from the National Death Index. The secondary outcomes included accuracies of responses by both emergency clinicians and admitting internal medicine clinicians to the surprise question in identifying older patients with high 6-month and 12-month mortality.

RESULTS

The full cohort included 10 737 older adults (mean [SD] age, 75.9 [8.8] years; 5532 [52%] women; 10 157 [94.6%] white) in 16 223 visits treated in the ED and admitted to the hospital. There were 5132 patients (31.6%) with a Charlson Comorbidity Index score of 2 or more. Mortality rates were 8.3% at 1 month, 17.2% at 6 months, and 22.5% at 12 months. Emergency clinicians stated that they would not be surprised if the patient died in the next month for 2104 patients (19.6%). In multivariable analysis controlling for age, sex, race, admission diagnosis, and comorbid conditions, the odds of death at 1 month were higher in patients for whom clinicians answered that they would not be surprised if the patient died in the next 1 month compared with patients for whom clinicians answered that they would be surprised if the patient died in the next 1 month (odds ratio, 2.4 [95% CI, 2.2-2.7]; P < .001). However, the diagnostic test characteristics of the surprise question were poor (sensitivity, 20%; specificity, 93%; positive predictive value, 43%; negative predictive value, 82%; accuracy, 78%; area under the receiver operating curve of the multivariable model, 0.73 [95% CI, 0.72-0.74; P < .001]).

CONCLUSIONS AND RELEVANCE

This study found that asking the surprise question of emergency clinicians may be a valuable tool to identify older patients in the ED with a high risk of 1-month mortality. The effect of implementing the surprise question to improve population-level health care for older adults in the ED who are seriously ill remains to be seen.

Goals-of-Care Conversations for Older Adults With Serious Illness in the Emergency Department: Challenges and Opportunities

During the last 6 months of life, 75% of older adults with preexisting serious illness, such as advanced heart failure, lung disease, and cancer, visit the emergency department (ED). ED visits often mark an inflection point in these patients' illness trajectories, signaling a more rapid rate of decline. Although most patients are there seeking care for acute issues, many of them have priorities other than to simply live as long as possible; yet without discussion of preferences for treatment, they are at risk of receiving care not aligned with their goals. An ED visit may offer a unique "teachable moment" to empower patients to consider their ability to influence future medical care decisions. However, the constraints of the ED setting pose specific challenges, and little research exists to guide clinicians treating patients in this setting. We describe the current state of goals-of-care conversations in the ED, outline the challenges to conducting these conversations, and recommend a research agenda to better equip emergency physicians to guide shared decisionmaking for end-of-life care. Applying best practices for serious illness communication may help emergency physicians empower such patients to align their future medical care with their values and goals.

Socioeconomic Status and Health Services Utilization for Children With Complex Chronic Conditions Liable to Receive Nurse-Led Services: A Cross-Sectional Study

AIM

To analyze the use of health services for children with severe chronic diseases, seeking to identify patterns of use according to sociodemographic and clinical conditions, and to identify unmet needs of care coordination that could benefit from nursing case management services.

DESIGN

Cross-sectional study.

METHODS

Children treated in ambulatory and hospital care in Granada, Spain, with complex chronic diseases in 2016 were analyzed to determine their use of healthcare resources. Socioeconomic variables were evaluated, along with clinical status and duration of their conditions.

RESULTS

In total, 265 children were analyzed (mean age 7.3 years, SD 4.63; 56.6% male). The average duration of the disease was 63.26 months (SD 54.09). The most common types of disease were neurological (35.80%), congenital (23.90%), and oncological (18.90%). Multivariate analysis showed that children in need of advanced care (β = 0.71), with a relatively recent diagnosis (β = -0.11), with criteria for palliative care 1 (β = -0.26), and whose mothers were older (β = 0.36) and had a higher educational level (β = 0.19) made greater use of healthcare resources during the preceding 12 months, whether urgent or scheduled (r² = 78.0%, p < .001).

CONCLUSIONS

Children with higher needs for advanced care have a heterogeneous use of healthcare resources depending on certain clinical and sociodemographic determinants. This finding highlights the importance of the identification of profiles of children and families for care coordination. The presence of sociodemographic determinants may need individualized approaches to assure a timely health care utilization.

CLINICAL RELEVANCE

A significant proportion of the children used multiple health services, being treated at several centers simultaneously, and producing up to 139 total yearly contacts with the health system. Policymakers, healthcare providers, and patients' families should engage in a redesign of healthcare services for these children, providing comprehensive and coordinated systems of care for this population.

