1
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Zhang M, Zhao Y, Peng M. Palliative care screening tools and patient outcomes: a systematic review. BMJ Support Palliat Care 2024:spcare-2024-005093. [PMID: 39181701 DOI: 10.1136/spcare-2024-005093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2024] [Accepted: 07/19/2024] [Indexed: 08/27/2024]
Abstract
BACKGROUND Palliative care (PC) refers to providing patients with physical, psychological, mental, and other care and humanistic care services in a multidisciplinary collaborative mode with end-of-stage patients and family members as the centre. The PC screening tool (PCST) was developed to identify individuals who may benefit from PC services and is widely assumed to improve patient outcomes. OBJECTIVES The purpose is to understand which specific PCST has been applied to clinical patients and to analyse and summarise the impact of using these tools on patient outcomes. METHODS A systematic review of articles published on PCST was performed in PubMed, Web of Science, CINAHL and MEDLINE in January 2024. All original research articles on PCST fulfilling the following eligibility criteria were included (1) utilisation and evaluation of tools was the primary objective and (2) at least one patient outcome was reported. RESULTS A total of 22 studies were included, 12 studies used a prospective study, 4 studies used a non-RCT and 6 studies used an RCT. The studies were heterogeneous regarding study characteristics, especially patient outcomes. In total, 24 different patient outcomes were measured, of which 16 outcomes measured in 12 studies significantly improved. CONCLUSIONS We found that the majority of included studies reported that implementing PCST can improve patient outcomes to some extent, especially when used to improve in reducing hospitalisation time and patient readmission rate. However, there is a lack of high-quality research on this widely used screening tool.
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Affiliation(s)
- Meiying Zhang
- Cancer Hospital Chinese Academy of Medical Sciences, Beijing, China
| | - Yuxia Zhao
- Cancer Hospital Chinese Academy of Medical Sciences, Beijing, China
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2
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Wiencek C. Palliative Care in the Intensive Care Unit: The Standard of Care. AACN Adv Crit Care 2024; 35:112-124. [PMID: 38848570 DOI: 10.4037/aacnacc2024525] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2024]
Abstract
Intensive care unit-based palliative care has evolved over the past 30 years due to the efforts of clinicians, researchers, and advocates for patient-centered care. Although all critically ill patients inherently have palliative care needs, the path was not linear but rather filled with the challenges of blending the intensive care unit goals of aggressive treatment and cure with the palliative care goals of symptom management and quality of life. Today, palliative care is considered an essential component of high-quality critical care and a core competency of all critical care nurses, advanced practice nurses, and other intensive care unit clinicians. This article provides an overview of the current state of intensive care unit-based palliative care, examines how the barriers to such care have shifted, reviews primary and specialist palliative care, addresses the impact of COVID-19, and presents resources to help nurses and intensive care unit teams achieve optimal outcomes.
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Affiliation(s)
- Clareen Wiencek
- Clareen Wiencek is Professor of Nursing, University of Virginia School of Nursing, 202 Jeanette Lancaster Way, Charlottesville, VA 22908
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Hadler RA, Gao Y, Beck B, Moeckli J, Massarweh N, Mosher H, Vaughan-Sarrazin M. Palliative Care Utilization and Hospital Transfers in Veterans Treated in Telecritical Care-Supported Intensive Care Units Versus Non-Telecritical Care Intensive Care Units. J Palliat Med 2024; 27:756-762. [PMID: 38324007 DOI: 10.1089/jpm.2023.0548] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2024] Open
Abstract
Background: Although telecritical care (TCC) implementation is associated with reduced mortality and interhospital transfer rates, its impact on goal-concordant care delivery in critical illness is unknown. We hypothesized that implementation of TCC across the Veterans' Health Administration system resulted in increased palliative care consultation and goals of care evaluation, yielding reduced transfer rates. Methods: We included veterans admitted to intensive care units between 2008 and 2022. We compared palliative care consultation and transfer rates before and after TCC implementation with rates in facilities that never implemented TCC. We used generalized linear mixed multivariable models to assess the associations between TCC initiation, palliative care consultation, and transfer and subsequently used mediation analysis to evaluate potential causality in this relationship. Results: Overall, 1,020,901 veterans met inclusion criteria. Demographic characteristics of patients were largely comparable across groups, although TCC facilities served more rural veterans. Palliative care consultation rates increased substantially in both ever-TCC and never-TCC hospitals during the study period (2.3%-4.3%, and 1.6%-4.7%, p < 0.01). Admissions post-TCC implementation were associated with an increased likelihood of palliative care consultation (odds ratio [OR] 1.08, 95% confidence interval [CI] 1.01-1.15). TCC implementation was also associated with a reduction in transfer rates (OR 0.90, 95% CI 0.84-0.95). Mediation analysis did not demonstrate a causal relationship between TCC implementation, palliative care consultation, and reductions in interhospital transfer rate. Conclusions: TCC is associated with increased palliative care engagement, while TCC and palliative care engagement are both independently related to reduced transfers.
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Affiliation(s)
- Rachel A Hadler
- VA Quality Scholars Fellow, Iowa City Veterans Affairs Health Care System, Iowa City, Iowa, USA
- Department of Anesthesiology, Emory University, Atlanta, Georgia, USA
- Emory Critical Care Center, Emory University, Atlanta, Georgia, USA
- Division of Palliative Care, Department of Geriatrics and Extended Care, Atlanta Veterans Administration Health Care System, Decatur, Georgia, USA
| | - Yubo Gao
- Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
- Center for Access and Delivery Research and Evaluation, Iowa City Veterans Affairs Health Care System, Iowa City, Iowa, USA
| | - Brice Beck
- Center for Access and Delivery Research and Evaluation, Iowa City Veterans Affairs Health Care System, Iowa City, Iowa, USA
| | - Jane Moeckli
- Center for Access and Delivery Research and Evaluation, Iowa City Veterans Affairs Health Care System, Iowa City, Iowa, USA
| | - Nader Massarweh
- Department of Surgery, Atlanta Veterans Administration Health Care System, Decatur, Georgia, USA
- Division of Surgical Oncology, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia, USA
- Department of Surgery, Morehouse School of Medicine, Atlanta, Georgia, USA
| | - Hilary Mosher
- Geriatric Research Education and Clinical Center, Minneapolis Veterans Affairs Health Care System, Minneapolis, Minnesota, USA
| | - Mary Vaughan-Sarrazin
- Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
- Center for Access and Delivery Research and Evaluation, Iowa City Veterans Affairs Health Care System, Iowa City, Iowa, USA
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4
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Schallenburger M, Schwartz J, Icks A, In der Schmitten J, Batzler YN, Meier S, Mendez-Delgado M, Tenge T, Neukirchen M. Triggers of intensive care patients with palliative care needs from nurses' perspective: a mixed methods study. Crit Care 2024; 28:181. [PMID: 38807236 PMCID: PMC11134896 DOI: 10.1186/s13054-024-04969-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2024] [Accepted: 05/24/2024] [Indexed: 05/30/2024] Open
Abstract
PURPOSE Triggers have been developed internationally to identify intensive care patients with palliative care needs. Due to their work, nurses are close to the patient and their perspective should therefore be included. In this study, potential triggers were first identified and then a questionnaire was developed to analyse their acceptance among German intensive care nurses. METHODS For the qualitative part of this mixed methods study, focus groups were conducted with intensive care nurses from different disciplines (surgery, neurosurgery, internal medicine), which were selected by convenience. Data were analysed using the "content-structuring content analysis" according to Kuckartz. For the quantitative study part, the thus identified triggers formed the basis for questionnaire items. The questionnaire was tested for comprehensibility in cognitive pretests and for feasibility in a pilot survey. RESULTS In the qualitative part six focus groups were conducted at four university hospitals. From the data four main categories (prognosis, interprofessional cooperation, relatives, patients) with three to 15 subcategories each could be identified. The nurses described situations requiring palliative care consults that related to the severity of the disease, the therapeutic course, communication within the team and between team and patient/relatives, and typical characteristics of patients and relatives. In addition, a professional conflict between nurses and physicians emerged. The questionnaire, which was developed after six cognitive interviews, consists of 32 items plus one open question. The pilot had a response rate of 76.7% (23/30), whereby 30 triggers were accepted with an agreement of ≥ 50%. CONCLUSION Intensive care nurses see various triggers, with interprofessional collaboration and the patient's prognosis playing a major role. The questionnaire can be used for further surveys, e.g. interprofessional triggers could be developed.
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Affiliation(s)
- Manuela Schallenburger
- Interdisciplinary Centre for Palliative Medicine, Medical Faculty, University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Jacqueline Schwartz
- Interdisciplinary Centre for Palliative Medicine, Medical Faculty, University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany.
- Center of Integrated Oncology Aachen, Bonn, Cologne (CIO ABCD), Heinrich-Heine-University, Düsseldorf, Germany.
| | - Andrea Icks
- Institute of Health Services Research and Health Economics, Centre for Health and Society, Medical Faculty, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
- Center of Integrated Oncology Aachen, Bonn, Cologne (CIO ABCD), Heinrich-Heine-University, Düsseldorf, Germany
| | - Jürgen In der Schmitten
- Institute of Family Medicine/General Practice, Medical Faculty, University of Duisburg-Essen, Essen, Germany
| | - Yann-Nicolas Batzler
- Interdisciplinary Centre for Palliative Medicine, Medical Faculty, University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Stefan Meier
- Department of Anaesthesiology, Medical Faculty, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Miguel Mendez-Delgado
- Department of Anaesthesiology, Medical Faculty, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Theresa Tenge
- Department of Anaesthesiology, Medical Faculty, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Martin Neukirchen
- Interdisciplinary Centre for Palliative Medicine, Medical Faculty, University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
- Department of Anaesthesiology, Medical Faculty, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
- Center of Integrated Oncology Aachen, Bonn, Cologne (CIO ABCD), Heinrich-Heine-University, Düsseldorf, Germany
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5
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Phillips TN, Gormley DK, Donaworth S. Integrating Palliative Care Screening in the Intensive Care Unit: A Quality Improvement Project. Crit Care Nurse 2024; 44:41-48. [PMID: 38555966 DOI: 10.4037/ccn2024652] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/02/2024]
Abstract
BACKGROUND Patients admitted to the intensive care unit have complex medical problems and increased rates of mortality and recurrent hospitalization for the following 10 years compared with patients without a history of critical illness. Delayed access to palliative care can result in untreated symptoms, lack of understanding of care preferences, and preventable admissions. Despite studies supporting palliative care screening, there is no standardized method to assess palliative care needs of patients admitted to critical care units. LOCAL PROBLEM A community hospital critical care team identified a need for an improved palliative care process for patients admitted to the intensive care unit. METHODS The aim of this quality improvement project was to improve patient access to timely palliative care consultation while increasing the reach of the palliative care team. Guided by the Institute for Healthcare Improvement model of plan-do-study-act cycles, the team created a palliative care screening tool with clinical indicators for nurses to use upon patient admission. Patients with numeric scores indicating positive screening tool results could be automatically referred for palliative care consultation. RESULTS Of 267 patients, 59 (22%) had positive screening tool results, compared with 31 (11.6%) identified with the traditional consultative method. Descriptive analysis revealed that patients identified for referral without use of the screening tool were hospitalized a mean of 6 days until consultation was requested. CONCLUSION The screening process can maximize the benefit of palliative care services with early patient identification, improved consultation efficiency, decreased critical care resource use, and reduced readmission rates.
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Affiliation(s)
- Traci N Phillips
- Traci N. Phillips is a board-certified adult acute care nurse practitioner and a member of the pulmonary and critical care service at Bon Secours Mercy Health Anderson, Cincinnati, Ohio
| | - Denise K Gormley
- Denise K. Gormley is a professor emerita and past dean at the University of Cincinnati College of Nursing, Cincinnati
| | - Sherry Donaworth
- Sherry Donaworth is an associate professor of clinical nursing at the University of Cincinnati College of Nursing and is board certified as an adult acute care nurse practitioner and as a family nurse practitioner
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You JY, Ligasaputri LD, Katamreddy A, Para K, Kavanagh E, Salgunan R, Gulani P. A Case-Control Study Evaluating the Impact of Dedicated Palliative Care Training on Critical Care Interventions at the end of Life. J Palliat Care 2024; 39:111-114. [PMID: 34397289 DOI: 10.1177/08258597211037436] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Many patients admitted to intensive care units (ICUs) are at high risk of dying. We hypothesize that focused training sessions for ICU providers by palliative care (PC) certified experts will decrease aggressive medical interventions at the end of life. We designed and implemented a 6-session PC training program in communication skills and goals of care (GOC) meetings for ICU teams, including house staff, critical care fellows, and attendings. We then reviewed charts of ICU patients treated before and after the intervention. Forty-nine of 177 (28%) and 63 of 173 (38%) patients were identified to be at high risk of death in the pre- and postintervention periods, respectively, and were included based on the study criteria. Inpatient mortality (45% vs 33%; P = .24) and need for mechanical ventilation (59% vs 44%, P = .13) were slightly higher in the preintervention population, but the difference was not statistically significant. The proportion of patients in whom the decision not to initiate renal replacement therapy was made because of poor prognosis was significantly higher in the postintervention population (14% vs 67%, P = .05). There was a nonstatistically significant trend toward earlier GOC discussions (median time from ICU admission to GOC 4 vs 3 days) and fewer critical care interventions such as tracheostomies (17% vs 4%, P = .19). Our study demonstrates that directed PC training of ICU teams has a potential to reduce end of life critical care interventions in patients with a poor prognosis.
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Affiliation(s)
- Jee Y You
- Jacobi Medical Center, USA
- Albert Einstein College of Medicine, USA
| | - Lie D Ligasaputri
- Jacobi Medical Center, USA
- Albert Einstein College of Medicine, USA
- University of California, San Francisco, USA
| | | | - Kiran Para
- Jacobi Medical Center, USA
- Albert Einstein College of Medicine, USA
| | | | - Reka Salgunan
- Jacobi Medical Center, USA
- Albert Einstein College of Medicine, USA
| | - Perminder Gulani
- Jacobi Medical Center, USA
- Albert Einstein College of Medicine, USA
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7
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Lin M, Rholl E, Andescavage N, Ackerman O, Fisher D, Lanzel AF, Mahmood LA. Improving Prenatal Palliative Care Consultation Using Diagnostic Trigger Criteria. J Pain Symptom Manage 2024; 67:e137-e145. [PMID: 37858635 DOI: 10.1016/j.jpainsymman.2023.10.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Revised: 10/09/2023] [Accepted: 10/10/2023] [Indexed: 10/21/2023]
Abstract
BACKGROUND Three percent of pregnancies are complicated by congenital anomalies. Prenatal integration of pediatric palliative care (PPC) may be hindered by non-standardized PPC referral processes. This quality improvement (QI) project aimed to improve prenatal PPC consultation using a diagnostic trigger list. MEASURES Main outcome measure was the percentage of prenatal PPC consults completed based on diagnostic trigger list eligibility. Balancing measures included stakeholder perspectives on PPC consults and products. INTERVENTION Interventions included creation and implementation of a diagnostic trigger list for prenatal PPC consultation, educational initiatives with stakeholders, and iterative modifications of our prenatal consultation process. OUTCOMES Interventions increased consultation rates ≥80% during the first six months of QI implementation (baseline vs. post-interventions) although this increase was not consistently sustained over a 12-month period. CONCLUSIONS/LESSONS LEARNED Diagnostic trigger lists improve initial rates of prenatal PPC consultation and additional interventions are likely needed to sustain this increase.
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Affiliation(s)
- Matthew Lin
- Division of Neonatology (M.L.), Department of Pediatrics, New York University School of Medicine, New York, New York, USA.
| | - Erin Rholl
- Division of Neonatology (E.R.), Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Nickie Andescavage
- Division of Neonatology (N.A.), Children's National Hospital, Washington, District of Columbia, USA; School of Medicine and Health Sciences (N.A., D.F., A.F.L., L.A.M.), George Washington University, Washington, District of Columbia, USA
| | - Olivia Ackerman
- Prenatal Pediatrics Institute (O.A.), Children's National Hospital, Washington, District of Columbia, USA
| | - Deborah Fisher
- School of Medicine and Health Sciences (N.A., D.F., A.F.L., L.A.M.), George Washington University, Washington, District of Columbia, USA; Pediatric Palliative Care Program (D.F., A.F.L., L.A.M.), Children's National Hospital, Washington, District of Columbia, USA
| | - Ashley F Lanzel
- School of Medicine and Health Sciences (N.A., D.F., A.F.L., L.A.M.), George Washington University, Washington, District of Columbia, USA; Pediatric Palliative Care Program (D.F., A.F.L., L.A.M.), Children's National Hospital, Washington, District of Columbia, USA
| | - Laila A Mahmood
- School of Medicine and Health Sciences (N.A., D.F., A.F.L., L.A.M.), George Washington University, Washington, District of Columbia, USA; Pediatric Palliative Care Program (D.F., A.F.L., L.A.M.), Children's National Hospital, Washington, District of Columbia, USA
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8
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Shalman D. Clinical outcomes of a joint ICU and palliative care multidisciplinary rounding model: A retrospective cohort study. PLoS One 2024; 19:e0297288. [PMID: 38300936 PMCID: PMC10833514 DOI: 10.1371/journal.pone.0297288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Accepted: 01/02/2024] [Indexed: 02/03/2024] Open
Abstract
OBJECTIVES This retrospective cohort study assessed whether implementation of a joint inpatient palliative care (IPC) and ICU multidisciplinary rounding model affected clinical outcomes including ICU length of stay (LOS). METHODS Beginning in October of 2018, an IPC physician joined the pre-existing ICU multidisciplinary rounds. Data were collected for ICU patients admitted during a 6-month period before this intervention and a 6-month period after the intervention. Data were extracted from an integrated electronic medical records (EMR) data system and compared by Wilcoxon and chi-square test for continuous and categorical variables respectively. Negative binomial regression was used to analyze the primary outcome measure, ICU LOS. RESULTS Patients in the intervention group spent fewer days in the ICU (3.7 vs. 3.9 days, p = 0.05; RR 0.82, 95% CI 0.70-0.97, p = 0.02) and in the hospital (7.5 vs. 7.8 days, p<0.01) compared to the pre-intervention group. The rate of CPR was lower in the intervention group, but the difference was not statistically significant [13(3.1%) vs. 23(5.3%), p = 0.10]. The groups did not differ significantly in rate of hospital mortality, number of days connected to mechanical ventilation via endotracheal tube, or bounceback to the ED or hospital. Multivariable analysis of the primary outcome demonstrated that patients with prior palliative care involvement had longer ICU LOS (RR 1.46, 95% CI 1.04-2.06, p = 0.03) when controlling for other variables. CONCLUSION The presented joint IPC-ICU multidisciplinary rounding model was associated with a statistically significant reduction in ICU and hospital LOS, but the clinical significance of this reduction is unclear.
