Palliative Care for Extracorporeal Life Support: Insights From the National Inpatient Sample

Perceptions on Specialist Palliative Care Involvement During and After Cardiopulmonary Resuscitation: A Qualitative Study

IMPORTANCE

Cardiopulmonary resuscitation (CPR) is an exceptional physical situation and may lead to significant psychological, spiritual, and social distress in patients and their next of kin. Furthermore, clinicians might experience distress related to a CPR event. Specialist palliative care (sPC) integration could address these aspects but is not part of routine care.

OBJECTIVES

This study aimed to explore perspectives on sPC integration during and after CPR. A needs assessment for sPC, possible triggers indicating need, and implementation strategies were addressed.

DESIGN SETTING AND PARTICIPANTS

A multiprofessional qualitative semistructured focus group study was conducted in a German urban academic teaching hospital. Participants were clinicians (nursing staff, residents, and consultants) working in the emergency department and ICUs (internal medicine and surgical).

ANALYSIS

The focus groups were recorded and subsequently transcribed. Data material was analyzed using the content-structuring content analysis according to Kuckartz.

RESULTS

Seven focus groups with 18 participants in total were conducted online from July to November 2022. Six main categories (two to five subcategories) were identified: understanding (of palliative care and death), general CPR conditions (e.g., team, debriefing, and strains), prognosis (e.g., preexisting situation, use of extracorporeal support), next of kin (e.g., communication, presence during CPR), treatment plan (patient will and decision-making), and implementation of sPC (e.g., timing, trigger factors).

CONCLUSIONS

Perceptions about the need for sPC to support during and after CPR depend on roles, areas of practice, and individual understanding of sPC. Although some participants perceive CPR itself as a trigger for sPC, others define, for example, pre-CPR-existing multimorbidity or complex family dynamics as possible triggers. Suggestions for implementation are multifaceted, especially communication by sPC is emphasized. Specific challenges of extracorporeal CPR need to be explored further. Overall, the focus groups show that the topic is considered relevant, and studies on outcomes are warranted.

Caring for Patients Requiring Venous Arterial Extracorporeal Membrane Oxygenation: Can Upstream Palliative Care Make a Difference?

OBJECTIVE

Palliative care consultation is relevant for patients requiring Venous-Arterial Extracorporeal Membrane Oxygenation (VA-ECMO); however, evidence is limited to support its value. For this population, we compared length of stay (LOS) (primary outcome), operational metrics and goals of care (GOC) frequency before and after a collaboration between cardiothoracic (CT) surgery and Geriatrics and Palliative Medicine (GaP).

METHODS

Retrospective chart review of patients (18+) admitted to a quaternary center that required VA-ECMO between 2019-2021 and received GaP consultation. Demographics, LOS, times to consult, illness severity, GOC, and outcomes were analyzed.

RESULTS

120 patients met inclusion criteria and 64 (53.3%) had GaP consultation. No differences were observed regarding demographics and insertion status (emergent vs elective). Median (IQR) days to GaP consult for 2019, 2020 and 2021 were 6.5 (4.0-14.5), 5.0 (2.0-11.0) and 3.0 (2.0-5.0), respectively (P = .006). Median days from insertion to consult for 2019, 2020 and 2021 were 6.0 (4.0-20.0), 3.0 (1.0-6.0) and 2.0 (1.0-4.0) (P = .003). Among survivors, over the 3-year course, median LOS was not statistically different. Between expired patients, median (IQR) LOS for 2019, 2020, and 2021 was 28.5 (23.0-40.0), 12.0 (8.0-14.0), 11.0 (5.0-17.0) days (P = .013). For patients not seen by GaP, 8 (14.3%) GOC notes were documented, compared with 42 (65.6%) for patients seen. Mortality was similar (53.6% vs 53.1% [GaP]).

CONCLUSION

For patient on VA-ECMO, early GaP consultation may improve hospital LOS and GOC rates. We suggest organizations consider early palliative integration when instituting mechanical circulatory support.

Palliative Care Utilization in Patients Requiring Extracorporeal Membrane Oxygenation: An Observational Study

Palliative care (PC) is a model of care centered around improving the quality of life for individuals with life-limiting illnesses. Few studies have examined its impact in patients on extracorporeal membrane oxygenation (ECMO). We aimed to describe demographics, clinical characteristics, and complications associated with PC consultation in adult patients requiring ECMO support. We analyzed data from an ECMO registry, including patients aged 18 years and older who have received either venoarterial (VA)- or venovenous (VV)-ECMO support between July 2016 and September 2021. We used analysis of variance and Fisher exact tests to identify factors associated with PC consultation. Of 256, 177 patients (69.1%) received VA-ECMO support and 79 (30.9%) received VV-ECMO support. Overall, 115 patients (44.9%) received PC consultation while on ECMO. Patients receiving PC consultation were more likely to be non-white (47% vs. 53%, p = 0.016), have an attending physician from a medical versus surgical specialty (65.3% vs. 39.6%), have VV-ECMO (77.2% vs. 30.5%, p < 0.001), and have longer ECMO duration (6.2 vs. 23.0, p < 0.001). Patients were seen by the PC team on an average of 7.6 times (range, 1-35), with those who died having significantly more visits (11.2 vs. 5.6, p < 0.001) despite the shorter hospital stay. The average time from cannulation to the first PC visit was 5.3 ± 5 days. Congestive heart failure in VA-ECMO, coronavirus disease 2019 infection in VV-ECMO, and non-white race and longer ECMO duration for all patients were associated with PC consultation. We found that despite the benefits of PC, it is underused in this population.