Reduction of healthcare costs by implementing palliative family conference with the decision to withdraw life-sustaining treatments

BACKGROUND

Evidence regarding the impact of early palliative family conferences (PFCs) and decision to withdraw life-sustaining treatment (DTW) on healthcare costs in an intensive care unit (ICU) setting is inconsistent.

METHODS

We retrospectively analyzed patients who died in an ICU from 2013 to 2016. PFCs held within 7 days after ICU admission and DTWs were verified by reviewing medical records and claims data. Comparisons were first made between patients with and without DTWs, and secondly, between DTW patients with and without PFCs within 7 days. Propensity score matching methods were used to examine the difference in costs between patients with and without DTWs and PFCs within 7 days.

RESULTS

Of the 579 patients included, those with DTWs (n = 73) had a longer ICU stay than those without (n = 506) (12.9 ± 7.1 vs. 8.4 ± 9.6 days, p < 0.001). The DTW patients were more likely to have a "do-not-resuscitate" order (p < 0.001) and PFCs within 7 days (p < 0.001) and had lower healthcare costs (USD 7358 ± 4116 vs. 8669 ± 9,535, p = 0.038). After matching, healthcare cost reduction for patients with DTWs, compared with those without DTWs, was USD 3467 [95% CI, 915-6019] (p < 0.001). Compared with DTW patients without PFCs within 7 days, the costs for DTW patients with PFCs within 7 days further reduced to USD 3042 [95%CI, 1358-4725] (p < 0.001).

CONCLUSION

Palliative family conferences held within 7 days after ICU admission with decisions to withdraw life-sustaining treatments significantly lowered healthcare costs.

A decision-aid tool for ICU admission triage is associated with a reduction in potentially inappropriate intensive care unit admissions

PURPOSE

Intensive care unit (ICU) admission triage occurs frequently and often involves highly subjective decisions that may lead to potentially inappropriate ICU admissions. In this study, we evaluated the effect of implementing a decision-aid tool for ICU triage on ICU admission decisions.

METHODS

This was a prospective, before-after study. Urgent ICU referrals to ten ICUs in a tertiary hospital in Brazil were assessed before and after the implementation of the decision-aid tool. Our primary outcome was the proportion of potentially inappropriate ICU referrals (defined as priority 4B or 5 referrals, accordingly to the Society of Critical Care Medicine guidelines of 1999 and 2016, respectively) admitted to the ICU within 48 h. We conducted multivariate analyses to adjust for potential confounders and evaluated the interaction between phase and triage priority.

RESULTS

Of the 2201 patients analyzed, 1184 (53.8%) patients were admitted to the ICU. After adjustment for confounders, implementation of the decision-aid tool was associated with a reduction in potentially inappropriate ICU admissions using either the 1999 [adjOR (95% CI) = 0.36 (0.13-0.97)] or 2016 [adjOR (95%CI) = 0.35 (0.13-0.96)] definitions.

CONCLUSION

Implementation of a decision-aid tool for ICU triage was associated with a reduction in potentially inappropriate ICU admissions.

Effect of a palliative care program on trends in intensive care unit utilization and do-not-resuscitate orders during terminal hospitalizations. An interrupted time series analysis

OBJECTIVE

To assess the effect of the implementation of a palliative care program on do-not-resuscitate orders and intensive care unit utilization during terminal hospitalizations.

METHODS

Data were retrospectively collected for all patients who died in a tertiary hospital in Brazil from May 2014 to September 2016. We analyzed the frequency of do-not-resuscitate orders and intensive care unit admissions among in-hospital deaths. Interrupted time series analyses were used to evaluate differences in trends of do-not-resuscitate orders and intensive care unit admissions before (17 months) and after (12 months) the implementation of a palliative care program.

RESULTS

We analyzed 48,372 hospital admissions and 1,071 in-hospital deaths. Deaths were preceded by do-not-resuscitate orders in 276 (25.8%) cases and admissions to the intensive care unit occurred in 814 (76%) cases. Do-not-resuscitate orders increased from 125 (20.4%) to 151 (33%) cases in the pre-implementation and post-implementation periods, respectively (p < 0.001). Intensive care unit admissions occurred in 469 (76.5%) and 345 (75.3%) cases in the pre-implementation and post-implementation periods, respectively (p = 0.654). Interrupted time series analyses confirmed a trend of increased do-not-resuscitate order registrations, from an increase of 0.5% per month pre-implementation to an increase of 2.9% per month post-implementation (p < 0.001), and demonstrated a trend of decreased intensive care unit utilization, from an increase of 0.6% per month pre-implementation to a decrease of -0.9% per month in the post-implementation period (p = 0.001).