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Affiliation(s)
- Dov Shalman
- Department of Geriatric, Palliative, and Continuing Care, Kaiser Permanente Southern California, Los Angeles, California, United States of America
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9
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Michels G, John S, Janssens U, Raake P, Schütt KA, Bauersachs J, Barchfeld T, Schucher B, Delis S, Karpf-Wissel R, Kochanek M, von Bonin S, Erley CM, Kuhlmann SD, Müllges W, Gahn G, Heppner HJ, Wiese CHR, Kluge S, Busch HJ, Bausewein C, Schallenburger M, Pin M, Neukirchen M. [Palliative aspects in clinical acute and emergency medicine as well as intensive care medicine : Consensus paper of the DGIIN, DGK, DGP, DGHO, DGfN, DGNI, DGG, DGAI, DGINA and DG Palliativmedizin]. Med Klin Intensivmed Notfmed 2023; 118:14-38. [PMID: 37285027 PMCID: PMC10244869 DOI: 10.1007/s00063-023-01016-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/13/2023] [Indexed: 06/08/2023]
Abstract
The integration of palliative medicine is an important component in the treatment of various advanced diseases. While a German S3 guideline on palliative medicine exists for patients with incurable cancer, a recommendation for non-oncological patients and especially for palliative patients presenting in the emergency department or intensive care unit is missing to date. Based on the present consensus paper, the palliative care aspects of the respective medical disciplines are addressed. The timely integration of palliative care aims to improve quality of life and symptom control in clinical acute and emergency medicine as well as intensive care.
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Affiliation(s)
- Guido Michels
- Zentrum für Notaufnahme, Krankenhaus der Barmherzigen Brüder Trier, Medizincampus der Universitätsmedizin Mainz, Nordallee 1, 54292, Trier, Deutschland.
| | - Stefan John
- Medizinische Klinik 8, Paracelsus Medizinische Privatuniversität und Universität Erlangen-Nürnberg, Klinikum Nürnberg-Süd, 90471, Nürnberg, Deutschland
| | - Uwe Janssens
- Klinik für Innere Medizin und Internistische Intensivmedizin, St.-Antonius-Hospital gGmbH, Eschweiler, Deutschland
| | - Philip Raake
- I. Medizinischen Klinik, Universitätsklinikum Augsburg, Herzzentrum Augsburg-Schwaben, Augsburg, Deutschland
| | - Katharina Andrea Schütt
- Klinik für Kardiologie, Angiologie und Internistische Intensivmedizin (Medizinische Klinik I), Uniklinik RWTH Aachen, Aachen, Deutschland
| | - Johann Bauersachs
- Klinik für Kardiologie und Angiologie, Zentrum Innere Medizin, Medizinische Hochschule Hannover, Hannover, Deutschland
| | - Thomas Barchfeld
- Medizinische Klinik II, Klinik für Pneumologie, Intensivmedizin und Schlafmedizin, Knappschaftskrankenhaus Dortmund, Klinikum Westfalen, Dortmund, Deutschland
| | - Bernd Schucher
- Abteilung Pneumologie, LungenClinic Großhansdorf, Großhansdorf, Deutschland
| | - Sandra Delis
- Helios Klinikum Emil von Behring GmbH, Berlin, Deutschland
| | - Rüdiger Karpf-Wissel
- Westdeutsches Lungenzentrum am Universitätsklinikum Essen gGmbH, Klinik für Pneumologie, Universitätsmedizin Essen Ruhrlandklinik, Essen, Deutschland
| | - Matthias Kochanek
- Medizinische Klinik I, Medizinische Fakultät und Uniklinik Köln, Center for Integrated Oncology (CIO) Cologne-Bonn, Universität zu Köln, Köln, Deutschland
| | - Simone von Bonin
- Medizinische Klinik und Poliklinik I, Universitätsklinikum Carl Gustav Carus, Technische Universität Dresden, Dresden, Deutschland
| | | | | | - Wolfgang Müllges
- Neurologische Klinik und Poliklinik, Universitätsklinikum Würzburg, Würzburg, Deutschland
| | - Georg Gahn
- Neurologische Klinik, Städtisches Klinikum Karlsruhe gGmbH, Karlsruhe, Deutschland
| | - Hans Jürgen Heppner
- Klinik für Geriatrie und Geriatrische Tagesklinik, Klinikum Bayreuth - Medizincampus Oberfranken, Bayreuth, Deutschland
| | - Christoph H R Wiese
- Klinik für Anästhesiologie, Universitätsklinikum Regensburg, Regensburg, Deutschland
- Klinik für Anästhesiologie und Intensivmedizin, HEH Kliniken Braunschweig, Braunschweig, Deutschland
| | - Stefan Kluge
- Klinik für Intensivmedizin, Universitätsklinikum Eppendorf, Hamburg, Deutschland
| | - Hans-Jörg Busch
- Universitätsklinikum, Universitäts-Notfallzentrum, Albert-Ludwigs-Universität Freiburg, Freiburg, Deutschland
| | - Claudia Bausewein
- Klinik und Poliklinik für Palliativmedizin, LMU Klinikum München, München, Deutschland
| | - Manuela Schallenburger
- Interdisziplinäres Zentrum für Palliativmedizin (IZP), Universitätsklinikum Düsseldorf, Heinrich-Heine-Universität Düsseldorf, Düsseldorf, Deutschland
| | - Martin Pin
- Zentrale Interdisziplinäre Notaufnahme, Florence-Nightingale-Krankenhaus Düsseldorf, Düsseldorf, Deutschland
| | - Martin Neukirchen
- Interdisziplinäres Zentrum für Palliativmedizin (IZP), Universitätsklinikum Düsseldorf, Heinrich-Heine-Universität Düsseldorf, Düsseldorf, Deutschland
- Klinik für Anästhesiologie, Universitätsklinikum Düsseldorf, Heinrich-Heine-Universität Düsseldorf, Düsseldorf, Deutschland
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10
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Grossoehme DH, Bish BM, Lou R, Khandelwal A, Brown M, Brown C, Teo E, Friebert S. Integrating Palliative Care into Burn Care: A Retrospective Application of Criteria for Appropriate Referral. J Burn Care Res 2023; 44:1365-1370. [PMID: 36638124 DOI: 10.1093/jbcr/irad005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Indexed: 01/14/2023]
Abstract
Burn injuries often require complex interdisciplinary care. Despite potential benefits, consultation with specialist palliative care typically occurs in 2% of burn admissions, due largely to lack of availability and misconceptions concerning palliative care. Criteria to guide consultation with specialist palliative care have been developed at this institution. The purpose of this study was to quantify the sensitivity and specificity of these criteria, and then optimize them. Retrospective examination of 388 admissions over 15 months at this adult and pediatric Burn Center were conducted. Chi-square or Fisher's exact test for categorical variables and Wilcoxon Rank Sum test for continuous variables were used to test for between-group differences in demographic and clinical characteristics. Logistic regression model was built to determine modified Baux cut-off score using Youden index (J) value. Criteria were sensitive (0.96) and specific (0.90), though with a low positive predictive value (0.43). Persons with lengths of stay greater than one week, advanced directives, Allow Natural Death orders, and/or deterioration events were significantly more likely to have had palliative care consulted. There were significant between-group differences (with/without palliative care consultation) based on burn surface area, modified Baux score, and mortality risk. Potential criteria revisions are proposed. Prospective adherence to revised criteria could provide useful guidance to providers and benefit to patients and families.
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Affiliation(s)
- Daniel H Grossoehme
- Haslinger Family Pediatric Palliative Care Center, Akron Children's Hospital, 215 West Bowery St, Akron, Ohio, USA
| | - Brianna M Bish
- Haslinger Family Pediatric Palliative Care Center, Akron Children's Hospital, 215 West Bowery St, Akron, Ohio, USA
- Kent State University College of Arts and Sciences, 850 University Esplanade, Kent, Ohio , USA
| | - Richard Lou
- Regional Burn Center, Akron Children's Hospital, One Perkins Square, Akron, Ohio, USA
| | - Anjay Khandelwal
- Regional Burn Center, Akron Children's Hospital, One Perkins Square, Akron, Ohio, USA
| | - Miraides Brown
- Rebecca D. Considine Research Institute, Akron Children's Hospital, One Perkins Square, Akron, Ohio, USA
| | - Carrie Brown
- Department of Pediatrics, University of Arkansas for Medical Sciences, 1 Children's Way, Little Rock, Arkansas, USA
| | - Esther Teo
- Department of Surgery, University of Arkansas for Medical Sciences, 1 Children's Way, Little Rock, Arkansas, USA
| | - Sarah Friebert
- Haslinger Family Pediatric Palliative Care Center, 215 West Bowery St, Akron Children's Hospital, Akron, Ohio, USA
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11
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Tao Z, Hays E, Meyers G, Siegel T. Frailty and Preoperative Palliative Care in Surgical Oncology. Curr Probl Cancer 2023; 47:101021. [PMID: 37865539 DOI: 10.1016/j.currproblcancer.2023.101021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Revised: 08/31/2023] [Accepted: 09/06/2023] [Indexed: 10/23/2023]
Abstract
In this paper, we discuss surgical palliative care for patients with cancer through the lens of frailty and the preoperative context. Historically, palliative care principles such as complex symptom management, high-risk decision-making and communication have played an important role in preoperative discussions of oncologic surgery for both palliative and curative intent. There is increasing motivation among surgeons to integrate palliative care into the perioperative period in order to more effectively and comprehensively address potential adverse functional and quality of life outcomes. We discuss how the concept of frailty, and various instruments to measure frailty, have impacted perioperative decision-making, review the roots of surgical risk stratification and counseling on acceptable perioperative risk, and explore the preoperative setting as a possible avenue by which primary and specialty palliative care integration may have beneficial impact for patients considering oncologic resections.
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Affiliation(s)
- Zoe Tao
- Department of Surgery, Oregon Health & Science University, Portland, Oregon
| | - Elizabeth Hays
- Department of Hospital Medicine, Oregon Health & Science University, Portland, Oregon; Section of Geriatrics, Oregon Health & Science University, Portland, Oregon
| | - Gabrielle Meyers
- Division of Hematology and Medical Oncology, Oregon Health & Science University, Portland, Oregon; Section of Geriatrics, Oregon Health & Science University, Portland, Oregon
| | - Timothy Siegel
- Department of Surgery, Oregon Health & Science University, Portland, Oregon; Section of Palliative Care, Division of Hematology & Medical Oncology, Oregon Health & Science University, Portland, Oregon.
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12
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Delgado-Corcoran C, Wawrzynski SE, Flaherty B, Kirkland B, Bodily S, Moore D, Cook LJ, Olson LM. Extracorporeal membrane oxygenation and paediatric palliative care in an ICU. Cardiol Young 2023; 33:1846-1852. [PMID: 36278475 DOI: 10.1017/s1047951122003018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVES Compare rates, clinical characteristics, and outcomes of paediatric palliative care consultation in children supported on extracorporeal membrane oxygenation admitted to a single-centre 16-bed cardiac or a 28-bed paediatric ICU. METHODS Retrospective review of clinical characteristics and outcomes of children (aged 0-21 years) supported on extracorporeal membrane oxygenation between January, 2017 and December, 2019 compared by palliative care consultation. MEASUREMENTS AND RESULTS One hundred children (N = 100) were supported with extracorporeal membrane oxygenation; 19% received a palliative care consult. Compared to non-consulted children, consulted children had higher disease severity measured by higher complex chronic conditions at the end of extracorporeal membrane oxygenation hospitalisation (5 versus. 3; p < 0.001), longer hospital length of stay (92 days versus 19 days; p < 0.001), and higher use of life-sustaining therapies after decannulation (79% versus 23%; p < 0.001). Consultations occurred mainly for longitudinal psychosocial-spiritual support after patient survived device deployment with a median of 27 days after cannulation. Most children died in the ICU after withdrawal of life-sustaining therapies regardless of consultation status. Over two-thirds of the 44 deaths (84%; n = 37) occurred during extracorporeal membrane oxygenation hospitalisation. CONCLUSIONS Palliative care consultation was rare showing that palliative care consultation was not viewed as an acute need and only considered when the clinical course became protracted. As a result, there are missed opportunities to involve palliative care earlier and more frequently in the care of extracorporeal membrane survivors and non-survivors and their families.
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Affiliation(s)
- Claudia Delgado-Corcoran
- Division of Critical Care, Department of Pediatrics, University of Utah, 295 Chipeta Way, PO BOX 581289, Salt Lake City, UT, USA
- Division of Pediatric Palliative Care, Department of Pediatrics, University of Utah, 100 N. Mario Capecchi Dr. Salt Lake City, UT, USA
| | - Sarah E Wawrzynski
- Pediatric Critical Care Services, Primary Children's Hospital, Intermountain Healthcare, 100 N. Mario Capecchi Dr. Salt Lake City, UT, USA
- University of Utah, College of Nursing, 10 S 2000 E, Salt Lake City, UT, USA
| | - Brian Flaherty
- Division of Critical Care, Department of Pediatrics, University of Utah, 295 Chipeta Way, PO BOX 581289, Salt Lake City, UT, USA
| | - Brandon Kirkland
- Division of Critical Care, Department of Pediatrics, University of Utah, 295 Chipeta Way, PO BOX 581289, Salt Lake City, UT, USA
| | - Stephanie Bodily
- Pediatric Critical Care Services, Primary Children's Hospital, Intermountain Healthcare, 100 N. Mario Capecchi Dr. Salt Lake City, UT, USA
| | - Dominic Moore
- Division of Critical Care, Department of Pediatrics, University of Utah, 295 Chipeta Way, PO BOX 581289, Salt Lake City, UT, USA
- Division of Pediatric Palliative Care, Department of Pediatrics, University of Utah, 100 N. Mario Capecchi Dr. Salt Lake City, UT, USA
| | - Lawrence J Cook
- Division of Critical Care, Department of Pediatrics, University of Utah, 295 Chipeta Way, PO BOX 581289, Salt Lake City, UT, USA
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13
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Balakrishna K, Ramasamy T, Venketeswaran MV. Initiation of Palliative Care Referral from the Intensive Care Unit for Advanced Stage Metastatic Cancer Patients: A Quality Improvement Process from a Tertiary Referral Cancer Institute from South India. Indian J Palliat Care 2023; 29:412-417. [PMID: 38058480 PMCID: PMC10696335 DOI: 10.25259/ijpc_267_2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2022] [Accepted: 10/04/2023] [Indexed: 12/08/2023] Open
Abstract
Objectives Critically ill cancer patients in the intensive care unit (ICU) did not have any palliative care (PC) intervention as there was no PC referral from the ICU. The project aimed to initiate PC referral for at least 50% of progressive palliative intent cancer patients in intensive care to enhance communication with patients and caregivers. We included PC physicians, oncologists, and psychologists in the team for this project. Material and Methods We used the A3 problem-solving method of quality improvement (QI) and also used the Plan Do Check Act process. The first baseline assessment over 6 months of ICU deaths of patients who could have benefited from PC referral was collected; this made us realise that PC could have been initiated for some patients. Process maps of patient admission into the ICU and the process of their discharge were constructed. Analysis of root causes that were barriers to referral was examined. We made a PC trigger tool after team consultations and consensus and started using it to initiate PC referrals. PC discharge protocol was also initiated. Educational discussions were held with residents and nurses to ensure the continued use of the trigger tool. Results PC referral from intensive care slowly went up from 0% to beyond 50% by November 2019 and reached over 70% by March 2020; patients getting discharged had details of PC centres near their homes. Conclusion Structured QI process and introducing the PC trigger tool led to the outcome of 50% PC referral for critically ill patients in ICU.
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Affiliation(s)
| | - Thendral Ramasamy
- Department of Anaesthesia and Pain and Palliative Care, Cancer Institute Women’s Indian Association, Chennai, Tamil Nadu, India
| | - Meenakshi V. Venketeswaran
- Department of Anaesthesia and Pain and Palliative Care, Cancer Institute Women’s Indian Association, Chennai, Tamil Nadu, India
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14
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Michels G, Schallenburger M, Neukirchen M. Recommendations on palliative care aspects in intensive care medicine. Crit Care 2023; 27:355. [PMID: 37723595 PMCID: PMC10506254 DOI: 10.1186/s13054-023-04622-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Accepted: 08/20/2023] [Indexed: 09/20/2023] Open
Abstract
BACKGROUND The timely integration of palliative care is important for patients suffering from various advanced diseases with limited prognosis. While a German S-3-guideline on palliative care exists for patients with incurable cancer, a recommendation for non-oncological patients and especially for integration of palliative care into intensive care medicine is missing to date. METHOD Ten German medical societies worked on recommendations on palliative care aspects in intensive care in a consensus process from 2018 to 2023. RESULTS Based on the german consensus paper, the palliative care aspects of the respective medical disciplines concerning intensive care are addressed. The recommendations partly refer to general situations, but also to specific aspects or diseases, such as geriatric issues, heart or lung diseases, encephalopathies and delirium, terminal renal diseases, oncological diseases and palliative emergencies in intensive care medicine. Measures such as non-invasive ventilation for symptom control and compassionate weaning are also included. CONCLUSION The timely integration of palliative care into intensive care medicine aims to improve quality of life and symptom control and also takes into acccount the often urgently needed support for patients' highly stressed relatives.
