Factors associated with non-beneficial treatments in end of life hospital admissions: a multicentre retrospective cohort study in Australia

Frailty as a trigger for goals-of-care discussions in rapid response calls: A single-centre retrospective cohort study

BACKGROUND

Timely goals-of-care (GOC) discussions are essential for end-of-life planning, particularly during acute hospital admissions, where ambiguity often persists. Frailty, prevalent in the ageing population and linked to adverse outcomes, underscores the need to align treatment strategies with quality of life. Recognising frailty as a trigger for GOC discussions during rapid response calls (RRCs) is critical for efficient resource management and improving patient outcomes.

METHODS

This single-centre retrospective cohort study included all hospitalised patients aged ≥65 years admitted between September 2021 and June 2023 who experienced an RRC. Frailty was assessed using the Clinical Frailty Scale (CFS) during the RRC. The primary outcome was to investigate whether frailty, specifically assessed by the CFS as screened during an RRC, could be a suitable clinical trigger for initiating GOC discussions. We also aimed to identify the proportion of patients with frailty (CFS score: ≥5) and predictors at the time of RRC, resulting in recommendations for GOC discussions.

RESULTS

Among 4954 patients, 1685 (34.0%) were classified as frail (CFS score: ≥5). Recommendations increased with frailty levels (nonfrail [CFS score: 1-4]: 6.6%, mildly frail [CFS score: 5]: 19.3%, moderate-to-severely frail [CFS score: 6-9]: 32.2%; p < 0.001). Frailty independently increased the probability of GOC recommendations during an RRC (area under the receiver operating characteristic curve = 0.71). The CFS cut-off point for GOC recommendations was ≥5. The presence of frailty was associated with higher odds of receiving GOC recommendations for mildly frail (CFS score: 5; odds ratio [OR] = 2.53; 95% confidence interval: 1.96-3.27) and moderate-to-severely frail (CFS score: 6-9; OR = 4.69; 95% confidence interval: 3.81-5.78) compared to nonfrail patients.

CONCLUSION

Frailty, identified during an RRC, served as a robust trigger for GOC recommendations, highlighting the importance of tailored proactive discussions before episodes of deterioration. Higher levels of frailty (CFS score: ≥5) demonstrate practical markers for aiding clinicians with proactive GOC discussions.

Did the Palliative Care Outcomes Collaboration (PCOC) program lead to improved end-of-life care quality and reduced non-beneficial treatments?

PURPOSE

Palliative Care Outcomes Collaboration (PCOC) is an internationally recognized program developed in Australia. Taiwan became the first country in Asia to implement PCOC in 2020. There is little research on the impact of PCOC in Asia. We sought to examine the effects of the Taiwan PCOC on palliative outcomes.

METHODS

The study analyzed the impact of PCOC with a retrospective cohort design. The hypotheses were that PCOC could improve end-of-life care quality and reduce non-beneficial treatments. The study enrolled patients with terminal illnesses from the inpatient palliative care units. General characteristics of participants were collected. Exclusion criteria were people without a diagnosis of terminal illness, aged 20 and younger, or with missing data.

RESULTS

The study collected 1,121 patients, 555 in the PCOC comparison group and 566 in the intervention group. Most patients were with terminal cancer (88.58%). The rates of hospital deaths in the PCOC and non-PCOC groups were 68.73% vs. 74.95% (P = 0.021). A multivariable logistic regression model, adjusting for age, sex, Charlson comorbidity index, and terminal cancer status, was utilized. The PCOC intervention significantly decreased hospital deaths (OR = 0.26, 95%CI 0. 16-0.41, P < 0.001).

CONCLUSIONS

PCOC in Taiwan significantly reduced hospital deaths among terminal patients, possibly due to effective symptom management and improved communication via the use of patient-reported outcomes. Further research is needed to support PCOC implementation in Asia and investigate collaboration programs' impact on end-of-life care quality and non-beneficial treatments.

Indian Society of Critical Care Medicine and Indian Association of Palliative Care Expert Consensus and Position Statements for End-of-life and Palliative Care in the Intensive Care Unit

End-of-life care (EOLC) exemplifies the joint mission of intensive and palliative care (PC) in their human-centeredness. The explosion of technological advances in medicine must be balanced with the culture of holistic care. Inevitably, it brings together the science and the art of medicine in their full expression. High-quality EOLC in the ICU is grounded in evidence, ethical principles, and professionalism within the framework of the Law. Expert professional statements over the last two decades in India were developed while the law was evolving. Recent landmark Supreme Court judgments have necessitated a review of the clinical pathway for EOLC outlined in the previous statements. Much empirical and interventional evidence has accumulated since the position statement in 2014. This iteration of the joint Indian Society of Critical Care Medicine-Indian Association of Palliative Care (ISCCM-IAPC) Position Statement for EOLC combines contemporary evidence, ethics, and law for decision support by the bedside in Indian ICUs.