CONCLUSION

The implementation of a palliative care program was associated with a trend of increased registration of do-not-resuscitate orders and a trend of decreased intensive care unit utilization during terminal hospitalizations.

Impact of advance care planning on end-of-life management

PURPOSE OF REVIEW

The aim of this review is to critically appraise the recent evidence on different aspects of impact of advance care planning (ACP) in palliative care and to reflect on further implications on practice and research in the future.

RECENT FINDINGS

Evidence about various ACP impacts is rapidly growing and most common outcome measures are still advance directive completion, change in hospital admission rate and patients' and families' views and experiences with ACP. Mainly descriptive studies bring new information of ACP impact for specific groups of patients, their families, settings, countries, contexts, staff and healthcare system as such. It is not yet clear who and when would best conduct ACP, from general practitioners (GPs) to specialists in the hospitals and even lay-navigators for cancer patients; from early ACP conversations to critical ACP in acute events at the end-of-life. The need for ACP impacts high-quality evidence is becoming more urgent because latest future projections are showing higher palliative care needs than previously expected.

SUMMARY

Recent studies on various ACP impacts reveal variety of outcomes for different patient groups and settings, and are contributing to a wider picture of ACP situation around the world. However, high-quality evidence on ACP impact is still urgently expected in times of growing need for system-level changes for effective ACP implementation.

Culture and Palliative Care: Preferences, Communication, Meaning, and Mutual Decision Making

Palliative care is gaining acceptance across the world. However, even when palliative care resources exist, both the delivery and distribution of services too often are neither equitably nor acceptably provided to diverse population groups. The goal of this study was to illustrate tensions in the delivery of palliative care for diverse patient populations to help clinicians to improve care for all. We begin by defining and differentiating culture, race, and ethnicity, so that these terms-often used interchangeably-are not conflated and are more effectively used in caring for diverse populations. We then present examples from an integrative literature review of recent research on culture and palliative care to illustrate both how and why varied responses to pain and suffering occur in different patterns, focusing on four areas of palliative care: the formation of care preferences, communication patterns, different meanings of suffering, and decision-making processes about care. For each area, we provide international and multiethnic examples of variations that emphasize the need for personalization of care and the avoidance of stereotyping beliefs and practices without considering individual circumstances and life histories. We conclude with recommendations for improving palliative care research and practice with cultural perspectives, emphasizing the need to work in partnerships with patients, their family members, and communities to identify and negotiate culturally meaningful care, promote quality of life, and ensure the highest quality palliative care for all, both domestically and internationally.

Palliative care in the trauma ICU

PURPOSE OF REVIEW

The benefits of palliative care for critically ill patients are well recognized, yet acceptance into surgical culture is lagging. With the increasing proportion of geriatric trauma patients, integration of palliative medicine within daily intensive care services to facilitate goal-concordant care is imperative.

RECENT FINDINGS

Misconceptions of palliative medicine as it applies to trauma patients linger among trauma surgeons and many continue to practice without routine consultation of a palliative care service. Aggressive end-of-life care does not correlate with an improved family perception of medical care received near death. Additionally, elderly patients near the end of life often prefer palliative treatments over life-extending therapy, and their treatment preferences are often not achieved. A new geriatric-specific prognosis calculator estimates the risk of mortality after trauma, which is useful in starting goals of care discussions with older patients and their families.

SUMMARY

Shifting our quality focus from 30-day mortality rates to measurements of symptom control and achievement of patient treatment preferences will prioritize patient beneficence and autonomy. Ownership of surgical palliative care as a service provided by acute care surgeons will ensure that our patients with incurable injury and illness will receive optimal patient-centered care.

The impact of early palliative care on the quality of care during the last days of life: what does the evidence say?

PURPOSE OF REVIEW

The aim of this review is to critically appraise the existing evidence on 'early palliative care' (EPC), discuss its relationship with advance care planning, and to reflect on the impact of EPC on the quality of care provided during the last days of life.

RECENT FINDINGS

There are indicators that EPC may help to avoid aggressive treatment, shorten hospital stay, improve overall quality of life, and to see more frequently dying and death at the preferred place of care.