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Affiliation(s)
- Guido Michels
- Department of Emergency Medicine, Hospital of the Barmherzige Brüder, Trier, Germany
| | - Manuela Schallenburger
- Interdisciplinary Centre for Palliative Medicine, Heinrich-Heine-University Duesseldorf, University Hospital Duesseldorf, Düsseldorf, Germany.
| | - Martin Neukirchen
- Interdisciplinary Centre for Palliative Medicine, Heinrich-Heine-University Duesseldorf, University Hospital Duesseldorf, Düsseldorf, Germany
- Department of Anaesthesiology, Heinrich-Heine-University Duesseldof, Düsseldorf, Germany
- Center of integrated oncology Aachen, Bonn, Cologne (CIO ABCD) Heinrich-Heine-University, Düsseldorf, Germany
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15
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Lustig K, Elsner F, Krumm N, Klasen M, Rolke R, Peuckmann-Post V. [Transition from intensive care to palliative care : A retrospective analysis of 102 consultation requests]. DIE ANAESTHESIOLOGIE 2023; 72:627-634. [PMID: 37548677 PMCID: PMC10457234 DOI: 10.1007/s00101-023-01306-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Revised: 05/23/2023] [Accepted: 06/01/2023] [Indexed: 08/08/2023]
Abstract
BACKGROUND The transition of patients from the intensive care unit (ICU) to the palliative care (PC) ward often implies changes including establishing a palliative concept. Adaptation of therapeutic goals can be challenging for medical staff, patients and relatives; however, descriptions of these transition trajectories are rare. OBJECTIVE The aim of this retrospective study was to characterize the consultation requests of the ICU to the PC consultation team as well as the patients by a description of trajectories and interventions. METHODS Retrospective analysis of all patients receiving intensive care at RWTH Aachen University Hospital in 2019 for whom a PC consultation was requested. The patient population transferred from the ICU to the PC ward was compared with the non-transferred population. In each case, the primary consultation was evaluated regarding the following factors: question, vigilance, length of time from consultation request to its performance, and primary focus of the question. The question focus was categorized into "symptom control", "counselling" and "transfer" (tick options). In addition, a free text field was available for further notes. Exploration of diagnoses was complemented by accessing the electronic health records. RESULTS A total of 102 consultation requests from the ICU to the PC ward were evaluated. The morbidity of patients was high, and most patients had at least one of the following diagnoses: pulmonary (62%), cardiovascular (61%), and/or neurological disease (55%). Of the patients 32 (31%) were transferred to the PC ward, among whom weakness (94%), fatigue (77%), anxiety (55%), pain (53%), and dyspnea (48%) were the most frequently noted symptoms. Of the transferred patients 5 (16%) could be discharged to home, nursing home, hospice or other. In total, 35 (34%) of all patients who were seen by palliative care specialists on ICUs in 2019 could be discharged alive. The most frequent reasons for nonadmission were lack of capacity of the PC ward (33%), dying while being on the waiting list (20%), and refusal by the patient (20%). Of the patients, 7 (26%) died within 48 h after they had been transferred to the PC ward. Performed consultation services "symptom control" (χ2 = 10.17; p < 0.05) and "counselling" (χ2 = 12.82; p < 0.001), which were requested by the intensive care physicians, showed a significant linkage with the respective intervention performed by the palliative care team. On the other hand, no statistically significant difference was found for requested and performed "transfer" of patients from ICUs to PC ward. Comparing the transferred versus non-transferred patient population, a significantly more frequent transfer of patients with malignant tumors (p = 0.00) was observed. CONCLUSION The need for palliative care support in the ICUs exceeded the admission capacity of the PC ward. Future studies should further examine palliative care models in intensive care medicine.
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Affiliation(s)
- Kathrin Lustig
- Klinik für Palliativmedizin, Medizinische Fakultät, RWTH Aachen University, Aachen, Deutschland
| | - Frank Elsner
- Klinik für Palliativmedizin, Medizinische Fakultät, RWTH Aachen University, Aachen, Deutschland
| | - Norbert Krumm
- Klinik für Palliativmedizin, Medizinische Fakultät, RWTH Aachen University, Aachen, Deutschland
| | - Martin Klasen
- AIXTRA, Kompetenzzentrum für Training und Patientensicherheit, Medizinische Fakultät, RWTH Aachen University, Aachen, Deutschland
- Klinik für Anästhesiologie, Medizinische Fakultät, RWTH Aachen University, Aachen, Deutschland
| | - Roman Rolke
- Klinik für Palliativmedizin, Medizinische Fakultät, RWTH Aachen University, Aachen, Deutschland
| | - Vera Peuckmann-Post
- Klinik für Anästhesiologie, Medizinische Fakultät, RWTH Aachen University, Aachen, Deutschland.
- Institut für Arbeits‑, Sozial- und Umweltmedizin, Medizinische Fakultät, RWTH Aachen University, Aachen, Deutschland.
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16
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Michels G, John S, Janssens U, Raake P, Schütt KA, Bauersachs J, Barchfeld T, Schucher B, Delis S, Karpf-Wissel R, Kochanek M, von Bonin S, Erley CM, Kuhlmann SD, Müllges W, Gahn G, Heppner HJ, Wiese CHR, Kluge S, Busch HJ, Bausewein C, Schallenburger M, Pin M, Neukirchen M. [Palliative aspects in clinical acute and emergency medicine as well as intensive care medicine: consensus paper of the DGIIN, DGK, DGP, DGHO, DGfN, DGNI, DGG, DGAI, DGINA and DGPalliativmedizin]. Pneumologie 2023; 77:544-549. [PMID: 37399837 DOI: 10.1055/a-2079-4210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/05/2023]
Abstract
The timely integration of palliative medicine is an important component in the treatment of various advanced diseases. While a German S-3-guideline on palliative medicine exists for patients with incurable cancer, a recommendation for non-oncological patients and especially for palliative patients being treated in the emergency department or intensive care unit is missing to date. Based on the present consensus paper, the palliative care aspects of the respective medical disciplines are addressed. The timely integration of palliative care aims to improve quality of life and symptom control in clinical acute and emergency medicine as well as intensive care.
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Affiliation(s)
- Guido Michels
- Zentrum für Notaufnahme, Krankenhaus der Barmherzigen Brüder Trier, Medizincampus der Universitätsmedizin Mainz, Trier, Deutschland
| | - Stefan John
- Medizinische Klinik 8, Paracelsus Medizinische Privatuniversität & Universität Erlangen-Nürnberg, Klinikum Nürnberg-Süd, Nürnberg, Deutschland
| | - Uwe Janssens
- Klinik für Innere Medizin und Internistische Intensivmedizin, St.-Antonius-Hospital gGmbH, Eschweiler, Deutschland
| | - Philip Raake
- I. Medizinischen Klinik, Universitätsklinikum Augsburg, Herzzentrum Augsburg-Schwaben, Augsburg, Deutschland
| | - Katharina Andrea Schütt
- Uniklinik RWTH Aachen, Klinik für Kardiologie, Angiologie und Internistische Intensivmedizin (Medizinische Klinik I), Aachen, Deutschland
| | - Johann Bauersachs
- Medizinische Hochschule Hannover, Klinik für Kardiologie und Angiologie, Zentrum Innere Medizin, Hannover, Deutschland
| | - Thomas Barchfeld
- Medizinische Klinik II, Klinik für Pneumologie, Intensivmedizin und Schlafmedizin, Knappschaftskrankenhaus Dortmund, Klinikum Westfalen, Deutschland
| | - Bernd Schucher
- LungenClinic Grosshansdorf, Abteilung Pneumologie, Großhansdorf, Deutschland
| | - Sandra Delis
- Helios Klinikum Emil von Behring GmbH, Berlin, Deutschland
| | - Rüdiger Karpf-Wissel
- Universitätsmedizin Essen Ruhrlandklinik, Westdeutsches Lungenzentrum am Universitätsklinikum Essen gGmbH, Klinik für Pneumologie, Essen, Deutschland
| | - Matthias Kochanek
- Medizinische Klinik I, Medizinische Fakultät und Uniklinik Köln, Center for Integrated Oncology (CIO) Cologne-Bonn, Uniklinik Köln, Köln, Deutschland
| | - Simone von Bonin
- Medizinische Klinik und Poliklinik I, Universitätsklinikum Carl Gustav Carus an der Technischen Universität Dresden, Dresden, Deutschland
| | | | | | - Wolfgang Müllges
- Neurologische Klinik und Poliklinik, Universitätsklinikum Würzburg, Würzburg, Deutschland
| | - Georg Gahn
- Neurologische Klinik, Städtisches Klinikum Karlsruhe gGmbH, Karlsruhe, Deutschland
| | - Hans Jürgen Heppner
- Klinik für Geriatrie und Geriatrische Tagesklinik, Klinikum Bayreuth - Medizincampus Oberfranken, Bayreuth, Deutschland
| | - Christoph H R Wiese
- Klinik für Anästhesiologie, Universitätsklinikum Regensburg, Regensburg, Deutschland
- Klinik für Anästhesiologie und Intensivmedizin, HEH Kliniken Braunschweig, Braunschweig, Deutschland
| | - Stefan Kluge
- Klinik für Intensivmedizin, Universitätsklinikum Eppendorf, Hamburg, Deutschland
| | - Hans-Jörg Busch
- Universitätsklinikum, Universitäts-Notfallzentrum, Albert-Ludwigs-Universität Freiburg, Freiburg, Deutschland
| | - Claudia Bausewein
- Klinik und Poliklinik für Palliativmedizin, LMU Klinikum München, München, Deutschland
| | - Manuela Schallenburger
- Interdisziplinäres Zentrum für Palliativmedizin (IZP), Heinrich Heine Universität Düsseldorf, Universitätsklinikum Düsseldorf, Düsseldorf, Deutschland
| | - Martin Pin
- Zentrale Interdisziplinäre Notaufnahme, Florence-Nightingale-Krankenhaus Düsseldorf, Düsseldorf, Deutschland
| | - Martin Neukirchen
- Interdisziplinäres Zentrum für Palliativmedizin (IZP), Heinrich Heine Universität Düsseldorf, Universitätsklinikum Düsseldorf, Düsseldorf, Deutschland
- Klinik für Anästhesiologie, Heinrich Heine Universität Düsseldorf, Universitätsklinikum Düsseldorf, Düsseldorf, Deutschland
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17
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Michels G, John S, Janssens U, Raake P, Schütt KA, Bauersachs J, Barchfeld T, Schucher B, Delis S, Karpf-Wissel R, Kochanek M, von Bonin S, Erley CM, Kuhlmann SD, Müllges W, Gahn G, Heppner HJ, Wiese CHR, Kluge S, Busch HJ, Bausewein C, Schallenburger M, Pin M, Neukirchen M. [Palliative aspects in clinical acute and emergency medicine as well as intensive care medicine : Consensus paper of the DGIIN, DGK, DGP, DGHO, DGfN, DGNI, DGG, DGAI, DGINA and DGPalliativmedizin]. DIE ANAESTHESIOLOGIE 2023:10.1007/s00101-023-01315-y. [PMID: 37394611 DOI: 10.1007/s00101-023-01315-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/04/2023]
Abstract
The timely integration of palliative medicine is an important component in the treatment of various advanced diseases. While a German S‑3-guideline on palliative medicine exists for patients with incurable cancer, a recommendation for non-oncological patients and especially for palliative patients presenting in the emergency department or intensive care unit is missing to date. Based on the present consensus paper, the palliative care aspects of the respective medical disciplines are addressed. The timely integration of palliative care aims to improve quality of life and symptom control in clinical acute and emergency medicine as well as intensive care.
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Affiliation(s)
- Guido Michels
- Zentrum für Notaufnahme, Krankenhaus der Barmherzigen Brüder Trier, Medizincampus Trier der Universitätsmedizin Mainz, Nordallee 1, 54292, Trier, Deutschland.
| | - Stefan John
- Medizinische Klinik 8, Paracelsus Medizinische Privatuniversität & Universität Erlangen-Nürnberg, Klinikum Nürnberg-Süd, Nürnberg, Deutschland
| | - Uwe Janssens
- Klinik für Innere Medizin und Internistische Intensivmedizin, St.-Antonius-Hospital gGmbH, Eschweiler, Deutschland
| | - Philip Raake
- I. Medizinischen Klinik, Universitätsklinikum Augsburg, Herzzentrum Augsburg-Schwaben, Augsburg, Deutschland
| | - Katharina Andrea Schütt
- Klinik für Kardiologie, Angiologie und Internistische Intensivmedizin (Medizinische Klinik I), Uniklinik RWTH Aachen, Aachen, Deutschland
| | - Johann Bauersachs
- Klinik für Kardiologie und Angiologie, Zentrum Innere Medizin, Medizinische Hochschule Hannover, Hannover, Deutschland
| | - Thomas Barchfeld
- Medizinische Klinik II, Klinik für Pneumologie, Intensivmedizin und Schlafmedizin, Knappschaftskrankenhaus Dortmund, Klinikum Westfalen, Dortmund, Deutschland
| | - Bernd Schucher
- Abteilung Pneumologie, LungenClinic Grosshansdorf, Großhansdorf, Deutschland
| | - Sandra Delis
- Helios Klinikum Emil von Behring GmbH, Berlin, Deutschland
| | - Rüdiger Karpf-Wissel
- Universitätsmedizin Essen Ruhrlandklinik, Westdeutsches Lungenzentrum am Universitätsklinikum Essen gGmbH, Klinik für Pneumologie, Essen, Deutschland
| | - Matthias Kochanek
- Medizinische Klinik I, Medizinische Fakultät und Uniklinik Köln, Center for Integrated Oncology (CIO) Cologne-Bonn, Uniklinik Köln, Köln, Deutschland
| | - Simone von Bonin
- Medizinische Klinik und Poliklinik I, Universitätsklinikum Carl Gustav Carus an der Technischen Universität Dresden, Dresden, Deutschland
| | | | | | - Wolfgang Müllges
- Neurologische Klinik und Poliklinik, Universitätsklinikum Würzburg, Würzburg, Deutschland
| | - Georg Gahn
- Neurologische Klinik, Städtisches Klinikum Karlsruhe gGmbH, Karlsruhe, Deutschland
| | - Hans Jürgen Heppner
- Klinik für Geriatrie und Geriatrische Tagesklinik, Klinikum Bayreuth - Medizincampus Oberfranken, Bayreuth, Deutschland
- Institut für Biomedizin des Alterns, Universität Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen-Nürnberg, Deutschland
- HELIOS Klinikum Schwelm, Schwelm, Deutschland
| | - Christoph H R Wiese
- Klinik für Anästhesiologie, Universitätsklinikum Regensburg, Regensburg, Deutschland
- Klinik für Anästhesiologie und Intensivmedizin, HEH Kliniken Braunschweig, Braunschweig, Deutschland
| | - Stefan Kluge
- Klinik für Intensivmedizin, Universitätsklinikum Eppendorf, Hamburg, Deutschland
| | - Hans-Jörg Busch
- Zentrum für Notfall- und Rettungsmedizin, Universitäts-Notfallzentrum (UNZ), Medizinische Fakultät, Albert-Ludwigs-Universität Freiburg, Freiburg, Deutschland
| | - Claudia Bausewein
- Klinik und Poliklinik für Palliativmedizin, LMU Klinikum München, München, Deutschland
| | - Manuela Schallenburger
- Interdisziplinäres Zentrum für Palliativmedizin (IZP), Heinrich Heine Universität Düsseldorf, Universitätsklinikum Düsseldorf, Düsseldorf, Deutschland
| | - Martin Pin
- Zentrale Interdisziplinäre Notaufnahme, Florence-Nightingale-Krankenhaus Düsseldorf, Düsseldorf, Deutschland
| | - Martin Neukirchen
- Interdisziplinäres Zentrum für Palliativmedizin (IZP), Heinrich Heine Universität Düsseldorf, Universitätsklinikum Düsseldorf, Düsseldorf, Deutschland
- Klinik für Anästhesiologie, Heinrich Heine Universität Düsseldorf, Universitätsklinikum Düsseldorf, Düsseldorf, Deutschland
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18
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Michels G, John S, Janssens U, Raake P, Schütt KA, Bauersachs J, Barchfeld T, Schucher B, Delis S, Karpf-Wissel R, Kochanek M, von Bonin S, Erley CM, Kuhlmann SD, Müllges W, Gahn G, Heppner HJ, Wiese CHR, Kluge S, Busch HJ, Bausewein C, Schallenburger M, Pin M, Neukirchen M. [Palliative aspects in clinical acute and emergency medicine as well as intensive care medicine : Consensus paper of the DGIIN, DGK, DGP, DGHO, DGfN, DGNI, DGG, DGAI, DGINA and DGPalliativmedizin]. Z Gerontol Geriatr 2023:10.1007/s00391-023-02213-z. [PMID: 37394541 DOI: 10.1007/s00391-023-02213-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/04/2023]
Abstract
The timely integration of palliative medicine is an important component in the treatment of various advanced diseases. While a German S‑3-guideline on palliative medicine exists for patients with incurable cancer, a recommendation for non-oncological patients and especially for palliative patients presenting in the emergency department or intensive care unit is missing to date. Based on the present consensus paper, the palliative care aspects of the respective medical disciplines are addressed. The timely integration of palliative care aims to improve quality of life and symptom control in clinical acute and emergency medicine as well as intensive care.
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Affiliation(s)
- Guido Michels
- Zentrum für Notaufnahme, Krankenhaus der Barmherzigen Brüder Trier, Medizincampus Trier der Universitätsmedizin Mainz, Nordallee 1, 54292, Trier, Deutschland.
| | - Stefan John
- Medizinische Klinik 8, Paracelsus Medizinische Privatuniversität & Universität Erlangen-Nürnberg, Klinikum Nürnberg-Süd, Nürnberg, Deutschland
| | - Uwe Janssens
- Klinik für Innere Medizin und Internistische Intensivmedizin, St.-Antonius-Hospital gGmbH, Eschweiler, Deutschland
| | - Philip Raake
- I. Medizinischen Klinik, Universitätsklinikum Augsburg, Herzzentrum Augsburg-Schwaben, Augsburg, Deutschland
| | - Katharina Andrea Schütt
- Klinik für Kardiologie, Angiologie und Internistische Intensivmedizin (Medizinische Klinik I), Uniklinik RWTH Aachen, Aachen, Deutschland
| | - Johann Bauersachs
- Klinik für Kardiologie und Angiologie, Zentrum Innere Medizin, Medizinische Hochschule Hannover, Hannover, Deutschland
| | - Thomas Barchfeld
- Medizinische Klinik II, Klinik für Pneumologie, Intensivmedizin und Schlafmedizin, Knappschaftskrankenhaus Dortmund, Klinikum Westfalen, Dortmund, Deutschland
| | - Bernd Schucher
- Abteilung Pneumologie, LungenClinic Grosshansdorf, Großhansdorf, Deutschland
| | - Sandra Delis
- Helios Klinikum Emil von Behring GmbH, Berlin, Deutschland
| | - Rüdiger Karpf-Wissel
- Universitätsmedizin Essen Ruhrlandklinik, Westdeutsches Lungenzentrum am Universitätsklinikum Essen gGmbH, Klinik für Pneumologie, Essen, Deutschland
| | - Matthias Kochanek
- Medizinische Klinik I, Medizinische Fakultät und Uniklinik Köln, Center for Integrated Oncology (CIO) Cologne-Bonn, Uniklinik Köln, Köln, Deutschland
| | - Simone von Bonin
- Medizinische Klinik und Poliklinik I, Universitätsklinikum Carl Gustav Carus an der Technischen Universität Dresden, Dresden, Deutschland
| | | | | | - Wolfgang Müllges
- Neurologische Klinik und Poliklinik, Universitätsklinikum Würzburg, Würzburg, Deutschland
| | - Georg Gahn
- Neurologische Klinik, Städtisches Klinikum Karlsruhe gGmbH, Karlsruhe, Deutschland
| | - Hans Jürgen Heppner
- Klinik für Geriatrie und Geriatrische Tagesklinik, Klinikum Bayreuth - Medizincampus Oberfranken, Bayreuth, Deutschland
- Institut für Biomedizin des Alterns, Universität Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen-Nürnberg, Deutschland
- HELIOS Klinikum Schwelm, Schwelm, Deutschland
| | - Christoph H R Wiese
- Klinik für Anästhesiologie, Universitätsklinikum Regensburg, Regensburg, Deutschland
- Klinik für Anästhesiologie und Intensivmedizin, HEH Kliniken Braunschweig, Braunschweig, Deutschland
| | - Stefan Kluge
- Klinik für Intensivmedizin, Universitätsklinikum Eppendorf, Hamburg, Deutschland
| | - Hans-Jörg Busch
- Zentrum für Notfall- und Rettungsmedizin, Universitäts-Notfallzentrum (UNZ), Medizinische Fakultät, Albert-Ludwigs-Universität Freiburg, Freiburg, Deutschland
| | - Claudia Bausewein
- Klinik und Poliklinik für Palliativmedizin, LMU Klinikum München, München, Deutschland
| | - Manuela Schallenburger
- Interdisziplinäres Zentrum für Palliativmedizin (IZP), Heinrich Heine Universität Düsseldorf, Universitätsklinikum Düsseldorf, Düsseldorf, Deutschland
| | - Martin Pin
- Zentrale Interdisziplinäre Notaufnahme, Florence-Nightingale-Krankenhaus Düsseldorf, Düsseldorf, Deutschland
| | - Martin Neukirchen
- Interdisziplinäres Zentrum für Palliativmedizin (IZP), Heinrich Heine Universität Düsseldorf, Universitätsklinikum Düsseldorf, Düsseldorf, Deutschland
- Klinik für Anästhesiologie, Heinrich Heine Universität Düsseldorf, Universitätsklinikum Düsseldorf, Düsseldorf, Deutschland
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19
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Downar J, Hua M, Wunsch H. Palliative Care in the Intensive Care Unit: Past, Present, and Future. Crit Care Clin 2023; 39:529-539. [PMID: 37230554 DOI: 10.1016/j.ccc.2023.01.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
In this article, the authors review the origins of palliative care within the critical care context and describe the evolution of symptom management, shared decision-making, and comfort-focused care in the ICU from the 1970s to the early 2000s. The authors also review the growth of interventional studies in the past 20 years and indicate areas for future study and quality improvement for end-of-life care among the critically ill.