Top Ten Tips Palliative Care Clinicians Should Know About Working With Adults Receiving Extracorporeal Membrane Oxygenation

Extracorporeal membrane oxygenation (ECMO) is an invasive intervention that is both resource- and labor-intensive. It can also be emotionally challenging for all involved. Palliative care (PC) clinicians can support adult patients, families, surrogate decision makers, and the interdisciplinary team (IDT) throughout ECMO, starting at the time of ECMO initiation through discontinuation and to bereavement in the event of a patient's death. In addition to knowing the basics of ECMO circuitry, indications to start ECMO, and the complex decision points throughout treatment, PC clinicians must understand the critical need for specialist and IDT coordination when discussing prognosis and resuscitation, clarifying goals of care, and identifying future treatment options. Not only are PC clinicians' skills needed to manage symptoms and psychosocial needs but also during end-of-life care, which can often be rapid and requires team consensus to ensure a smooth clinical process with continuous family support. While using their expert communication skills to conduct frequent family meetings, ideally starting within one week of ECMO initiation and weekly thereafter, PC clinicians offer a consistent presence and "big picture" perspective for patients and families, while other members of the IDT may rotate regularly. PC clinicians will also be called on to assist members of the IDT to debrief about the understandable moral and emotional distress they may experience while providing care for patients receiving ECMO and their families.

Early palliative care consultation offsets hospitalization duration and costs for elderly patients with traumatic brain injuries: Insights from a Level 1 trauma center

We identified factors and outcomes associated with inpatient palliative care (PC) consultation, stratified into early and late timing, for patients over age 65 with traumatic brain injuries (TBI). Patients over age 65 presenting to a single institution with TBI and intracranial hemorrhage from January 2013-September 2020 were included. Patient demographics and various outcomes were analyzed. Inpatient PC consultation was uncommon (4 % out of 576 patients). Characteristics associated with likelihood of consultation were severe TBI (OR = 5.030, 95 % CI 1.096-23.082, p =.038) and pre-existing dementia (OR = 6.577, 95 % CI 1.726-25.073, p =.006). Average consultation timing was 8.6 (standard deviation ± 7.0) days. Patients with PC consults had longer overall (p =.0031) and intensive care unit (ICU) length of stays (LOS) (p <.0001), more days intubated (p <.0001) and higher costs (p =.0006), although those with earlier-than-average PC consultation had shorter overall (p =.0062) and ICU (p =.011) LOS as well as fewer ventilator days (p =.030) and lower costs (p =.0003). Older patients with TBI are more likely to receive PC based on pre-existing dementia and severe TBI. Patients with PC consultations had worse LOS and higher costs. However, these effects were mitigated by earlier PC involvement. Our study emphasizes the need for timely PC consultation in a vulnerable patient population.

Palliative Care Impact on COVID-19 Patients Requiring Extracorporeal Membrane Oxygenation

CONTEXT

Patients with severe respiratory failure from COVID-19 refractory to conventional therapies may be treated with extracorporeal membrane oxygenation (ECMO). ECMO requirement is associated with high mortality and prolonged hospital course. ECMO is a high-resource intervention with significant burdens placed on caregivers and families with limited data on the integration of palliative care consultation (PCC).

OBJECTIVES

To explore the role of standard vs. automatic PCC in the management of COVID patients on ECMO.

METHODS

Retrospective chart review of all COVID patients on ECMO admitted from March 2020 to May 2021 at a large volume academic medical center with subsequent analysis.

RESULTS

Forty-eight patients were included in the analysis. Twenty-six (54.2%) received PCC of which 42% of consults were automatically initiated. PCC at any point in admission was associated with longer duration on ECMO (24.5 vs. 37 days; P &lt; 0.05). Automatic PCC resulted in more family meetings than standard PCC (0 vs. 3; P &lt; 0.05) and appears to trend with reduced time on ECMO, shorter length of stay, and higher DNAR rates at death, though results were not significant. Decedents not receiving PCC had higher rates of no de-escalation of interventions at time of death (31% vs. 11%), indicating full intensive care measures continued through death.

CONCLUSIONS

Among patients with COVID-19 receiving ECMO, PCC may be associated with a shift to DNAR status particularly with automatic PCC. There may be a further impact on length of stay, duration of time on ECMO and care plan at end of life.