How to cite this article

Mani RK, Bhatnagar S, Butola S, Gursahani R, Mehta D, Simha S, et al. Indian Society of Critical Care Medicine and Indian Association of Palliative Care Expert Consensus and Position Statements for End-of-life and Palliative Care in the Intensive Care Unit. Indian J Crit Care Med 2024;28(3):200-250.

Process evaluation of a tailored nudge intervention to promote appropriate care and treatment of older patients at the end-of-life

BACKGROUND

Non-beneficial treatment affects a considerable proportion of older people in hospital, and some will choose to decline invasive treatments when they are approaching the end of their life. The Intervention for Appropriate Care and Treatment (InterACT) intervention was a 12-month stepped wedge randomised controlled trial with an embedded process evaluation in three hospitals in Brisbane, Australia. The aim was to increase appropriate care and treatment decisions for older people at the end-of-life, through implementing a nudge intervention in the form of a prospective feedback loop. However, the trial results indicated that the expected practice change did not occur. The process evaluation aimed to assess implementation using the Consolidated Framework for Implementation Research, identify barriers and enablers to implementation and provide insights into the lack of effect of the InterACT intervention.

METHODS

Qualitative data collection involved 38 semi-structured interviews with participating clinicians, members of the executive advisory groups overseeing the intervention at a site level, clinical auditors, and project leads. Online interviews were conducted at two times: implementation onset and completion. Data were coded to the Consolidated Framework for Implementation Research and deductively analysed.

RESULTS

Overall, clinicians felt the premise and clinical reasoning behind InterACT were strong and could improve patient management. However, several prominent barriers affected implementation. These related to the potency of the nudge intervention and its integration into routine clinical practice, clinician beliefs and perceived self-efficacy, and wider contextual factors at the health system level.

CONCLUSIONS

An intervention designed to change clinical practice for patients at or near to end-of-life did not have the intended effect. Future interventions targeting this area of care should consider using multi-component strategies that address the identified barriers to implementation and clinician change of practice.

TRIAL REGISTRATION

Australia New Zealand Clinical Trial Registry (ANZCTR), ACTRN12619000675123p (approved 06/05/2019).

Elements of Potentially Inappropriate Interventions and Patient Prognostic Profiles at the End of Life in Cardiology: A Qualitative Analysis

Background: The determination of what makes a medical treatment inappropriate is unclear with a small likelihood of consensus. Objectives: This study aimed to explore how clinicians in cardiology perceive "inappropriate treatment" and to collate the common profiles of cardiology patients receiving likely "inappropriate treatment" as perceived by clinicians in a multiethnic Asian context. Methods: A qualitative study was conducted using semistructured in-depth interviews with 32 clinicians involved in the care for cardiology patients at a large national cardiology center in Singapore. Results: Clinicians' accounts indicated that elements of potentially inappropriate treatment encompass patient-related treatment elements as well as quantitative and probability-based elements such as resource use and probability of treatment benefit. Patient prognostic profiles, characterized as likely to have received inappropriate treatment by clinicians, were organized into six categories according to demographic, clinical, and functional factors. Conclusions: The perception of inappropriateness of treatments among clinicians in cardiology was primarily focused on patient-related outcomes. Collated patient profiles may serve as meaningful indicators of patient cases receiving potentially inappropriate treatment for further research and intervention.

Impact of a prospective feedback loop on care review activities in older patients at the end of life. A stepped-wedge randomised trial

Background

Hospitalisation rates for older people are increasing, with end-of-life care becoming a more medicalised experience. Innovative approaches are warranted to support early identification of the end-of-life phase, communicate prognosis, provide care consistent with people’s preferences, and improve the use of healthcare resources. The Intervention for Appropriate Care and Treatment (InterACT) trial aimed to increase appropriate care and treatment decisions for older people at the end of life, through implementation of a prospective feedback loop. This paper reports on the care review outcomes.

Methods

A stepped-wedge randomised controlled trial was conducted in three large acute hospitals in Queensland, Australia between May 2020 and June 2021. The trial identified older people nearing the end of life using two validated tools for detecting deterioration and short-term death. Admitting clinical teams were provided with details of patients identified as at-risk with the goal of increasing awareness that end of life was approaching to facilitate appropriate patient centred care and avoid non-beneficial treatment. We examined the time between when the patient was identified as ‘at-risk’ and three outcomes: clinician-led care review discussions, review of care directive measures and palliative care referrals. These were considered useful indicators of appropriate care at the end of life.