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Affiliation(s)
- James Downar
- Division of Palliative Care, Department of Medicine, University of Ottawa, 43 Rue Bruyere, Suite 268J, Ottawa K1N 5C8, Canada; Department of Critical Care, The Ottawa Hospital, 1053 Carling Avenue, Ottawa, ON K1Y 4E9, Canada.
| | - May Hua
- Department of Anesthesiology, Columbia University, 622 West 168th Street, New York, NY 10032, USA; Department of Epidemiology, Mailman School of Public Health, Columbia University, 722 West 168th Street, New York, NY 10032, USA
| | - Hannah Wunsch
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, ON M4N 3M5, Canada; Department of Anesthesiology and Pain Medicine and Interdepartmental Division of Critical Care Medicine, University of Toronto, 2075 Bayview Avenue, Room D1.08, Toronto, Ontario M4N 3M5, Canada
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20
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Iguina MM, Danyalian AM, Luque I, Shaikh U, Kashan SB, Morgan D, Heller D, Danckers M. Characteristics, ICU Interventions, and Clinical Outcomes of Patients With Palliative Care Triggers in a Mixed Community-Based Intensive Care Unit. J Palliat Care 2023; 38:126-134. [PMID: 36632687 DOI: 10.1177/08258597221145326] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Objective: Integration of palliative care initiatives in the intensive care unit (ICU) benefit patients and improve outcomes. Palliative care triggers (PCTs) is a screening tool that aides in stratifying patients who would benefit most from an early palliative care approach. There is no consensus on PCT selection or best timing for implementation. We evaluated the clinical characteristics, ICU and palliative care interventions, and clinical outcomes of critically ill patients with PCT in a community-based mixed ICU. Methods: This retrospective study was conducted in a 44-bed adult, mixed ICU in a 407-bed community-based teaching hospital in Florida. Eleven PCTs were used as a screening tool during multidisciplinary rounds (MDRs). Patients were analyzed based on presence or absence of PCT as well as having met high (>2) versus low (<2) PCT. Data collected included patient demographics, ICU resource utilization and clinical outcomes. We considered a two-sided P value of less than .05 to indicate statistical significance with a 95% confidence interval. Results: Of 388 ICU patients, 189 (48.7%) met at least 1 PCT and 199 (51.3%) did not. The trigger group had higher Acute Physiology and Chronic Evaluation (APACHE) and Sequential Organ Failure Assessment (SOFA) scores within 24 h of ICU admission. The most common PCTs identified were ICU length of stay greater than 7 days or readmission to ICU, terminal prognosis and assisting family in transitioning goals of care. There were statistically significant differences in ICU resource utilization, palliative care interventions, and overall worse clinical outcomes in the trigger-detected group. Similar findings were seen in the cohort with high PCT (>2). Conclusions: Our study supports the implementation of a tailored 11-item palliative care screening tool to effectively identify ICU patients with high ICU and palliative care interventions and worse clinical outcomes.
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Affiliation(s)
- Michele M Iguina
- Department of Medicine, HCA Florida Aventura Hospital, Aventura, FL, USA
- Division of Critical Care, HCA Florida Aventura Hospital, Aventura, FL, USA
| | - Aunie M Danyalian
- Department of Medicine, HCA Florida Aventura Hospital, Aventura, FL, USA
- Division of Critical Care, HCA Florida Aventura Hospital, Aventura, FL, USA
| | - Ilko Luque
- Research Department, Graduate Medical Education, HCA East Florida Division, 23686Aventura Hospital and Medical Center, Aventura, FL, USA
| | - Umair Shaikh
- Department of Medicine, Piedmont Eastside Medical Center, Snellville, GA, USA
| | - Sanaz B Kashan
- Department of Medicine, HCA Florida Aventura Hospital, Aventura, FL, USA
| | - Dionne Morgan
- Department of Medicine, HCA Florida Aventura Hospital, Aventura, FL, USA
- Division of Critical Care, HCA Florida Aventura Hospital, Aventura, FL, USA
| | - Daniel Heller
- Department of Medicine, HCA Florida Aventura Hospital, Aventura, FL, USA
- Division of Critical Care, HCA Florida Aventura Hospital, Aventura, FL, USA
| | - Mauricio Danckers
- Department of Medicine, HCA Florida Aventura Hospital, Aventura, FL, USA
- Division of Critical Care, HCA Florida Aventura Hospital, Aventura, FL, USA
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21
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Cox CE, Gu J, Ashana DC, Pratt EH, Haines K, Ma J, Olsen MK, Parish A, Casarett D, Al-Hegelan MS, Naglee C, Katz JN, O'Keefe YA, Harrison RW, Riley IL, Bermejo S, Dempsey K, Johnson KS, Docherty SL. Trajectories of Palliative Care Needs in the ICU and Long-Term Psychological Distress Symptoms. Crit Care Med 2023; 51:13-24. [PMID: 36326263 PMCID: PMC10191149 DOI: 10.1097/ccm.0000000000005701] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVES While palliative care needs are assumed to improve during ICU care, few empiric data exist on need trajectories or their impact on long-term outcomes. We aimed to describe trajectories of palliative care needs during ICU care and to determine if changes in needs over 1 week was associated with similar changes in psychological distress symptoms at 3 months. DESIGN Prospective cohort study. SETTING Six adult medical and surgical ICUs. PARTICIPANTS Patients receiving mechanical ventilation for greater than or equal to 2 days and their family members. MEASUREMENTS AND MAIN RESULTS The primary outcome was the 13-item Needs at the End-of-Life Screening Tool (NEST; total score range 0-130) completed by family members at baseline, 3, and 7 days. The Patient Health Questionnaire-9 (PHQ-9), Generalized Anxiety Disorder-7 (GAD-7), and Post-Traumatic Stress Scale (PTSS) were completed at baseline and 3 months. General linear models were used to estimate differences in distress symptoms by change in need (NEST improvement ≥ 10 points or not). One-hundred fifty-nine family members participated (median age, 54.0 yr [interquartile range (IQR), 44.0-63.0 yr], 125 [78.6%] female, 54 [34.0%] African American). At 7 days, 53 (33%) a serious level of overall need and 35 (22%) ranked greater than or equal to 1 individual need at the highest severity level. NEST scores improved greater than or equal to 10 points in only 47 (30%). Median NEST scores were 22 (IQR, 12-40) at baseline and 19 (IQR, 9-37) at 7 days (change, -2.0; IQR, -11.0 to 5.0; p = 0.12). There were no differences in PHQ-9, GAD-7, or PTSS change scores by change in NEST score (all p > 0.15). CONCLUSIONS Serious palliative care needs were common and persistent among families during ICU care. Improvement in needs was not associated with less psychological distress at 3 months. Serious needs may be commonly underrecognized in current practice.
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Affiliation(s)
- Christopher E Cox
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Duke University School of Medicine, Durham, NC
- Program to Support People and Enhance Recovery (ProSPER), Duke University, Durham, NC
| | - Jessie Gu
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Duke University School of Medicine, Durham, NC
- Program to Support People and Enhance Recovery (ProSPER), Duke University, Durham, NC
| | - Deepshikha Charan Ashana
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Duke University School of Medicine, Durham, NC
- Program to Support People and Enhance Recovery (ProSPER), Duke University, Durham, NC
| | - Elias H Pratt
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Duke University School of Medicine, Durham, NC
- Program to Support People and Enhance Recovery (ProSPER), Duke University, Durham, NC
| | - Krista Haines
- Program to Support People and Enhance Recovery (ProSPER), Duke University, Durham, NC
- Department of Surgery, Division of Trauma and Critical Care and Acute Care Surgery, Duke University, Durham, NC
| | - Jessica Ma
- Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, Duke University, Durham, NC
- Geriatric Research, Education, and Clinical Center, Durham VA Healthcare System, Durham, NC
| | - Maren K Olsen
- Department of Biostatistics and Bioinformatics, Duke University, Durham, NC
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, NC
| | - Alice Parish
- Department of Biostatistics and Bioinformatics, Duke University, Durham, NC
| | - David Casarett
- Department of Medicine, Section of Palliative Care and Hospice Medicine, Duke University, Durham, NC
| | - Mashael S Al-Hegelan
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Duke University School of Medicine, Durham, NC
| | - Colleen Naglee
- Department of Anesthesiology, Duke University, Durham, NC
- Department of Neurology, Division of Neurocritical Care, Duke University, Durham, NC
| | - Jason N Katz
- Division of Cardiology, Department of Medicine, Duke University School of Medicine, Durham, NC
| | - Yasmin Ali O'Keefe
- Department of Neurology, Division of Neurocritical Care, Duke University, Durham, NC
| | - Robert W Harrison
- Division of Cardiology, Department of Medicine, Duke University School of Medicine, Durham, NC
| | - Isaretta L Riley
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Duke University School of Medicine, Durham, NC
- Program to Support People and Enhance Recovery (ProSPER), Duke University, Durham, NC
| | - Santos Bermejo
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Duke University School of Medicine, Durham, NC
- Program to Support People and Enhance Recovery (ProSPER), Duke University, Durham, NC
| | - Katelyn Dempsey
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Duke University School of Medicine, Durham, NC
- Program to Support People and Enhance Recovery (ProSPER), Duke University, Durham, NC
| | - Kimberly S Johnson
- Geriatric Research, Education, and Clinical Center, Durham VA Healthcare System, Durham, NC
- Division of Geriatrics, Department of Medicine, Duke University School of Medicine, Durham, NC
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22
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Braulke F, Kober K, Arndt A, Papendick M, Strauss A, Kramm CM, Thoms KM, König A, Gaedcke J, Gallwas J, Wulf S, Szuszies C, Wulf G, Rödel R, Wolfer S, Malinova V, Overbeck TR, Hinterthaner M, Lotz J, Nauck F, Ernst M, Stadelmann C, Ströbel P, Ellenrieder V, Asendorf T, Rieken S. Optimizing the structure of interdisciplinary tumor boards for effective cancer care. Front Oncol 2023; 13:1072652. [PMID: 37182140 PMCID: PMC10171921 DOI: 10.3389/fonc.2023.1072652] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Accepted: 03/31/2023] [Indexed: 05/16/2023] Open
Abstract
Introduction Multi-professional interdisciplinary tumor boards (ITB) are essential institutions to discuss all newly diagnosed, relapsed or complex cancer patients in a team of specialists to find an optimal cancer care plan for each individual patient with regard to national and international clinical practice guidelines, patient´s preference and comorbidities. In a high-volume cancer center, entity-specific ITBs take place at least once a week discussing a large number of patients. To a high level of expertise and dedication, this also requires an enormous amount of time for physicians, cancer specialists and administrative support colleagues, especially for radiologists, pathologists, medical oncologists and radiation oncologists, who must attend all cancer-specific boards according to certification requirements. Methods In this 15-month prospective German single-center analysis, we examined the established structures of 12 different cancer-specific ITBs at the certified Oncology Center and demonstrate tools helping to optimize processes before, during and after the boards for optimal, time-saving procedures. Results By changing pathways, introducing revised registration protocols and new digital supports we could show that the workload of preparation by radiologists and pathologists could be reduced significantly by 22.9% (p=<0.0001) and 52.7% (p=<0.0001), respectively. Furthermore, two questions were added to all registration forms about the patient´s need for specialized palliative care support that should lead to more awareness and early integration of specialized help. Discussion There are several ways to reduce the workload of all ITB team members while maintaining high quality recommendations and adherence to national and international guidelines.
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Affiliation(s)
- Friederike Braulke
- Comprehensive Cancer Center, University Medical Center Göttingen, Göttingen, Germany
| | - Kathrin Kober
- Comprehensive Cancer Center, University Medical Center Göttingen, Göttingen, Germany
| | - Andreas Arndt
- Comprehensive Cancer Center, University Medical Center Göttingen, Göttingen, Germany
| | - Maximilian Papendick
- Comprehensive Cancer Center, University Medical Center Göttingen, Göttingen, Germany
| | - Arne Strauss
- Department of Urology, University Medical Center Göttingen, Göttingen, Germany
| | - Christof Maria Kramm
- Division of Pediatric Hematology and Oncology, Department of Pediatrics and Adolescent Medicine, University Medical Center Göttingen, Göttingen, Germany
| | - Kai-Martin Thoms
- Department of Dermatology, Venereology and Allergology, University Medical Center Göttingen, Göttingen, Germany
| | - Alexander König
- Department of Gastroenterology, Gastrointestinal Oncology and Endocrinology, University Medical Center Göttingen, Göttingen, Germany
| | - Jochen Gaedcke
- Department of General, Visceral and Pediatric Surgery, University Medical Center Göttingen, Göttingen, Germany
| | - Julia Gallwas
- Department of Gynaecology and Obstetrics, University Medical Center Göttingen, Göttingen, Germany
| | - Svenja Wulf
- Department of Gynaecology and Obstetrics, University Medical Center Göttingen, Göttingen, Germany
| | - Christoph Szuszies
- Department of Hematology and Medical Oncology, University Medical Center Göttingen, Göttingen, Germany
| | - Gerald Wulf
- Department of Hematology and Medical Oncology, University Medical Center Göttingen, Göttingen, Germany
| | - Ralph Rödel
- Department of Otorhinolaryngology, University Medical Center Göttingen, Göttingen, Germany
| | - Susanne Wolfer
- Department of Oral and Maxillofacial Surgery, University Medical Center Göttingen, Göttingen, Germany
| | - Vesna Malinova
- Department of Neurosurgery, University Medical Center Göttingen, Göttingen, Germany
| | - Tobias R. Overbeck
- Department of Hematology and Medical Oncology, University Medical Center Göttingen, Göttingen, Germany
| | - Marc Hinterthaner
- Department of Thoracic and Cardiovascular Surgery, University Medical Center Göttingen, Göttingen, Germany
| | - Joachim Lotz
- Institute for Diagnostic and Interventional Radiology, University Medical Center Göttingen, Göttingen, Germany
| | - Friedemann Nauck
- Department of Palliative Medicine, University Medical Center Göttingen, Göttingen, Germany
| | - Marielle Ernst
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Göttingen, Göttingen, Germany
| | - Christine Stadelmann
- Institute of Neuropathology, University Medical Center Göttingen, Göttingen, Germany
| | - Philipp Ströbel
- Institute of Pathology, University Medical Center Göttingen, Göttingen, Germany
| | - Volker Ellenrieder
- Department of Gastroenterology, Gastrointestinal Oncology and Endocrinology, University Medical Center Göttingen, Göttingen, Germany
| | - Thomas Asendorf
- Department of Medical Statistics, University Medical Center Göttingen, Göttingen, Germany
| | - Stefan Rieken
- Department of Radiotherapy and Radiation Oncology, University Medical Center Göttingen, Göttingen, Germany
- *Correspondence: Stefan Rieken,
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23
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Spencer AL, Nunn AM, Miller PR, Russell GB, Carmichael SP, Neri KE, Marterre B. The value of compassion: Healthcare savings of palliative care consults in trauma. Injury 2023; 54:249-255. [PMID: 36307268 PMCID: PMC11210453 DOI: 10.1016/j.injury.2022.10.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Revised: 10/03/2022] [Accepted: 10/18/2022] [Indexed: 11/05/2022]
Abstract
BACKGROUND The effects of palliative care (PC) consultation on patient costs and hospitalization metrics in the adult trauma population are unclear. STUDY DESIGN We interrogated our Level I trauma center databases from 1/1/19 to 3/31/21 for patients age ≥18 admitted to the trauma service. Patients undergoing PC consult were matched using propensity scoring to those without PC consultation based on age, admission Glasgow Coma Scale score, Injury Severity Score and Head Abbreviated Injury Scale. Total costs, total cost per day, hospital length of stay (LOS), ICU LOS, intubation days, discharge disposition, and rates of nephrology consultation and tracheostomy/feeding tube placements were compared. RESULTS 140 unique patients underwent PC consultation and were matched to a group not receiving PC consult during the same period. Median total costs in the PC cohort were $39,532 compared to $70,330 in the controls (p<0.01). Median costs per day in the PC cohort were $3,495 vs $17,970 in the controls (p<0.01). Median costs per ICU day in the PC cohort were $3,774 vs $17,127 in the controls (p<0.01). Mean hospital LOS (15.7 vs 7 days), ICU LOS (7.9 vs 2.9 days), and ventilator days (5.1 vs 1.5) were significantly higher in the PC cohort (all p<0.01). Rates of nephrology consultation (8.6 vs 2.1%, p = 0.03) and tracheostomy/feeding tube placements (12.1 vs 1.4%, p<0.01) were also higher in the PC group. Patients were more likely to discharge to hospice if they received a PC consult (33.6 vs 2.1%, p<0.01). Mean time to PC consult was 7.2 days (range 1 hour to 45 days). LOS post-consult correlated positively with time to PC consultation (r = 0.27, p<0.01). CONCLUSION Expert PC services are known to alleviate suffering and avert patient goal- and value-incongruent care. While trauma patients demand significant resources, PC consultation offered in concordance with life-sustaining interventions is associated with significant savings to patients and the healthcare system. Given the correlation between LOS following PC consult and time to PC consult, savings may be amplified by earlier PC consultation in appropriate patients.