SUMMARY

The evidence from randomized controlled trials supports the integration of palliative care early in the disease trajectory. However, in terms of outcomes and quality indicators for care in the last days of life, evidence is still lacking. Predominantly, when it comes to the outcomes which may be more difficult to assess, such as spiritual aspects, or the social network, for which more comprehensive information is needed. These outcomes should not be neglected in palliative care studies, particularly when they can provide meaningful information about patient and family adjustment, and focus on psychosocial aspects rather than physical symptom control.

Evaluating the Economic Impact of Palliative and End-of-Life Care Interventions on Intensive Care Unit Utilization and Costs from the Hospital and Healthcare System Perspective

Purpose of report: Understanding the impact of palliative care interventions on intensive care unit (ICU) costs and utilization is critical for demonstrating the value of palliative care. Performing these economic assessments, however, can be challenging. The purpose of this special report is to highlight and discuss important considerations when assessing ICU utilization and costs from the hospital perspective, with the goal of providing recommendations on methods to consider for future analyses.

FINDINGS

ICU length of stay (LOS) and associated costs of care are common and important outcome measures, but must be analyzed properly to yield valid conclusions. There is significant variation in costs by day of stay in the ICU with only modest differences between an ICU day at the end of a stay and the first day on the acute care floor; this variation must be appropriately accounted for analytically. Furthermore, reporting direct variable costs, in addition to total ICU costs, is needed to understand short-term and long-term impact of a reduction in LOS. Importantly, incentives for the hospital to realize savings vary depending on reimbursement policies.

SUMMARY

ICU utilization and costs are common outcomes in studies evaluating palliative care interventions. Accurate estimation and interpretation are key to understanding the economic implications of palliative care interventions.

Palliative Care Consultation for Goals of Care and Future Acute Care Costs: A Propensity-Matched Study

BACKGROUND

Hospitals are under increasing pressure to manage costs across multiple episodes of care. Most studies of the financial impact of palliative care have focused on costs during a single hospitalization.

OBJECTIVE

To compare future acute health-care costs and utilization between patients who received inpatient palliative care consultation for goals of care (Palliative Care Service [PCS]) and a propensity-matched cohort of patients who did not receive palliative care consultation (non-PCS) in a single academic medical center.

METHODS

Data were extracted from the hospital's electronic records for admissions and discharges between July 2014 and October 2016. A stratified propensity score matching was used to account for nonrandom assignment and potential inherent differences between PCS and non-PCS groups using variables of theoretical interest: age, gender, race, diagnosis, risk of mortality, and prior acute care costs.

RESULTS

The analytical sample for this study included 41 363 patients (PCS = 1853; non-PCS = 39 510). Future acute care costs were significantly higher in the non-PCS group after propensity score matching (highest tier = US$15 654 vs US$8831; second highest tier = US$12 200 vs US$5496; P = .0001). The non-PCS group also had significantly higher future acute care utilization across all propensity tiers and outcomes including 30-day readmission ( P = .0001), number of future hospital days ( P = .0001), and number of future intensive care unit days ( P = .0001).

CONCLUSION

Palliative care consultations for goals of care may decrease future health-care utilization with cost savings that persist into future hospitalizations.

Does anyone ever expect to die?

Patients who come to the intensive care unit are amongst the sickest patients in our hospitals. Patients can be admitted to the intensive care unit unexpectedly (following accidents or sudden onset of illness) or as unplanned but not necessarily truly 'unexpected' admissions. These patients often have significant underlying chronic health issues, including metastatic cancer, advanced cardiac, respiratory, renal, or hepatic failure, or frailty, with a high likelihood of death in the ensuing months. Using the Australian and New Zealand Intensive Care Society Clinical Trials Group Point Prevalence Program, a prospective single-day observational study across 46 Australian hospitals in 2014 and 2015, we found that less than 9% of intensive care unit patients (51/577) had an advance directive available. From these results, we provide two suggestions to increase intensive care's understanding of patients' end-of-life wishes. First, systematically target 'high risk of dying' patient groups for goals of care conversations in the outpatient setting. Such groups include those where one would not be 'surprised' if they died within a year. Second, as a society, more conversations about end-of-life wishes are needed.

Effects of hospital palliative care on health, length of stay, and in-hospital mortality across intensive and non-intensive-care units: A systematic review and metaanalysis

OBJECTIVE

Hospital palliative care has been shown to improve quality of life and optimize hospital utilization for seriously ill patients who need intensive care. The present review examined whether hospital palliative care in intensive care (ICU) and non-ICU settings will influence hospital length of stay and in-hospital mortality.