Results

In two hospitals there was a reduction in the review of care directive measures during the intervention compared with usual care at 21 days (reduced probability of − 0.08; 95% CI: − 0.12 to − 0.04 and − 0.14; 95% CI: − 0.21 to − 0.06). In one hospital there was a large reduction in clinician-led care review discussions at 21 days during the intervention (reduced probability of − 0.20; 95% CI: − 0.28 to − 0.13). There was little change in palliative care referrals in any hospital, with average probability differences at 21 days of − 0.01, 0.02 and 0.04.

Discussion

The results are disappointing as an intervention designed to improve care of hospitalised older people appeared to have the opposite effect on care review outcomes. The reasons for this may be a combination of the intervention design and health system challenges due to the pandemic that highlight the complexity of providing more appropriate care at the end of life.

Trial registration

Australia New Zealand Clinical Trial Registry, ACTRN12619000675123 (registered 6 May 2019).

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-022-03554-x.

Treatment limitations and clinical outcomes in critically ill frail patients with and without COVID-19 pneumonitis

BACKGROUND

The presence of treatment limitations in patients with frailty at intensive care unit (ICU) admission is unknown. We aimed to evaluate the presence and predictors of treatment limitations in patients with and without COVID-19 pneumonitis in those admitted to Australian and New Zealand ICUs.

METHODS

This registry-based multicenter, retrospective cohort study included all frail adults (≥16 years) with documented clinical frailty scale (CFS) scores, admitted to ICUs with admission diagnostic codes for viral pneumonia or acute respiratory distress syndrome (ARDS) over 2 years between January 01, 2020 and December 31, 2021. Frail patients (CFS ≥5) coded as having viral pneumonitis or ARDS due to COVID-19 were compared to those with other causes of viral pneumonitis or ARDS for documented treatment limitations.

RESULTS

884 frail patients were included in the final analysis from 129 public and private ICUs. 369 patients (41.7%) had confirmed COVID-19. There were more male patients in COVID-19 (55.3% vs 47.0%; p = 0.015). There were no differences in age or APACHE-III scores between the two groups. Overall, 36.0% (318/884) had treatment limitations, but similar between the two groups (35.8% [132/369] vs 36.1% [186/515]; p = 0.92). After adjusting for confounders, increasing frailty (OR = 1.72; 95%-CI 1.39-2.14), age (OR = 1.05; 95%-CI 1.04-1.06), and presence of chronic respiratory condition (OR = 1.58; 95%-CI 1.10-2.27) increased the likelihood of instituting treatment limitations. However, the presence of COVID-19 by itself did not influence treatment limitations (odds ratio [OR] = 1.39; 95%-CI 0.98-1.96).

CONCLUSIONS

The proportion of treatment limitations was similar in patients with frailty with or without COVID-19 pneumonitis at ICU admission.

Timely goals of care documentation in patients with frailty in the COVID-19 era: a retrospective multi-site study

BACKGROUND

Older frail patients are more likely to have timely goals of care (GOC) documentation than non-frail patients.

AIMS

To investigate whether timely documentation of GOC within 72 h differed in the context of the COVID-19 pandemic (2020), compared with the pre-COVID-19 era (2019) for older frail patients.

METHODS

Multi-site retrospective cohort study was conducted in two public hospitals where all consecutive frail adult patients aged ≥65 years were admitted under medical units for at least 24 h between 1 March 31 and October in 2019 and between 1 March and 31 October 2020 were included. The GOC was derived from electronic records. Frailty status was derived from hospital coding data using hospital frailty risk score (frail ≥5). The primary outcome was the documentation of GOC within 72 h of hospital admission. Secondary outcomes included hospital mortality, rapid response call, intensive care unit admission, prolonged hospital length of stay (≥10 days) and time to the documentation of GOC.

RESULTS

The study population comprised 2021 frail patients admitted in 2019 and 1849 admitted in 2020, aged 81.2 and 90.9 years respectively. The proportion of patients with timely GOC was lower in 2020, than 2019 (48.3% (893/1849) vs 54.9% (1109/2021); P = 0.021). After adjusting for confounding factors, patients in 2020 were less likely to receive timely GOC (odds ratio = 0.77; 95% confidence interval (CI) 0.68-0.88). Overall time to GOC documentation was longer in 2020 (hazard ratio = 0.86; 95% CI 0.80-0.93).

CONCLUSION

Timely GOC documentation occurred less frequently in frail patients during the COVID-19 pandemic than in the pre-COVID-19 era.