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Affiliation(s)
- Audrey L Spencer
- Department of Surgery, University of Arizona College of Medicine, 1501 North Campbell Avenue, Room 5411, Tower 4, Tucson, AZ 85724, United States of America.
| | - Andrew M Nunn
- Department of Surgery, Atrium Health Wake Forest Baptist, 1 Medical Center Boulevard, Winston-Salem, NC 27157, United States of America.
| | - Preston R Miller
- Department of Surgery, Atrium Health Wake Forest Baptist, 1 Medical Center Boulevard, Winston-Salem, NC 27157, United States of America.
| | - Gregory B Russell
- Department of Biostatistics & Data Science, Atrium Health Wake Forest Baptist, 1 Medical Center Boulevard, Winston-Salem, NC 27157, United States of America.
| | - Samuel P Carmichael
- Department of Surgery, Atrium Health Wake Forest Baptist, 1 Medical Center Boulevard, Winston-Salem, NC 27157, United States of America.
| | - Kristina E Neri
- Wake Forest University School of Medicine, Bowman Gray Center for Medical Education, 475 Vine Street, Winston-Salem, NC 27101, United States of America.
| | - Buddy Marterre
- Departments of Surgery & Internal Medicine, Atrium Health Wake Forest Baptist, 1 Medical Center Boulevard, Winston-Salem, NC 27157, United States of America.
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24
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Tsai WC, Tsai YC, Kuo KC, Cheng SY, Tsai JS, Chiu TY, Huang HL. Natural language processing and network analysis in patients withdrawing from life-sustaining treatments: a retrospective cohort study. BMC Palliat Care 2022; 21:225. [PMID: 36550430 PMCID: PMC9773475 DOI: 10.1186/s12904-022-01119-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2022] [Accepted: 12/07/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Providing palliative care to patients who withdraw from life-sustaining treatments is crucial; however, delays or the absence of such services are prevalent. This study used natural language processing and network analysis to identify the role of medications as early palliative care referral triggers. METHODS We conducted a retrospective observational study of 119 adult patients receiving specialized palliative care after endotracheal tube withdrawal in intensive care units of a Taiwan-based medical center between July 2016 and June 2018. Patients were categorized into early integration and late referral groups based on the median survival time. Using natural language processing, we analyzed free texts from electronic health records. The Palliative trigger index was also calculated for comparison, and network analysis was performed to determine the co-occurrence of terms between the two groups. RESULTS Broad-spectrum antibiotics, antifungal agents, diuretics, and opioids had high Palliative trigger index. The most common co-occurrences in the early integration group were micafungin and voriconazole (co-correlation = 0.75). However, in the late referral group, piperacillin and penicillin were the most common co-occurrences (co-correlation = 0.843). CONCLUSION Treatments for severe infections, chronic illnesses, and analgesics are possible triggers for specialized palliative care consultations. The Palliative trigger index and network analysis indicated the need for palliative care in patients withdrawing from life-sustaining treatments. This study recommends establishing a therapeutic control system based on computerized order entry and integrating it into a shared-decision model.
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Affiliation(s)
- Wei-Chin Tsai
- Department of Family Medicine, National Taiwan University Hospital Hsin-Chu Branch, No. 25, Ln. 442, Sec. 1, Jingguo Rd., North Dist., Hsinchu City, 300 Taiwan (R.O.C.)
| | - Yun-Cheng Tsai
- grid.412090.e0000 0001 2158 7670Department of Technology Application and Human Resource Development, National Taiwan Normal University, 162, Section 1, Heping E. Rd., Taipei City, 106 Taiwan (R.O.C.)
| | - Kuang-Cheng Kuo
- grid.19188.390000 0004 0546 0241Department of Medicine, National Taiwan University, No.1 Jen Ai Road Section 1, Taipei, 100 Taiwan (R.O.C.)
| | - Shao-Yi Cheng
- grid.19188.390000 0004 0546 0241Department of Family Medicine, College of Medicine and Hospital, National Taiwan University, 7 Chung-Shan South Road, Taipei, 100 Taiwan (R.O.C.)
| | - Jaw-Shiun Tsai
- grid.19188.390000 0004 0546 0241Department of Family Medicine, College of Medicine and Hospital, National Taiwan University, 7 Chung-Shan South Road, Taipei, 100 Taiwan (R.O.C.)
| | - Tai-Yuan Chiu
- grid.19188.390000 0004 0546 0241Department of Family Medicine, College of Medicine and Hospital, National Taiwan University, 7 Chung-Shan South Road, Taipei, 100 Taiwan (R.O.C.)
| | - Hsien-Liang Huang
- grid.19188.390000 0004 0546 0241Department of Medicine, National Taiwan University, No.1 Jen Ai Road Section 1, Taipei, 100 Taiwan (R.O.C.) ,grid.19188.390000 0004 0546 0241Department of Family Medicine, College of Medicine and Hospital, National Taiwan University, 7 Chung-Shan South Road, Taipei, 100 Taiwan (R.O.C.)
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25
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Alshehri HH, Wolf A, Öhlén J, Olausson S. Healthcare Professionals' Perspective on Palliative Care in Intensive Care Settings: An Interpretive Descriptive Study. Glob Qual Nurs Res 2022; 9:23333936221138077. [PMID: 36507302 PMCID: PMC9729985 DOI: 10.1177/23333936221138077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Revised: 09/24/2022] [Accepted: 10/04/2022] [Indexed: 12/12/2022] Open
Abstract
There is a growing need to integrate palliative care into intensive care units and to develop appropriate knowledge translation strategies. However, multiple challenges persist in attempts to achieve this objective. In this study, we aimed to explore intensive care professionals' perspectives on providing palliative and end-of-life care within an intensive care context. We used an interpretive description approach and interviewed 36 intensive care professionals at four hospitals in Saudi Arabia. Our findings reflect a discourse about end-of-life care driven by a do-not-resuscitate classification and challenges associated with family involvement in care goals. We provide key insights of importance for the development of strategies for the integration and knowledge translation of palliative care into intensive care contexts.
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Affiliation(s)
- Hanan Hamdan Alshehri
- Institute of Health and Care Sciences, Sahlgrenska Academy, University of Gothenburg, Sweden
- Hanan Hamdan Alshehri, University of Gothenburg Sahlgrenska Academy, Box 457 405 30 Göteborg, Goteborg 405 30, Sweden. Emails: ;
| | - Axel Wolf
- Institute of Health and Care Sciences, Sahlgrenska Academy, University of Gothenburg, Sweden
- University of Gothenburg and Region Västra Götaland, Sahlgrenska University Hospital/Östra, Sweden
| | - Joakim Öhlén
- Institute of Health and Care Sciences, Sahlgrenska Academy, University of Gothenburg, Sweden
- University of Gothenburg and Palliative Centre, Sahlgrenska University Hospital Region Västra Götaland, Sweden
| | - Sepideh Olausson
- Institute of Health and Care Sciences, Sahlgrenska Academy, University of Gothenburg, Sweden
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Gupta N, Gupta R, Gupta A. Rationale for integration of palliative care in the medical intensive care: A narrative literature review. World J Crit Care Med 2022; 11:342-348. [PMID: 36439323 PMCID: PMC9693909 DOI: 10.5492/wjccm.v11.i6.342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Revised: 05/01/2022] [Accepted: 09/07/2022] [Indexed: 02/05/2023] Open
Abstract
Despite the remarkable technological advancement in the arena of critical care expertise, the mortality of critically ill patients remains high. When the organ functions deteriorate, goals of care are not fulfilled and life-sustaining treatment becomes a burden on the patient and caregivers, then it is the responsibility of the physician to provide a dignified end to life, control the symptoms of the patient and provide psychological support to the family members. Palliative care is the best way forward for these patients. It is a multidimensional specialty which emphasizes patient and family-based care and aims to improve the quality of life of patients and their caregivers. Although intensive care and palliative care may seem to be at two opposite ends of the spectrum, it is necessary to amalgamate the postulates of palliative care in intensive care units to provide holistic care and best benefit patients admitted to intensive care units. This review aims to highlight the need for an alliance of palliative care with intensive care in the present era, the barriers to it, and models proposed for their integration and various ethical issues.
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Affiliation(s)
- Nishkarsh Gupta
- Department of Anesthesiology, All India Institute of Medical Sciences, Delhi 110029, India
| | - Raghav Gupta
- Department of Onco-Anesthesiology and Palliative Medicine, All India Institute of Medical Sciences, Delhi 110029, India
| | - Anju Gupta
- Department of Anesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, Delhi 110029, India
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Murali KP, Fonseca LD, Blinderman CD, White DB, Hua M. Clinicians' Views on the use of triggers for specialist palliative care in the ICU: A qualitative secondary analysis. J Crit Care 2022; 71:154054. [DOI: 10.1016/j.jcrc.2022.154054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Revised: 04/21/2022] [Accepted: 04/25/2022] [Indexed: 11/25/2022]
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Cox CE, Olsen MK, Parish A, Gu J, Ashana DC, Pratt EH, Haines K, Ma J, Casarett DJ, Al-Hegelan MS, Naglee C, Katz JN, O'Keefe YA, Harrison RW, Riley IL, Bermejo S, Dempsey K, Wolery S, Jaggers J, Johnson KS, Docherty SL. Palliative care phenotypes among critically ill patients and family members: intensive care unit prospective cohort study. BMJ Support Palliat Care 2022; 14:bmjspcare-2022-003622. [PMID: 36167642 PMCID: PMC10085460 DOI: 10.1136/spcare-2022-003622] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Accepted: 09/16/2022] [Indexed: 01/19/2023]
Abstract
OBJECTIVE Because the heterogeneity of patients in intensive care units (ICUs) and family members represents a challenge to palliative care delivery, we aimed to determine if distinct phenotypes of palliative care needs exist. METHODS Prospective cohort study conducted among family members of adult patients undergoing mechanical ventilation in six medical and surgical ICUs. The primary outcome was palliative care need measured by the Needs at the End-of-Life Screening Tool (NEST, range from 0 (no need) to 130 (highest need)) completed 3 days after ICU admission. We also assessed quality of communication, clinician-family relationship and patient centredness of care. Latent class analysis of the NEST's 13 items was used to identify groups with similar patterns of serious palliative care needs. RESULTS Among 257 family members, latent class analysis yielded a four-class model including complex communication needs (n=26, 10%; median NEST score 68.0), family spiritual and cultural needs (n=21, 8%; 40.0) and patient and family stress needs (n=43, 31%; 31.0), as well as a fourth group with fewer serious needs (n=167, 65%; 14.0). Interclass differences existed in quality of communication (median range 4.0-10.0, p<0.001), favourable clinician-family relationship (range 34.6%-98.2%, p<0.001) and both the patient centredness of care Eliciting Concerns (median range 4.0-5.0, p<0.001) and Decision-Making (median range 2.3-4.5, p<0.001) scales. CONCLUSIONS Four novel phenotypes of palliative care need were identified among ICU family members with distinct differences in the severity of needs and perceived quality of the clinician-family interaction. Knowledge of need class may help to inform the development of more person-centred models of ICU-based palliative care.
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Affiliation(s)
- Christopher E Cox
- Pulmonary and Critical Care Medicine, Duke University, Durham, North Carolina, USA
- Program to Support People and Enhance Recovery (ProSPER), Duke University, Durham, NC, USA
| | - Maren K Olsen
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, NC, USA
- Department of Biostatistics and Bioinformatics, Duke University, Durham, NC, USA
| | - Alice Parish
- Department of Biostatistics and Bioinformatics, Duke University, Durham, NC, USA
| | - Jessie Gu
- Pulmonary and Critical Care Medicine, Duke University, Durham, North Carolina, USA
| | - Deepshikha Charan Ashana
- Pulmonary and Critical Care Medicine, Duke University, Durham, North Carolina, USA
- Program to Support People and Enhance Recovery (ProSPER), Duke University, Durham, NC, USA
| | - Elias H Pratt
- Pulmonary and Critical Care Medicine, Duke University, Durham, North Carolina, USA
| | - Krista Haines
- Department of Surgery, Division of Trauma and Critical Care and Acute Care Surgery, Duke University, Durham, NC, USA
| | - Jessica Ma
- Section of Palliative Care and Hospice Medicine, Duke University, Durham, NC, USA
| | - David J Casarett
- Section of Palliative Care and Hospice Medicine, Duke University, Durham, NC, USA
| | - Mashael S Al-Hegelan
- Pulmonary and Critical Care Medicine, Duke University, Durham, North Carolina, USA
| | - Colleen Naglee
- Department of Anesthesiology, Duke University, Durham, North Carolina, USA
- Department of Neurology, Division of Neurocritical Care, Durham, North Carolina, USA
| | - Jason N Katz
- Department of Medicine, Division of Cardiology, Duke University, Durham, NC, USA
| | - Yasmin Ali O'Keefe
- Department of Neurology, Division of Neurocritical Care, Durham, North Carolina, USA
| | - Robert W Harrison
- Department of Medicine, Division of Cardiology, Duke University, Durham, NC, USA
| | - Isaretta L Riley
- Pulmonary and Critical Care Medicine, Duke University, Durham, North Carolina, USA
| | - Santos Bermejo
- Pulmonary and Critical Care Medicine, Duke University, Durham, North Carolina, USA
- Program to Support People and Enhance Recovery (ProSPER), Duke University, Durham, NC, USA
| | - Katelyn Dempsey
- Pulmonary and Critical Care Medicine, Duke University, Durham, North Carolina, USA
- Program to Support People and Enhance Recovery (ProSPER), Duke University, Durham, NC, USA
| | - Shayna Wolery
- Pulmonary and Critical Care Medicine, Duke University, Durham, North Carolina, USA
- Program to Support People and Enhance Recovery (ProSPER), Duke University, Durham, NC, USA
| | - Jennie Jaggers
- Pulmonary and Critical Care Medicine, Duke University, Durham, North Carolina, USA
- Program to Support People and Enhance Recovery (ProSPER), Duke University, Durham, NC, USA
| | - Kimberly S Johnson
- Division of Geriatrics, Center for Study of Aging and Human Development, Duke University, Durham, NC, USA
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Collaborative integration of palliative care in critically Ill stroke patients in the neurocritical care unit: A single center pilot study. J Stroke Cerebrovasc Dis 2022; 31:106586. [PMID: 35667164 DOI: 10.1016/j.jstrokecerebrovasdis.2022.106586] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Revised: 05/11/2022] [Accepted: 05/26/2022] [Indexed: 11/23/2022] Open
Abstract
INTRODUCTION Patients admitted to the Neurocritical Care Unit (NCCU) with moderate-to-severe acute strokes, along with their surrogate decision makers, have the potential for unrecognized or unmet emotional and psychological needs. Our primary objective was to determine if early integration of palliative care consultations within this cohort was feasible and would impact understanding, decision-making and emotional support to patients and their surrogate decision makers. Our secondary objective was to evaluate the long-term impact of early palliative care assessment on the development of post-traumatic stress disorder (PTSD). METHODS This was a single center prospective pilot study. Patients with moderate-to-severe ischemic and hemorrhagic strokes were randomized into two arms. The control arm received standard intensive care and the intervention arm received an additional early palliative care consultation within 72 hours of hospitalization. Study assessments with the participants were obtained on day 1-3, and day 5-7 of care with comparisons of total scores on the Questionnaire on Communication (QOC), Decisional Conflict Scale (DCS), and Hospital Anxiety and Depression Scale (HADS). Furthermore, comparisons of HADS and PTSD DSM-5 (PCL- 5) scores were completed at 3 months. Linear mixed effects models were conducted to examine the association between intervention and participant's scores. RESULTS A total of 22 participants were enrolled between February 2019 and April 2020. Statistically significant improvement in scores was seen in the total HADS score (p=0.043) and PCL5 score (p=0.033) at 3 months following intervention. CONCLUSION Collaboration between the intensive care and palliative care team with early palliative assessment may be beneficial in lowering anxiety, depression and PTSD symptoms in critically ill stroke patients and their caregivers. Further research is needed to validate these findings.
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Andersen SK, Vincent G, Butler RA, Brown EHP, Maloney D, Khalid S, Oanesa R, Yun J, Pidro C, Davis VN, Resick J, Richardson A, Rak K, Barnes J, Bezak KB, Thurston A, Reitschuler-Cross E, King LA, Barbash I, Al-Khafaji A, Brant E, Bishop J, McComb J, Chang CCH, Seaman J, Temel JS, Angus DC, Arnold R, Schenker Y, White DB. ProPACC: Protocol for a Trial of Integrated Specialty Palliative Care for Critically Ill Older Adults. J Pain Symptom Manage 2022; 63:e601-e610. [PMID: 35595373 PMCID: PMC9299559 DOI: 10.1016/j.jpainsymman.2022.02.344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Revised: 02/23/2022] [Accepted: 02/24/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND Each year, approximately one million older adults die in American intensive care units (ICUs) or survive with significant functional impairment. Inadequate symptom management, surrogates' psychological distress and inappropriate healthcare use are major concerns. Pioneering work by Dr. J. Randall Curtis paved the way for integrating palliative care (PC) specialists to address these needs, but convincing proof of efficacy has not yet been demonstrated. DESIGN We will conduct a multicenter patient-randomized efficacy trial of integrated specialty PC (SPC) vs. usual care for 500 high-risk ICU patients over age 60 and their surrogate decision-makers from five hospitals in Pennsylvania. INTERVENTION The intervention will follow recommended best practices for inpatient PC consultation. Patients will receive care from a multidisciplinary SPC team within 24 hours of enrollment that continues until hospital discharge or death. SPC clinicians will meet with patients, families, and the ICU team every weekday. SPC and ICU clinicians will jointly participate in proactive family meetings according to a predefined schedule. Patients in the control arm will receive routine ICU care. OUTCOMES Our primary outcome is patient-centeredness of care, measured using the modified Patient Perceived Patient-Centeredness of Care scale. Secondary outcomes include surrogates' psychological symptom burden and health resource utilization. Other outcomes include patient survival, as well as interprofessional collaboration. We will also conduct prespecified subgroup analyses using variables such as PC needs, measured by the Needs of Social Nature, Existential Concerns, Symptoms, and Therapeutic Interaction scale. CONCLUSIONS This trial will provide robust evidence about the impact of integrating SPC with critical care on patient, family, and health system outcomes.