METHOD

A systematic search of CINAHL/EBSCO, the Cochrane Library, Google Scholar, MEDLINE/Ovid, PubMed, and the Web of Science through 12 October 2016 identified 16 studies that examined the effects of hospital palliative care and reported on hospital length of stay and in-hospital death. Random-effects pooled odds ratios and mean differences with corresponding 95% confidence intervals were estimated. Heterogeneity was measured by the I 2 test. The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system was utilized to assess the overall quality of the evidence.

RESULTS

Of the reviewed 932 articles found in our search, we reviewed the full text of 76 eligible articles and excluded 60 of those, which resulted in a final total of 16 studies for analysis. Five studies were duplicated with regard to outcomes. A total of 18,330 and 9,452 patients were analyzed for hospital length of stay and in-hospital mortality from 11 and 10 studies, respectively. Hospital palliative care increased mean hospital length of stay by 0.19 days (pooled mean difference = 0.19; 95% confidence interval [CI 95%] = -2.22-2.61 days; p = 0.87; I 2 = 95.88%) and reduced in-hospital mortality by 34% (pooled odds ratio = 0.66; CI 95% = 0.52-0.84; p < 0.01; I 2 = 48.82%). The overall quality of evidence for both hospital length of stay and in-hospital mortality was rated as very low and low, respectively.

SIGNIFICANCE OF RESULTS

Hospital palliative care was associated with a 34% reduction of in-hospital mortality but had no correlation with hospital length of stay.

Identifying congestion levels, sources and determinants on intensive care units: the Portuguese case

Healthcare systems are facing a resources scarcity so they must be efficiently managed. On the other hand, it is commonly accepted that the higher the consumed resources, the higher the hospital production, although this is not true in practice. Congestion on inputs is an economic concept dealing with such situation and it is defined as the decreasing of outputs due to some resources overuse. This scenario gets worse when inpatients' high severity requires a strict and effective resources management, as happens in Intensive Care Units (ICU). The present paper employs a set of nonparametric models to evaluate congestion levels, sources and determinants in Portuguese Intensive Care Units. Nonparametric models based on Data Envelopment Analysis are employed to assess both radial and non-radial (in)efficiency levels and sources. The environment adjustment models and bootstrapping are used to correct possible bias, to remove the deterministic nature of nonparametric models and to get a statistical background on results. Considerable inefficiency and congestion levels were identified, as well as the congestion determinants, including the ICU specialty and complexity, the hospital differentiation degree and population demography. Both the costs associated with staff and the length of stay are the main sources of (weak) congestion in ICUs. ICUs management shall make some efforts towards resource allocation to prevent the congestion effect. Those efforts shall, in general, be focused on costs with staff and hospital days, although these congestion sources may vary across hospitals and ICU services, once several congestion determinants were identified.

Patterns of Cost for Patients Dying in the Intensive Care Unit and Implications for Cost Savings of Palliative Care Interventions

BACKGROUND

Terminal intensive care unit (ICU) stays represent an important target to increase value of care.

OBJECTIVE

To characterize patterns of daily costs of ICU care at the end of life and, based on these patterns, examine the role for palliative care interventions in enhancing value.

DESIGN

Secondary analysis of an intervention study to improve quality of care for critically ill patients.

SETTING/PATIENTS

572 patients who died in the ICU between 2003 and 2005 at a Level-1 trauma center.

METHODS

Data were linked with hospital financial records. Costs were categorized into direct fixed, direct variable, and indirect costs. Patterns of daily costs were explored using generalized estimating equations stratified by length of stay, cause of death, ICU type, and insurance status. Estimates from the literature of effects of palliative care interventions on ICU utilization were used to simulate potential cost savings under different time horizons and reimbursement models.

MAIN RESULTS

Mean cost for a terminal ICU stay was 39.3K ± 45.1K. Direct fixed costs represented 45% of total hospital costs, direct variable costs 20%, and indirect costs 34%. Day of admission was most expensive (mean 9.6K ± 7.6K); average cost for subsequent days was 4.8K ± 3.4K and stable over time and patient characteristics.

CONCLUSIONS

Terminal ICU stays display consistent cost patterns across patient characteristics. Savings can be realized with interventions that align care with patient preferences, helping to prevent unwanted ICU utilization at end of life. Cost modeling suggests that implications vary depending on time horizon and reimbursement models.