A Survey of Clinicians Regarding Goals of Care for Patients with Severe Comorbid Illnesses Hospitalized for an Acute Deterioration

Background

Patients with terminal illnesses hospitalized with acute deteriorations often suffer from unnecessary/inappropriate therapies at the end of their lives. Appropriate advance care planning (ACP) practices aligned to patients’ goals of care may mitigate this.

Materials and methods

To explore the rationale for clinical decision-making in hospitalized patients with terminal illnesses and formulate a practice pathway to streamline care. Between May and December 2018, a questionnaire survey with three case vignettes derived from intensive care unit (ICU) patients was emailed to ICU, respiratory and renal doctors, and nurses in two Sydney hospitals. Respondents chose various management options ranging from all active therapies to palliation. The primary outcome was the proportion of responses for each management option. With these and a thematic analysis of responses to identify barriers to ACP practice, a practice pathway was formulated.

Results

Of the 310 invited clinicians, 178 responded (57.4%). About 89.2% of respondents reported caring for dying patients frequently. Sixty percent saw patients suffering from prolonged therapies. Most respondents deemed patients in the case vignettes to be terminally ill, warranting ACP discussions. However, many still wanted to treat the acute deterioration with active ICU-level interventions. Most respondents reported being comfortable in having ACP discussions.

Conclusion

The survey showed discordance between the stated opinions and the choice of management options for terminally ill patients with acute deteriorations; possibly due to the lack of a considered approach in choosing management options that align with medical consensus and the patient's/family's wishes, a practice pathway is suggested to improve management.

How to cite this article

Sarangi RK, Rajamani A, Lakshmanan R, Srinivasan S, Arvind H. A Survey of Clinicians Regarding Goals of Care for Patients with Severe Comorbid Illnesses Hospitalized for an Acute Deterioration. Indian J Crit Care Med 2022;26(4):457–463.

Factors Influencing Potentially Futile Treatments at the End of Life in a Multiethnic Asian Cardiology Setting: A Qualitative Study

BACKGROUND

Modern medicine enables clinicians to save lives and prolong time to death, yet some treatments have little chance of conferring meaningful benefits for patients nearing the end-of-life. What clinicians perceive as driving futile treatment in the non-Western healthcare context is poorly understood.

AIM

This study aimed to explore clinicians' perceptions of the factors that influence futile treatment at the end of life within a tertiary hospital cardiac care setting.

DESIGN

We conducted semi-structured interviews with cardiologists, cardiac surgeons, and palliative care doctors from a large national cardiology center in Singapore. Interviews were transcribed verbatim and thematically analyzed.

RESULTS

A total of 32 clinicians were interviewed. We identified factors that contributed to the provision of potentially futile treatment in these theme areas: patient- and family-related, clinician-related, and institutional and societal factors. Family roles and cultural influences were most commonly cited by participants as affecting end-of-life decisions and altering the likelihood of futile treatment. Specialty-specific alignments within cardiology and availability of healthcare resources were also important factors underpinning futile treatment.

CONCLUSION

Family-related factors were a primary driver for futile treatment in a non-Western, multicultural setting. Future interventions should consider a targeted approach accounting for cultural and contextual factors to prevent and reduce futile treatment.

Physicians' perspective on potentially non-beneficial treatment when assessing patients with advanced disease for ICU admission: a qualitative study

OBJECTIVE

The use of intensive care at the end of life can be high, leading to inappropriate healthcare utilisation, and prolonged suffering for patients and families. The objective of the study was to determine which factors influence physicians' admission decisions in situations of potentially non-beneficial intensive care.

DESIGN

This is a secondary analysis of a qualitative study exploring the triage process. In-depth interviews were analysed using an inductive approach to thematic content analysis.

SETTING

Data were collected in a Swiss tertiary care centre between March and June 2013.

PARTICIPANTS

12 intensive care unit (ICU) physicians and 12 internists routinely involved in ICU admission decisions.

RESULTS

Physicians struggled to understand the request for intensive care for patients with advanced disease and full code status. Physicians considered patients' long-term vital and functional prognosis, but they also resorted to shortcuts, that is, a priori consensus about reasons for admitting a patient. Family pressure and unexpected critical events were determinants of admission to the ICU. Patient preferences, ICU physician's expertise and collaborative decision making facilitated refusal. Physicians were willing to admit a patient with advanced disease for a limited amount of time to fulfil a personal need.

CONCLUSIONS

In situations of potentially non-beneficial intensive care, the influence of shortcuts or context-related factors suggests that practice variations and inappropriate admission decisions are likely to occur. Institutional guidelines and timely goals of care discussions with patients with advanced disease and their families could contribute to ensuring appropriate levels of care.