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Affiliation(s)
- Sarah K Andersen
- Program on Ethics and Decision Making, The Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine (S.K.A., G.V., R.A.B., E.H.P.B., D.M., S.K., R.O., J.S., D.B.W.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Grace Vincent
- Program on Ethics and Decision Making, The Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine (S.K.A., G.V., R.A.B., E.H.P.B., D.M., S.K., R.O., J.S., D.B.W.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Rachel A Butler
- Program on Ethics and Decision Making, The Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine (S.K.A., G.V., R.A.B., E.H.P.B., D.M., S.K., R.O., J.S., D.B.W.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA; Palliative Research Center (PaRC) (R.A.B., J.R., K.B.B., A.T., L.A.K., J.S., R.A., Y.S., D.B.W.), University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Elke H P Brown
- Program on Ethics and Decision Making, The Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine (S.K.A., G.V., R.A.B., E.H.P.B., D.M., S.K., R.O., J.S., D.B.W.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Dave Maloney
- Program on Ethics and Decision Making, The Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine (S.K.A., G.V., R.A.B., E.H.P.B., D.M., S.K., R.O., J.S., D.B.W.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Sana Khalid
- Program on Ethics and Decision Making, The Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine (S.K.A., G.V., R.A.B., E.H.P.B., D.M., S.K., R.O., J.S., D.B.W.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Rae Oanesa
- Program on Ethics and Decision Making, The Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine (S.K.A., G.V., R.A.B., E.H.P.B., D.M., S.K., R.O., J.S., D.B.W.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - James Yun
- The CRISMA Center, Department of Critical Care Medicine (I.B., C.-C.H.C.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Carrie Pidro
- The CRISMA Center, Department of Critical Care Medicine (I.B., C.-C.H.C.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Valerie N Davis
- The CRISMA Center, Department of Critical Care Medicine (I.B., C.-C.H.C.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Judith Resick
- Palliative Research Center (PaRC) (R.A.B., J.R., K.B.B., A.T., L.A.K., J.S., R.A., Y.S., D.B.W.), University of Pittsburgh, Pittsburgh, Pennsylvania, USA; Department of Medicine, Division of General Internal Medicine, Section of Palliative Care and Medical Ethics (J.R., K.B.B., R.A., Y.S.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Aaron Richardson
- The CRISMA Center, Department of Critical Care Medicine (I.B., C.-C.H.C.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Kimberly Rak
- The CRISMA Center, Department of Critical Care Medicine (I.B., C.-C.H.C.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Jackie Barnes
- The CRISMA Center, Department of Critical Care Medicine (I.B., C.-C.H.C.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Karl B Bezak
- Palliative Research Center (PaRC) (R.A.B., J.R., K.B.B., A.T., L.A.K., J.S., R.A., Y.S., D.B.W.), University of Pittsburgh, Pittsburgh, Pennsylvania, USA; Department of Medicine, Division of General Internal Medicine, Section of Palliative Care and Medical Ethics (J.R., K.B.B., R.A., Y.S.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Andrew Thurston
- Palliative Research Center (PaRC) (R.A.B., J.R., K.B.B., A.T., L.A.K., J.S., R.A., Y.S., D.B.W.), University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Eva Reitschuler-Cross
- Department of Medicine, Division of General Internal Medicine (E.R.-C., C.-C.H.C.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Linda A King
- Palliative Research Center (PaRC) (R.A.B., J.R., K.B.B., A.T., L.A.K., J.S., R.A., Y.S., D.B.W.), University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Ian Barbash
- Department of Critical Care Medicine (I.B., A.-K., E.B., J.B.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA; Department of Medicine, Division of Pulmonary, Allergy and Critical Care (I.B., J.M.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA; The CRISMA Center, Department of Critical Care Medicine (I.B., C.-C.H.C.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Ali Al-Khafaji
- Department of Critical Care Medicine (I.B., A.-K., E.B., J.B.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Emily Brant
- Department of Critical Care Medicine (I.B., A.-K., E.B., J.B.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Jonathan Bishop
- Department of Critical Care Medicine (I.B., A.-K., E.B., J.B.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Jennifer McComb
- Department of Medicine, Division of Pulmonary, Allergy and Critical Care (I.B., J.M.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Chung-Chou H Chang
- Department of Medicine, Division of General Internal Medicine (E.R.-C., C.-C.H.C.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA; The CRISMA Center, Department of Critical Care Medicine (I.B., C.-C.H.C.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Jennifer Seaman
- Program on Ethics and Decision Making, The Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine (S.K.A., G.V., R.A.B., E.H.P.B., D.M., S.K., R.O., J.S., D.B.W.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA; Palliative Research Center (PaRC) (R.A.B., J.R., K.B.B., A.T., L.A.K., J.S., R.A., Y.S., D.B.W.), University of Pittsburgh, Pittsburgh, Pennsylvania, USA; Department of Acute and Tertiary Care (J.S.), University of Pittsburgh School of Nursing, Pittsburgh, Pennsylvania, USA
| | - Jennifer S Temel
- Division of Hematology/Oncology, Massachusetts General Hospital, Boston (J.S.T.), Massachusetts, USA
| | - Derek C Angus
- The CRISMA Center, Department of Critical Care Medicine (I.B., C.-C.H.C.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Robert Arnold
- Palliative Research Center (PaRC) (R.A.B., J.R., K.B.B., A.T., L.A.K., J.S., R.A., Y.S., D.B.W.), University of Pittsburgh, Pittsburgh, Pennsylvania, USA; The CRISMA Center, Department of Critical Care Medicine (I.B., C.-C.H.C.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Yael Schenker
- Palliative Research Center (PaRC) (R.A.B., J.R., K.B.B., A.T., L.A.K., J.S., R.A., Y.S., D.B.W.), University of Pittsburgh, Pittsburgh, Pennsylvania, USA; Department of Medicine, Division of General Internal Medicine, Section of Palliative Care and Medical Ethics (J.R., K.B.B., R.A., Y.S.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Douglas B White
- Program on Ethics and Decision Making, The Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine (S.K.A., G.V., R.A.B., E.H.P.B., D.M., S.K., R.O., J.S., D.B.W.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA; Palliative Research Center (PaRC) (R.A.B., J.R., K.B.B., A.T., L.A.K., J.S., R.A., Y.S., D.B.W.), University of Pittsburgh, Pittsburgh, Pennsylvania, USA.
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Mentzelopoulos SD, Chen S, Nates JL, Kruser JM, Hartog C, Michalsen A, Efstathiou N, Joynt GM, Lobo S, Avidan A, Sprung CL. Derivation and performance of an end-of-life practice score aimed at interpreting worldwide treatment-limiting decisions in the critically ill. Crit Care 2022; 26:106. [PMID: 35418103 PMCID: PMC9009016 DOI: 10.1186/s13054-022-03971-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Accepted: 03/21/2022] [Indexed: 11/13/2022] Open
Abstract
Background Limitations of life-sustaining interventions in intensive care units (ICUs) exhibit substantial changes over time, and large, contemporary variation across world regions. We sought to determine whether a weighted end-of-life practice score can explain a large, contemporary, worldwide variation in limitation decisions.
Methods The 2015–2016 (Ethicus-2) vs. 1999–2000 (Ethicus-1) comparison study was a two-period, prospective observational study assessing the frequency of limitation decisions in 4952 patients from 22 European ICUs. The worldwide Ethicus-2 study was a single-period prospective observational study assessing the frequency of limitation decisions in 12,200 patients from 199 ICUs situated in 8 world regions. Binary end-of-life practice variable data (1 = presence; 0 = absence) were collected post hoc (comparison study, 22/22 ICUs, n = 4592; worldwide study, 186/199 ICUs, n = 11,574) for family meetings, daily deliberation for appropriate level of care, end-of-life discussions during weekly meetings, written triggers for limitations, written ICU end-of-life guidelines and protocols, palliative care and ethics consultations, ICU-staff taking communication or bioethics courses, and national end-of-life guidelines and legislation. Regarding the comparison study, generalized estimating equations (GEE) analysis was used to determine associations between the 12 end-of-life practice variables and treatment limitations. The weighted end-of-life practice score was then calculated using GEE-derived coefficients of the end-of-life practice variables. Subsequently, the weighted end-of-life practice score was validated in GEE analysis using the worldwide study dataset. Results In comparison study GEE analyses, end-of-life discussions during weekly meetings [odds ratio (OR) 0.55, 95% confidence interval (CI) 0.30–0.99], end-of-life guidelines [OR 0.52, (0.31–0.87)] and protocols [OR 15.08, (3.88–58.59)], palliative care consultations [OR 2.63, (1.23–5.60)] and end-of-life legislation [OR 3.24, 1.60–6.55)] were significantly associated with limitation decisions (all P < 0.05). In worldwide GEE analyses, the weighted end-of-life practice score was significantly associated with limitation decisions [OR 1.12 (1.03–1.22); P = 0.008]. Conclusions Comparison study-derived, weighted end-of-life practice score partly explained the worldwide study’s variation in treatment limitations. The most important components of the weighted end-of-life practice score were ICU end-of-life protocols, palliative care consultations, and country end-of-life legislation.
Supplementary Information The online version contains supplementary material available at 10.1186/s13054-022-03971-9.
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Affiliation(s)
- Spyros D Mentzelopoulos
- First Department of Intensive Care Medicine, National and Kapodistrian University of Athens Medical School, Evaggelismos General Hospital, 45-47 Ipsilandou Street, 10675, Athens, Greece.
| | - Su Chen
- D2, K Lab, Department of Electrical and Computer Engineering, Rice University, Houston, TX, USA
| | - Joseph L Nates
- Critical Care Department, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jacqueline M Kruser
- Division of Allergy, Pulmonary, and Critical Care Medicine, The University of Wisconsin School of Medicine and Public Health, Madison, USA
| | - Christiane Hartog
- Department of Anesthesiology and Intensive Care Medicine, Charité University Medicine Berlin, Berlin, Germany.,Klinik Bavaria, Kreischa, Germany
| | - Andrej Michalsen
- Department of Anesthesiology, Critical Care, Emergency Medicine, and Pain Therapy, Konstanz Hospital, Konstanz, Germany
| | - Nikolaos Efstathiou
- School of Nursing, Institute of Clinical Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Gavin M Joynt
- Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, Shatin, Hong Kong SAR, China
| | - Suzana Lobo
- Critical Care Division - Faculty of Medicine São José do Rio Preto, São Paulo, Brazil
| | - Alexander Avidan
- Department of Anesthesiology, Critical Care and Pain Medicine, Hadassah Medical Organization and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Charles L Sprung
- Department of Anesthesiology, Critical Care and Pain Medicine, Hadassah Medical Organization and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
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Delgado-Corcoran C, Wawrzynski SE, Mansfield KJ, Flaherty B, DeCourcey DD, Moore D, Cook LJ, Ullrich CK, Olson LM. An Automatic Pediatric Palliative Care Consultation for Children Supported on Extracorporeal Membrane Oxygenation: A Survey of Perceived Benefits and Barriers. J Palliat Med 2022; 25:952-957. [PMID: 35319287 DOI: 10.1089/jpm.2021.0452] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: Pediatric palliative care (PPC) consultation is infrequent among children on extracorporeal membrane oxygenation (ECMO). Objective: Investigate intensive care unit (ICU) team members' perceptions of automatic PPC consultation for children on ECMO in an ICU in the United States. Methods: Cross-sectional survey assessing benefits, barriers to PPC, and consultation processes. Results: Of 291 eligible respondents, 48% (n = 140) completed the survey and 16% (n = 47) answered an open-ended question. Benefits included support in decision-making (n = 98; 70%) and identification of goals of care (n = 89; 64%). Barriers included perception of giving up on families (n = 59; 42%) and poor acceptability by other team members (n = 58; 41%). Respondents endorsed communication with the primary ICU team before (n = 122; 87%) and after (n = 129; 92%) consultation. Open-ended responses showed more positive (79% vs. 13%) than negative statements. Positive statements reflected on expanding PPC to other critically-ill children where negative statements revealed unrecognized value in PPC. Conclusions: Results demonstrate opportunities for education about the scope of PPC and improvements in PPC delivery.
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Affiliation(s)
- Claudia Delgado-Corcoran
- Division of Critical Care, Department of Pediatrics, University of Utah, Salt Lake City, Utah, USA.,Division of Pediatric Palliative Care, Department of Pediatrics, University of Utah, Salt Lake City, Utah, USA
| | - Sarah E Wawrzynski
- Pediatric Critical Care Services, Primary Children's Hospital, Intermountain Healthcare, Salt Lake City, Utah, USA.,College of Nursing, University of Utah, Salt Lake City, Utah, USA
| | | | - Brian Flaherty
- Division of Critical Care, Department of Pediatrics, University of Utah, Salt Lake City, Utah, USA
| | - Danielle D DeCourcey
- Division of Medical Critical Care, Department of Pediatrics, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Dominic Moore
- Division of Pediatric Palliative Care, Department of Pediatrics, University of Utah, Salt Lake City, Utah, USA
| | - Lawrence J Cook
- Division of Critical Care, Department of Pediatrics, University of Utah, Salt Lake City, Utah, USA
| | - Christina K Ullrich
- Division of Pediatric Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA.,Division of Hematology/Oncology, Boston Children's Hospital, Boston, Massachusetts, USA.,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
| | - Lenora M Olson
- Division of Critical Care, Department of Pediatrics, University of Utah, Salt Lake City, Utah, USA
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Igarashi Y, Tanaka Y, Ito K, Miyashita M, Kinoshita S, Kato A, Kizawa Y. Current status of palliative care delivery and self-reported practice in ICUs in Japan: a nationwide cross-sectional survey of physician directors. J Intensive Care 2022; 10:18. [PMID: 35303967 PMCID: PMC8932186 DOI: 10.1186/s40560-022-00605-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Accepted: 02/25/2022] [Indexed: 11/17/2022] Open
Abstract
Background It is currently unknown how widespread is the practice of palliative care in intensive care units (ICUs) in Japan. This study aimed to determine evaluate the delivery and self-reported practice of palliative care in ICUs in Japan. Methods A self-administered questionnaire was sent to the physician directors of all 873 ICUs in Japan in August 2020. Results Of the 873 institutions, 439 responded the questionnaire (response rate: 50%) and 413 responses were included in the analysis. The responding physicians thought palliative care was appropriate for physical symptoms (36%, 95% Confidence Interval [CI] 32–41), the provision of information (32%, 95% CI: 28–37), psychological distress (25%, 95% CI: 21–29) and in Post Intensive Care Syndrome (PICS) prevention (20%, 95% CI: 17–24). Only 4% (95% CI: 2–6) of participants indicated that they always provided palliative care screening for the patients admitted to the ICU. The most common method to determine eligibility for palliative care was the “prediction of prognosis by clinician’s experience” (54%, 95% CI: 50–59). Thirty-one percent (95% CI: 27–36) of participants responded that there was no clear method used to decide which patients need palliative care. Fifty-four percent of the participants answered they had no standardized protocols for symptom management at all. Less than 5% answered they had standardized protocols for end-of-life symptom management or terminal weaning off mechanical ventilation including extubation of endotracheal tubes. Conclusions In Japan, the dissemination of palliative care and its integration into ICU care appears insufficient. To improve the quality of life of patients who are admitted to ICU, it may be useful to implement palliative care screening and multidisciplinary conferences, to develop standardized protocols for symptom management and withholding or withdrawing of life-sustaining treatment, and to educate primary palliative care for all ICU physicians.
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Affiliation(s)
- Yuko Igarashi
- Department of Palliative Medicine, Kobe University Graduate School of Medicine, 7-5-1 Kusunokicho, Chuo-ku, Kobe, Hyogo, 650-0017, Japan
| | - Yuta Tanaka
- Department of Palliative Nursing, Health Sciences, Tohoku University Graduate School of Medicine, 2-1 Seiryo-machi, Aoba-ku, Sendai, Miyagi, 980-8575, Japan
| | - Kaori Ito
- Department of Emergency Medicine, Division of Acute Care Surgery, Teikyo University School of Medicine, 2-11-1 Kaga, Itabasi-ku, Tokyo, 173-8606, Japan
| | - Mitsunori Miyashita
- Department of Palliative Nursing, Health Sciences, Tohoku University Graduate School of Medicine, 2-1 Seiryo-machi, Aoba-ku, Sendai, Miyagi, 980-8575, Japan
| | - Satomi Kinoshita
- College of Nursing, Kanto Gakuin University, 1-50-1 Mutsuurahigashi, Kanazawa-ku, Yokohama Kanagawa, 236-8503, Japan
| | - Akane Kato
- Department of Palliative Nursing, Health Sciences, Tohoku University Graduate School of Medicine, 2-1 Seiryo-machi, Aoba-ku, Sendai, Miyagi, 980-8575, Japan.,Department of Adult and Geriatric Nursing, School of Health Science, Shinshu University, 3-1-1, Asahi, Matsumoto, Nagano, 390-8621, Japan
| | - Yoshiyuki Kizawa
- Department of Palliative Medicine, Kobe University Graduate School of Medicine, 7-5-1 Kusunokicho, Chuo-ku, Kobe, Hyogo, 650-0017, Japan.
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Tanaka Y, Kato A, Ito K, Igarashi Y, Kinoshita S, Kizawa Y, Miyashita M. Attitudes of Physicians toward Palliative Care in Intensive Care Units: A Nationwide Cross-Sectional Survey in Japan. J Pain Symptom Manage 2022; 63:440-448. [PMID: 34656654 DOI: 10.1016/j.jpainsymman.2021.09.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Revised: 09/18/2021] [Accepted: 09/22/2021] [Indexed: 11/26/2022]
Abstract
CONTEXT Palliative care is an essential component of comprehensive care for patients with critical illnesses. In Japan, little is known about palliative care in intensive care units (ICUs), and palliative care approaches are not widespread. OBJECTIVE This study aimed to better understand the attitudes of physicians toward palliative care and the utilization and needs of specialized palliative care consultations in ICUs in Japan. METHODS A nationwide, self-administered questionnaire was distributed ICU physician directors in all hospitals with ICUs. RESULTS Questionnaires were distributed to 873 ICU physician directors; valid responses were received from 436 ICU physician director (50% response rate). Among the respondents, 94% (n = 411) felt that primary palliative care should be strengthened in ICUs; 89% (n = 386) wanted ICU physicians to collaborate with specialists, such as palliative care teams (PCTs); and 71% (n = 311) indicated the need for specialized palliative care consultations; however, only 38% (n = 166) actually consulted, and only 6% (n = 28) consulted more than 10 patients in the past year. Physicians most commonly consulted PCT for patients with serious end-of-life illness (24%) (n = 107), intractable pain (21%) (n = 92), and providing psychological support to family members (43%, n = 187). The potential barriers in providing primary and specialized palliative care included being unable to understand the patients' intentions (54%, n = 235), lack of knowledge and skills in palliative care (53%, n = 230), and inability to consult with PCTs in a timely manner (46%, n = 201). CONCLUSIONS These data suggest a need for primary palliative care education in ICUs and improved access to specialized palliative care consultations.
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Affiliation(s)
- Yuta Tanaka
- Department of Palliative Nursing, Health Sciences (Y.T., M.M.), Tohoku University Graduate School of Medicine, Sendai, Miyagi, Japan.
| | - Akane Kato
- Department of Adult and Geriatric Nursing, Health Sciences (A.K.), Shinshu University School of Medicine, Matsumoto, Nagano, Japan
| | - Kaori Ito
- Department of Emergency Medicine, Division of Acute Care Surgery (K.I.), Teikyo University School of Medicine, Itabasi-ku, Tokyo, Japan
| | - Yuko Igarashi
- Department of Palliative Medicine (Y.I., Y.K.), Kobe University Graduate School of Medicine, Kobe, Hyogo, Japan
| | - Satomi Kinoshita
- College of Nursing, Kanto Gakuin University (S.K.), Yokohama Kanagawa, Japan
| | - Yoshiyuki Kizawa
- Department of Palliative Medicine (Y.I., Y.K.), Kobe University Graduate School of Medicine, Kobe, Hyogo, Japan
| | - Mitsunori Miyashita
- Department of Palliative Nursing, Health Sciences (Y.T., M.M.), Tohoku University Graduate School of Medicine, Sendai, Miyagi, Japan
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Palliative Care Utilization Following Out-of-Hospital Cardiac Arrest in Pediatrics. Crit Care Explor 2022; 10:e0639. [PMID: 35211682 PMCID: PMC8860333 DOI: 10.1097/cce.0000000000000639] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVES: Pediatric out-of-hospital cardiac arrest (OHCA) is associated with significant morbidity and mortality. Pediatric palliative care (PPC) services could provide an integral component of the comprehensive care necessary for these patients and their families. The main objectives of this study are to examine the utilization of PPC following OHCA and compare the differences in characteristics between children who received PPC with those who did not. DESIGN: Retrospective cohort study. SETTING: An urban, tertiary PICU. PATIENTS: Children less than 21 years old admitted from October 2009 to October 2019 with an admitting diagnosis of OHCA and minimum PICU length of stay (LOS) of 48 hours. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Of the 283 patient charts reviewed, 118 patient encounters met inclusion criteria. Of those, 34 patients (28.8%) received a PPC consultation during hospitalization. Patients who received PPC had a longer PICU LOS (14.5 vs 4.0 d), a greater number of ventilator days (12.5 vs 4.0 d), and a larger proportion of do-not-resuscitate (DNR) statuses (41% vs 19%). When comparing the disposition of survivors, a greater proportion was discharged to rehab or nursing facilities (47% vs 28%), with no difference in mortality rates (53% vs 50%). In the multivariate logistic regression model, older age, longer LOS, and code status (DNR) were all associated with higher likelihood of PPC utilization. Data were analyzed using descriptive, Mann-Whitney U, and Fisher exact statistics. CONCLUSIONS: Our study demonstrates PPC services following OHCA are underutilized given the high degree of morbidity and mortality. The impact of automatic PPC consultation in all OHCA patients who survive beyond 48 hours should be explored further. Future studies are warranted to understand the benefits and barriers of PPC integration into standard postarrest care for patients and families.
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Cralley A, Madsen H, Robinson C, Platnick C, Madison S, Trabert T, Cohen M, Cothren Burlew C, Sauaia A, Platnick KB. Sustainability of Palliative Care Principles in the Surgical Intensive Care Unit Using a Multi-Faceted Integration Model. J Palliat Care 2022; 37:562-569. [PMID: 35138198 DOI: 10.1177/08258597221079438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE(S) Understanding patient goals of care is essential in any setting, and especially so in an urban, safety net trauma centers' Surgical Intensive Care Units (SICU). This underscores the need for implementation of palliative care principles and practices, such as identification of surrogate decision makers, goals-of-care discussions, and CPR directives, in the SICU. METHODS A pragmatic, quality improvement study utilizing a retrospective, pre- and post-intervention continuum analysis. Interventions included a surgeon champion, resident education, and an electronic medical record template, called the Advanced Care Planning (ACP) Note, for use on daily rounds. We reviewed the charts of all adults admitted to the SICU before, during, and after these interventions to identify the incidence of surrogate decision maker documentation by SICU residents. RESULTS There was an early and enthusiastic adoption in ACP note utilization by SICU residents over the study period. Rates of documenting surrogate decision makers increased throughout the study period (p < 0.0001). Having an ACP note in the chart was associated with significantly higher rates of documented surrogate decision makers (p < 0.0001). CONCLUSIONS Through the integration of targeted education, standardization of an electronic medical record tool for palliative care documentation, and incorporation of palliative care goals into daily rounding ICU checklists, we significantly increased identification of surrogate decision makers in the SICU of our urban Level One trauma center. Chart review from one year post-intervention showed sustained commitment to the use of the ACP note and identification of surrogate decision makers.
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Affiliation(s)
| | - Helen Madsen
- Denver Health and Hospital Authority, Denver, CO, USA.,University of Colorado School of Medicine, Aurora, CO, USA
| | | | | | | | | | | | | | - Angela Sauaia
- Denver Health and Hospital Authority, Denver, CO, USA.,University of Colorado Anschutz Medical Campus, Aurora, CO, USA
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Cox CE, Ashana DC, Haines KL, Casarett D, Olsen MK, Parish A, O’Keefe YA, Al-Hegelan M, Harrison RW, Naglee C, Katz JN, Frear A, Pratt EH, Gu J, Riley IL, Otis-Green S, Johnson KS, Docherty SL. Assessment of Clinical Palliative Care Trigger Status vs Actual Needs Among Critically Ill Patients and Their Family Members. JAMA Netw Open 2022; 5:e2144093. [PMID: 35050358 PMCID: PMC8777568 DOI: 10.1001/jamanetworkopen.2021.44093] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
IMPORTANCE Palliative care consultations in intensive care units (ICUs) are increasingly prompted by clinical characteristics associated with mortality or resource utilization. However, it is not known whether these triggers reflect actual palliative care needs. OBJECTIVE To compare unmet needs by clinical palliative care trigger status (present vs absent). DESIGN, SETTING, AND PARTICIPANTS This prospective cohort study was conducted in 6 adult medical and surgical ICUs in academic and community hospitals in North Carolina between January 2019 and September 2020. Participants were consecutive patients receiving mechanical ventilation and their family members. EXPOSURE Presence of any of 9 common clinical palliative care triggers. MAIN OUTCOMES AND MEASURES The primary outcome was the Needs at the End-of-Life Screening Tool (NEST) score (range, 0-130, with higher scores reflecting greater need), which was completed after 3 days of ICU care. Trigger status performance in identifying serious need (NEST score ≥30) was assessed using sensitivity, specificity, positive and negative likelihood ratios, and C statistics. RESULTS Surveys were completed by 257 of 360 family members of patients (71.4% of the potentially eligible patient-family member dyads approached) with a median age of 54.0 years (IQR, 44-62 years); 197 family members (76.7%) were female, and 83 (32.3%) were Black. The median age of patients was 58.0 years (IQR, 46-68 years); 126 patients (49.0%) were female, and 88 (33.5%) were Black. There was no difference in median NEST score between participants with a trigger present (45%) and those with a trigger absent (55%) (21.0; IQR, 12.0-37.0 vs 22.5; IQR, 12.0-39.0; P = .52). Trigger presence was associated with poor sensitivity (45%; 95% CI, 34%-55%), specificity (55%; 95% CI, 48%-63%), positive likelihood ratio (1.0; 95% CI, 0.7-1.3), negative likelihood ratio (1.0; 95% CI, 0.8-1.2), and C statistic (0.50; 95% CI, 0.44-0.57). CONCLUSIONS AND RELEVANCE In this cohort study, clinical palliative care trigger status was not associated with palliative care needs and no better than chance at identifying the most serious needs, which raises questions about an increasingly common clinical practice. Focusing care delivery on directly measured needs may represent a more person-centered alternative.
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Affiliation(s)
- Christopher E. Cox
- Division of Pulmonary and Critical Care Medicine, Duke University School of Medicine, Durham, North Carolina
- Program to Support People and Enhance Recovery (ProSPER), Duke University, Durham, North Carolina
| | - Deepshikha Charan Ashana
- Division of Pulmonary and Critical Care Medicine, Duke University School of Medicine, Durham, North Carolina
- Program to Support People and Enhance Recovery (ProSPER), Duke University, Durham, North Carolina
| | - Krista L. Haines
- Program to Support People and Enhance Recovery (ProSPER), Duke University, Durham, North Carolina
- Division of Trauma and Critical Care and Acute Care Surgery, Department of Surgery, Duke University, Durham, North Carolina
| | - David Casarett
- Section of Palliative Care and Hospice Medicine, Duke University, Durham, North Carolina
| | - Maren K. Olsen
- Department of Biostatistics and Bioinformatics, Duke University, Durham, North Carolina
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, North Carolina
| | - Alice Parish
- Department of Biostatistics and Bioinformatics, Duke University, Durham, North Carolina
| | | | - Mashael Al-Hegelan
- Division of Pulmonary and Critical Care Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Robert W. Harrison
- Division of Cardiology, Duke University School of Medicine, Durham, North Carolina
| | - Colleen Naglee
- Department of Anesthesiology, Duke University, Durham, North Carolina
| | - Jason N. Katz
- Division of Cardiology, Duke University School of Medicine, Durham, North Carolina
| | - Allie Frear
- Division of Pulmonary and Critical Care Medicine, Duke University School of Medicine, Durham, North Carolina
- Program to Support People and Enhance Recovery (ProSPER), Duke University, Durham, North Carolina
| | - Elias H. Pratt
- Division of Pulmonary and Critical Care Medicine, Duke University School of Medicine, Durham, North Carolina
- Program to Support People and Enhance Recovery (ProSPER), Duke University, Durham, North Carolina
| | - Jessie Gu
- Division of Pulmonary and Critical Care Medicine, Duke University School of Medicine, Durham, North Carolina
- Program to Support People and Enhance Recovery (ProSPER), Duke University, Durham, North Carolina
| | - Isaretta L. Riley
- Division of Pulmonary and Critical Care Medicine, Duke University School of Medicine, Durham, North Carolina
| | | | - Kimberly S. Johnson
- Division of General Internal Medicine, Duke University School of Medicine, Durham, North Carolina
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Hua M, Fonseca LD, Morrison RS, Wunsch H, Fullilove R, White DB. What Affects Adoption of Specialty Palliative Care in Intensive Care Units: A Qualitative Study. J Pain Symptom Manage 2021; 62:1273-1282. [PMID: 34182102 PMCID: PMC8648909 DOI: 10.1016/j.jpainsymman.2021.06.015] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Revised: 06/10/2021] [Accepted: 06/16/2021] [Indexed: 10/21/2022]
Abstract
CONTEXT Although many patients with critical illness may benefit from involvement of palliative care specialists, adoption of these services in the intensive care unit (ICU) is variable. OBJECTIVE To characterize reasons for variable buy-in for specialty palliative care in the ICU, and identify factors associated with routine involvement of specialists in appropriate cases. METHODS Qualitative study using in-depth, semi-structured interviews with ICU attendings, nurses, and palliative care clinicians, purposively sampled from eight ICUs (medical, surgical, cardiothoracic, neurological) with variable use of palliative care services within two urban, academic medical centers. Interviews were transcribed and coded using an iterative and inductive approach with constant comparison. RESULTS We identified three types of specialty palliative care adoption in ICUs, representing different phases of buy-in. The "nascent" phase was characterized by the need for education about palliative care services and clarification of which patients may be appropriate for involvement. During the key "transitional" phase, use of specialists depended on development of "comfort and trust", which centered on four aspects of the ICU-palliative care clinician relationship: 1) increasing familiarity between clinicians; 2) navigating shared responsibility with primary clinicians; 3) having a collaborative approach to care; and 4) having successful experiences. In the "mature" phase, ICU and palliative care clinicians worked to strengthen their existing collaboration, but further adoption was limited by the availability and resources of the palliative care team. CONCLUSION This conceptual framework identifying distinct phases of adoption may assist institutions aiming to foster sustained adoption of specialty palliative care in an ICU setting.
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Affiliation(s)
- May Hua
- Department of Anesthesiology, Columbia University College of Physicians and Surgeons, New York, USA; Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, USA.
| | - Laura D Fonseca
- Department of Anesthesiology, Columbia University College of Physicians and Surgeons, New York, USA
| | - R Sean Morrison
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, USA; James J Peters VA, Bronx, New York, USA
| | - Hannah Wunsch
- Department of Anesthesiology, Columbia University College of Physicians and Surgeons, New York, USA; Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Department of Anesthesiology and Pain Medicine and Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Robert Fullilove
- Department of Sociomedical Sciences, Mailman School of Public Health, Columbia University, New York, USA
| | - Douglas B White
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
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DiGangi Condon KA, Berger JT, Shurpin KM. I've Got the Power: Nurses' Moral Distress and Perceptions of Empowerment. Am J Crit Care 2021; 30:461-465. [PMID: 34719711 DOI: 10.4037/ajcc2021112] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
BACKGROUND Nurses experience moral distress when they feel disempowered or impeded in taking the ethically right course of action. Research suggests an inverse relationship between moral distress and empowerment. In the intensive care unit, providing palliative care services may reduce moral distress because palliative care is often provided in situations that give rise to moral distress. OBJECTIVE To evaluate the effect of nurses' use of a palliative care screening tool on their moral distress and perceptions of empowerment. METHODS A pretest-posttest pilot study was conducted involving day-shift medical intensive care unit nurses. The nurses administered a palliative care screening tool to their assigned patients daily for 8 weeks and communicated the results to an attending physician or fellow. Demographic information was collected, along with data on nurses' moral distress and perceptions of structural and workplace empowerment before and after the intervention. Moral distress was evaluated using the Moral Distress Scale-Revised. Perceptions of structural and workplace empowerment were quantified using the Conditions for Work Effectiveness Questionnaire-II and the Global Empowerment Scale, respectively. RESULTS Preintervention and postintervention surveys were completed by 17 nurses. Paired-sample t tests revealed a significant decrease in the frequency of moral distress (t16 = -2.22, P = .04) and a significant increase in workplace empowerment (t16 = -2.75, P = .01). No significant changes in moral distress intensity or structural empowerment were found. CONCLUSION Nurses' sense of empowerment and the frequency of moral distress are favorably affected by active participation in assessing and communicating patients' palliative care needs.
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Affiliation(s)
- Kathleen A. DiGangi Condon
- Kathleen A. DiGangi Condon is a nurse practitioner, Division of Palliative Medicine and Bioethics, Department of Medicine, NYU Langone Health–Long Island, Mineola, New York
| | - Jeffrey T. Berger
- Jeffrey T. Berger is a professor of medicine, NYU Long Island School of Medicine, and chief, Division of Palliative Medicine and Bioethics, Department of Medicine, NYU Langone Health–Long Island
| | - Kathleen M. Shurpin
- Kathleen M. Shurpin is a professor, Stony Brook University School of Nursing, Stony Brook, New York
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Nadkarni Y, Kukec I, Gruber P, Jhanji S, Droney J. Integrated palliative care: triggers for referral to palliative care in ICU patients. Support Care Cancer 2021; 30:2173-2181. [PMID: 34704155 DOI: 10.1007/s00520-021-06542-w] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2021] [Accepted: 09/03/2021] [Indexed: 12/21/2022]
Abstract
INTRODUCTION Palliative care within intensive care units (ICU) benefits decision-making, symptom control, and end-of-life care. It has been shown to reduce the length of ICU stay and the use of non-beneficial and unwanted life-sustaining therapies. However, it is often initiated late or not at all. There is increasing evidence to support screening ICU patients using palliative care referral criteria or "triggers". The aim of the project was to assess the need for palliative care referral during ICU admission using "trigger" tools. METHODS Electronic record review of cancer patients who died in or within 30 days of discharge from oncology ICU, between 2016 and 2018. Patients referred to palliative care before or during ICU admission were identified. Three sets of palliative care referral "triggers" were applied: one that is being tested locally and two internationally derived tools. The proportion of patients who met any of these triggers during their final ICU admission was calculated. RESULTS Records of 149 patients were reviewed: median age 65 (range 20-83). Most admissions (89%) were unplanned, with the most common diagnoses being haemato-oncology (31%) and gastrointestinal (16%) cancers. Most (73%) were unknown to palliative care pre-ICU admission; 44% were referred between admission and death. The median time from referral to death was 0 day (range 0-19). On ICU admission, 97-99% warranted referral to palliative care using locally and internationally derived triggers. CONCLUSION All "trigger" tools identified a high proportion of patients who may have warranted a palliative care referral either before or during admission to ICU. The routine use of trigger tools could help streamline referral pathways and underpin the development of an effective consultative model of palliative care within the ICU setting to enhance decision-making about appropriate treatment and patient-centred care.
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Affiliation(s)
- Yashna Nadkarni
- Critical Care Unit, Anaesthetics Department, Royal Marsden NHS Foundation Trust, London, UK.
| | - Ivana Kukec
- University Hospital Centre Zagreb, Zagreb, Croatia
| | - Pascale Gruber
- Critical Care Unit, Anaesthetics Department, Royal Marsden NHS Foundation Trust, London, UK
| | - Shaman Jhanji
- Critical Care Unit, Anaesthetics Department, Royal Marsden NHS Foundation Trust, London, UK
| | - Joanne Droney
- Symptom Control and Palliative Care Team, Royal Marsden NHS Foundation Trust, London, UK
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Creutzfeldt CJ. Palliative Care and Shared Decision Making in the Neurocritical Care Unit. ACTA ACUST UNITED AC 2021; 27:1430-1443. [PMID: 34618767 DOI: 10.1212/con.0000000000001003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
PURPOSE OF REVIEW This article reviews the evidence on integrating palliative care into the care of patients with various types of serious neurologic illness, emphasizes the importance of palliative care in the neurocritical care unit, and suggests tools for clinicians to improve their communication skills and decision making. RECENT FINDINGS Palliative care is a holistic approach to medical care that aims to relieve physical, psychological, social, and spiritual suffering. It is both a medical specialty as young as neurocritical care itself and an approach to patient care by all clinicians who manage patients with serious illness. Patients presenting to the neurocritical care unit and their families have unique palliative care needs that challenge communication and shared decision making. SUMMARY Palliative care, effective communication, and shared decision making require a set of core skills that all neurology clinicians should master.
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Ammar MA, Ammar AA, Cheung CC, Akhtar S. Pharmacological Adjuncts to Palliation in the Trauma Patient: Optimal Symptom Management. CURRENT TRAUMA REPORTS 2021. [DOI: 10.1007/s40719-021-00215-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Poi CH, Koh MYH, Koh TLY, Wong YL, Mei Ong WY, Gu C, Yow FC, Tan HL. Integrating Palliative Care Into a Neurosurgical Intensive Care Unit (NS-ICU): A Quality Improvement (QI) Project. Am J Hosp Palliat Care 2021; 39:667-677. [PMID: 34525873 DOI: 10.1177/10499091211045616] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVES We conducted a pilot quality improvement (QI) project with the aim of improving accessibility of palliative care to critically ill neurosurgical patients. METHODS The QI project was conducted in the neurosurgical intensive care unit (NS-ICU). Prior to the QI project, referral rates to palliative care were low. The ICU-Palliative Care collaborative comprising of the palliative and intensive care team led the QI project from 2013 to 2015. The interventions included engaging key stake-holders, establishing formal screening and referral criteria, standardizing workflows and having combined meetings with interdisciplinary teams in ICU to discuss patients' care plans. The Palliative care team would review patients for symptom optimization, attend joint family conferences with the ICU team and support patients and families post-ICU care. We also collected data in the post-QI period from 2016 to 2018 to review the sustainability of the interventions. RESULTS Interventions from our QI project and the ICU-Palliative Care collaborative resulted in a significant increase in the number of referrals from 9 in 2012 to 44 in 2014 and 47 the year later. The collaboration was beneficial in facilitating transfers out of ICU with more deaths outside ICU on comfort-directed care (96%) than patients not referred (75.7%, p < 0.05). Significantly more patients had a Do-Not-Resuscitation (DNR) order upon transfer out of ICU (89.7%) compared to patients not referred (74.2.%, p < 0.001), and had fewer investigations in the last 48 hours of life (p < 0.001). Per-day ICU cost was decreased for referred patients (p < 0.05). CONCLUSIONS Multi-faceted QI interventions increased referral rates to palliative care. Referred patients had fewer investigations at the end-of-life and per-day ICU costs.
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Affiliation(s)
- Choo Hwee Poi
- Department of Palliative Medicine, Tan Tock Seng Hospital, Singapore, Singapore.,Palliative Care Centre for Excellence in Research and Education, Singapore, Singapore
| | - Mervyn Yong Hwang Koh
- Department of Palliative Medicine, Tan Tock Seng Hospital, Singapore, Singapore.,Palliative Care Centre for Excellence in Research and Education, Singapore, Singapore
| | - Tessa Li-Yen Koh
- Department of Palliative Medicine, Tan Tock Seng Hospital, Singapore, Singapore.,Palliative Care Centre for Excellence in Research and Education, Singapore, Singapore
| | - Yu-Lin Wong
- Anaesthesiology, Intensive Care and Pain Medicine Department, Tan Tock Seng Hospital, Singapore, Singapore
| | | | - Chunguang Gu
- Nursing Service, Tan Tock Seng Hospital, Singapore, Singapore
| | | | - Hui Ling Tan
- Anaesthesiology, Intensive Care and Pain Medicine Department, Tan Tock Seng Hospital, Singapore, Singapore
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Delgado-Corcoran C, Bennett EE, Bodily SA, Wawrzynski SE, Green D, Moore D, Cook LJ, Olson LM. Prevalence of specialised palliative care consultation for eligible children within a paediatric cardiac ICU. Cardiol Young 2021; 31:1458-1464. [PMID: 33597068 PMCID: PMC8547172 DOI: 10.1017/s1047951121000433] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVE Retrospectively apply criteria from Center to Advance Palliative Care to a cohort of children treated in a cardiac ICU and compare children who received a palliative care consultation to those who were eligible for but did not receive one. METHODS Medical records of children admitted to a cardiac ICU between January 2014 and June 2017 were reviewed. Selected criteria include cardiac ICU length of stay >14 days and/or ≥ 3 hospitalisations within a 6-month period. MEASUREMENTS AND RESULTS A consultation occurred in 17% (n = 48) of 288 eligible children. Children who received a consult had longer cardiac ICU (27 days versus 17 days; p < 0.001) and hospital (91 days versus 35 days; p < 0.001) lengths of stay, more complex chronic conditions at the end of first hospitalisation (3 versus1; p < 0.001) and the end of the study (4 vs.2; p < 0.001), and higher mortality (42% versus 7%; p < 0.001) when compared with the non-consulted group. Of the 142 pre-natally diagnosed children, only one received a pre-natal consult and 23 received it post-natally. Children who received a consultation (n = 48) were almost 2 months of age at the time of the consult. CONCLUSIONS Less than a quarter of eligible children received a consultation. The consultation usually occurred in the context of medical complexity, high risk of mortality, and at an older age, suggesting potential opportunities for more and earlier paediatric palliative care involvement in the cardiac ICU. Screening criteria to identify patients for a consultation may increase the use of palliative care services in the cardiac ICU.
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Affiliation(s)
- Claudia Delgado-Corcoran
- Division of Critical Care, Department of Pediatrics, University of Utah, 295 Chipeta Way, PO BOX 581289, Salt Lake City, UT, 84108, USA
- Division of Pediatric Palliative Care, Department of Pediatrics, University of Utah, 100 N. Mario Capecchi Dr. Salt Lake City, UT, 84113, USA
| | - Erin E Bennett
- Division of Critical Care, Department of Pediatrics, University of Arkansas for Medical Sciences, Arkansas Children's Hospital. 1 Children's Way, Little Rock, AR, 72202, USA
| | - Stephanie A Bodily
- Pediatric Critical Care Services, Primary Children's Hospital, Intermountain Healthcare, 100 N. Mario Capecchi Dr. Salt Lake City, UT, 84113, USA
| | - Sarah E Wawrzynski
- Pediatric Critical Care Services, Primary Children's Hospital, Intermountain Healthcare, 100 N. Mario Capecchi Dr. Salt Lake City, UT, 84113, USA
| | - Danielle Green
- Division of Critical Care, Department of Pediatrics, University of Utah, 295 Chipeta Way, PO BOX 581289, Salt Lake City, UT, 84108, USA
| | - Dominic Moore
- Division of Pediatric Palliative Care, Department of Pediatrics, University of Utah, 100 N. Mario Capecchi Dr. Salt Lake City, UT, 84113, USA
| | - Lawrence J Cook
- Division of Critical Care, Department of Pediatrics, University of Utah, 295 Chipeta Way, PO BOX 581289, Salt Lake City, UT, 84108, USA
| | - Lenora M Olson
- Division of Critical Care, Department of Pediatrics, University of Utah, 295 Chipeta Way, PO BOX 581289, Salt Lake City, UT, 84108, USA
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Evaluation of automated specialty palliative care in the intensive care unit: A retrospective cohort study. PLoS One 2021; 16:e0255989. [PMID: 34379687 PMCID: PMC8357176 DOI: 10.1371/journal.pone.0255989] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Accepted: 07/28/2021] [Indexed: 01/31/2023] Open
Abstract
Introduction Automated specialty palliative care consultation (SPC) has been proposed as an intervention to improve patient-centered care in the intensive care unit (ICU). Existing automated SPC trigger criteria are designed to identify patients at highest risk of in-hospital death. We sought to evaluate common mortality-based SPC triggers and determine whether these triggers reflect actual use of SPC consultation. We additionally aimed to characterize the population of patients who receive SPC without meeting mortality-based triggers. Methods We conducted a retrospective cohort study of all adult ICU admissions from 2012–2017 at an academic medical center with five subspecialty ICUs to determine the sensitivity and specificity of the five most common SPC triggers for predicting receipt of SPC. Among ICU admissions receiving SPC, we assessed differences in patients who met any SPC trigger compared to those who met none. Results Of 48,744 eligible admissions, 1,965 (4.03%) received SPC; 979 (49.82%) of consultations met at least 1 trigger. The sensitivity and specificity for any trigger predicting SPC was 49.82% and 79.61%, respectively. Patients who met no triggers but received SPC were younger (62.71 years vs 66.58 years, mean difference (MD) 3.87 years (95% confidence interval (CI) 2.44–5.30) p<0.001), had longer ICU length of stay (11.43 days vs 8.42 days, MD -3.01 days (95% CI -4.30 –-1.72) p<0.001), and had a lower rate of in-hospital death (48.68% vs 58.12%, p<0.001). Conclusion Mortality-based triggers for specialty palliative care poorly reflect actual use of SPC in the ICU. Reliance on such triggers may unintentionally overlook an important population of patients with clinician-identified palliative care needs.
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Hamdan Alshehri H, Wolf A, Öhlén J, Olausson S. Managerial and organisational prerequisites for the integration of palliative care in the intensive care setting: A qualitative study. J Nurs Manag 2021; 29:2715-2723. [PMID: 34355447 DOI: 10.1111/jonm.13436] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Revised: 07/28/2021] [Accepted: 07/29/2021] [Indexed: 11/30/2022]
Abstract
AIM To explore the association of organizational structures when integrating palliative care in intensive care units. BACKGROUND Palliative care within intensive care settings has been widely recognized as an area requiring improvement when caring for patients and their families. Despite this, intensive care units continue to struggle to integrate palliative care. METHODS A qualitative descriptive methodology was used. Data were collected through research interviews with 15 managers and 36 health care professionals working in intensive care. The data were analysed adopting constant comparative analysis. RESULTS This study provides insight into a diverse range of perspectives on organizational structure in the context of facilitation and the challenges posed. Three themes were identified: Do not resuscitate policy as a gateway to palliative care, facilitating family members to enable participation and support and barriers for palliative care in intensive care unit as a result of intensive care organization. CONCLUSIONS In fostering a sustainable organizational culture and practice development in intensive care, the findings indicate the need for specific palliative care policies and implementation strategies tailored according to context. IMPLICATIONS FOR NURSING MANAGEMENT Management has a responsibility to facilitate dialogue within any multidisciplinary team regarding palliative care and, in particular, to focus on 'do not resuscitate' policies as a gateway into this conversation.
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Affiliation(s)
- Hanan Hamdan Alshehri
- Institute of Health and Care Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Princess Nourah bint Abdulrahman University, Riyadh, Saudi Arabia
| | - Axel Wolf
- Region Västra Götaland, Vastra Gotaland County, Sweden.,Department of Anaesthesiology and Intensive Care Medicine, University Hospital/Östra, Gothenburg, Sweden
| | - Joakim Öhlén
- Institute of Health and Care Sciences and University of Gothenburg Centre for Person-Centred Care, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Palliative Centre, Sahlgrenska University Hospital Region Västra Götaland, Gothenburg, Sweden
| | - Sepideh Olausson
- Institute of Health and Care Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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Barasa L, Shah J, Weru J, Ali SK. Assessment of Palliative Care Needs in a Kenyan Intensive Care Unit Using a Trigger-Based Model. J Pain Symptom Manage 2021; 62:260-266. [PMID: 33359216 DOI: 10.1016/j.jpainsymman.2020.12.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Revised: 12/03/2020] [Accepted: 12/16/2020] [Indexed: 11/20/2022]
Abstract
CONTEXT Palliative care triggers have been used in the intensive care unit (ICU) setting, usually in high-income countries, to identify patients who may benefit from palliative care consults. The utility and benefits of palliative care triggers in the ICU have not been previously studied in sub-Saharan Africa. OBJECTIVES Our objectives were to determine the prevalence of ICU admissions in those who met at least one palliative care trigger and whether a palliative care consult influenced the length of ICU stay and time to change of goals order. METHODS We conducted a prospective observational cohort study within our ICU at the Aga Khan University Hospital, Nairobi, between December 2019 and August 2020. Data including initiation of a palliative care consult, length of ICU stay, mortality, and time to change of goals order were collected. RESULTS During our study period, 72 of 159 (45.9%) patients met at least one palliative care trigger point. Of the patients who met the palliative care triggers, only 29.2% received a palliative care consult. Patients who received palliative care consults had higher rates of change of goals orders signed (52.3%) vs. those who did not (P = 0.009). There was no statistically significant difference between the consult and nonconsult groups in regard to length of ICU stay, time to change of goals order, and mortality. CONCLUSION A trigger-based model, geared to the needs of the specific ICU, may be one way of improving integration of palliative care into the ICU, especially in sub-Saharan Africa.
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Affiliation(s)
- Linda Barasa
- Department of Medicine, Aga Khan University, Nairobi, Kenya
| | - Jasmit Shah
- Department of Medicine, Aga Khan University, Nairobi, Kenya
| | - John Weru
- Department of Medicine, Aga Khan University, Nairobi, Kenya
| | - Sayed K Ali
- Department of Medicine, Aga Khan University, Nairobi, Kenya.
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Miller PH, Flaherty CN, Bail JR. Palliative Care in the Intensive Care Unit. Crit Care Nurse 2021; 41:11-12. [PMID: 33791760 DOI: 10.4037/ccn2021867] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
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Green DJ, Bennett E, Olson LM, Wawrzynski S, Bodily S, Moore D, Mansfield KJ, Wilkins V, Cook L, Delgado-Corcoran C. Timing of Pediatric Palliative Care Consults in Hospitalized Patients with Heart Disease. J Pediatr Intensive Care 2021; 12:63-70. [PMID: 36742256 PMCID: PMC9894702 DOI: 10.1055/s-0041-1730916] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Accepted: 04/07/2021] [Indexed: 02/07/2023] Open
Abstract
Pediatric palliative care (PPC) provides an extra layer of support for families caring for a child with complex heart disease as these patients often experience lifelong morbidities with frequent hospitalizations and risk of early mortality. PPC referral at the time of heart disease diagnosis provides early involvement in the disease trajectory, allowing PPC teams to longitudinally support patients and families with symptom management, complex medical decision-making, and advanced care planning. We analyzed 113 hospitalized pediatric patients with a primary diagnosis of heart disease and a PPC consult to identify timing of first PPC consultation in relation to diagnosis, complex chronic conditions (CCC), and death. The median age of heart disease diagnosis was 0 days with a median of two CCCs while PPC consultation did not occur until a median age of 77 days with a median of four CCCs. Median time between PPC consult and death was 33 days (interquartile range: 7-128). Death often occurred in the intensive care unit ( n = 36, 67%), and the most common mode was withdrawal of life-sustaining therapies ( n = 31, 57%). PPC referral often occurred in the context of medical complexity and prolonged hospitalization. Referral close to the time of heart disease diagnosis would allow patients and families to fully utilize PPC benefits that exist outside of end-of-life care and may influence the mode and location of death. PPC consultation should be considered at the time of heart disease diagnosis, especially in neonates and infants with CCCs.
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Affiliation(s)
- Danielle J. Green
- Department of Pediatrics, Division of Pediatric Critical Care, University of Utah, Salt Lake City, Utah, United States,Address for correspondence Danielle J. Green, MD Department of Pediatrics, Division of Pediatric Critical CarePO Box 581289, Salt Lake City, UT 84158United States
| | - Erin Bennett
- Department of Pediatrics, Division of Critical Care, University of Arkansas for Medical Sciences, Little Rock, Arkansas, United States
| | - Lenora M. Olson
- Department of Pediatrics, Division of Pediatric Critical Care, University of Utah, Salt Lake City, Utah, United States
| | - Sarah Wawrzynski
- University of Utah College of Nursing, Salt Lake City, Utah, United States,Pediatric Critical Care Services, Primary Children's Hospital, Salt Lake City, Utah, United States
| | - Stephanie Bodily
- Pediatric Critical Care Services, Primary Children's Hospital, Salt Lake City, Utah, United States
| | - Dominic Moore
- Department of Pediatrics, Division of Palliative Care Medicine, University of Utah, Salt Lake City, Utah, United States
| | - Kelly J. Mansfield
- Pediatric Critical Care Services, Primary Children's Hospital, Salt Lake City, Utah, United States
| | - Victoria Wilkins
- Department of Pediatrics, Division of Inpatient Medicine, University of Utah, Salt Lake City, Utah, United States
| | - Lawrence Cook
- Department of Pediatrics, Division of Pediatric Critical Care, University of Utah, Salt Lake City, Utah, United States
| | - Claudia Delgado-Corcoran
- Department of Pediatrics, Division of Pediatric Critical Care, University of Utah, Salt Lake City, Utah, United States,Department of Pediatrics, Division of Palliative Care Medicine, University of Utah, Salt Lake City, Utah, United States
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Martz K, Alderden J, Bassett R, Swick D. Outcomes Associated With a Nurse-Driven Palliative Care Screening Tool in the Intensive Care Unit. Crit Care Nurse 2021; 40:23-29. [PMID: 32476026 DOI: 10.4037/ccn2020702] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
BACKGROUND Access to specialty palliative care delivery in the intensive care unit is inconsistent across institutions. The intensive care unit at the study institution uses a screening tool to identify patients likely to benefit from specialty palliative care, yet little is known about outcomes associated with the use of screening tools. OBJECTIVE To identify outcomes associated with specialty palliative care referral among patients with critical illness. METHODS Records of 112 patients with positive results on palliative care screening were retrospectively reviewed to compare outcomes between patients who received a specialty palliative care consult and those who did not. Primary outcome measures were length of stay, discharge disposition, and escalation of care. RESULTS Sixty-five patients (58%) did not receive a palliative care consult. No significant differences were found in length of hospital or intensive care unit stay. Most patients who experienced mechanical ventilation did not receive a palliative care consultation (χ2 = 5.14, P = .02). Patients who were discharged to home were also less likely to receive a consult (χ2 = 4.1, P = .04), whereas patients who were discharged to hospice were more likely to receive a consult (χ2 = 19.39, P < .001). CONCLUSIONS Unmet needs exist for specialty palliative care. Understanding the methods of identifying patients for specialty palliative care and providing them with such care is critically important. Future research is needed to elucidate the factors providers use in their decisions to order or defer specialty palliative care consultation.
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Affiliation(s)
- Kim Martz
- Kim Martz is Associate Professor Emeritus, Boise State University School of Nursing, Faculty Mentor, St Luke's Health System, Boise, Idaho
| | - Jenny Alderden
- Jenny Alderden is an assistant professor, University of Utah College of Nursing, Salt Lake City, Utah
| | - Rick Bassett
- Rick Bassett is an adult clinical nurse specialist, St Luke's Health System
| | - Dawn Swick
- Dawn Swick is a staff nurse, St Luke's Health System
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