Clinical PotpourriClinical significance of palliative care assessment in patients referred for urgent intensive care unit admission: A cohort study☆
Introduction
The global burden of critical illness is high and is likely to increase as the population ages [1]. In the United States, for instance, it has been estimated that roughly 1 in 5 Americans die using intensive care unit (ICU) services [2]. Moreover, perceptions of inappropriate care in the ICU are reported frequently worldwide [3], [4] and much of that care may be seen as nonbeneficial or not consistent with patients' values and preferences [5].
There are several key steps in the evolution of decision making in relation to end-of-life situations in the hospital, from the admission of an at-risk patient to the occurrence of an acute deterioration and its management in the critical care setting [6]. Advanced care planning or palliative care (PC) referral in the wards or during ICU stay may reduce inappropriate ICU admissions and ICU length of stay [7]. In addition, rapid response systems activation during acute deterioration has been associated with modifications in goals of care decisions [8]. However, although it has been suggested that such acute deterioration events could be used as indicators to trigger PC assessment [9], there is little research on the epidemiology of deteriorating patients in the hospital to help discriminating which patients would benefit from such assessment [10], [11].
Co-occurrence of PC assessment and urgent ICU referral in the same hospital admission could be used as a marker for high-risk patients that may benefit from goals of care discussions. The aim of this study was to evaluate clinical characteristics at the moment of urgent ICU referral that could differentiate patients with concurrent PC and ICU referral from patients with ICU referral only.
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Ethics, consent, and permission
This study was approved, and a waiver for informed consent was granted, by the Hospital das Clinicas da Faculdade de Medicina da Universidade de Sao Paulo (HCFMUSP) research ethics committee (approval number 638.864).
Setting
The Central Institute of the HCFMUSP is an academic, tertiary hospital with about 1100 hospital beds and 110 ICU beds, divided in 10 ICUs. The Central Institute is a referral center for acutely ill medical, surgical, and trauma patients and also for elective medical and complex
Results
From May 2014 to May 2015, there were 44 291 admissions to the hospital. There were 3115 urgent ICU referrals, of which 639 were excluded (612 repeated requests and 27 requests for patients younger than 16 years), leaving 2476 patients for final analysis. In the period of the study, there were 843 PC assessments (Figure).
Discussion
This study has shown that clinical characteristics at the moment of urgent ICU referral were associated with the co-occurrence of PC assessment and ICU admission referral in the same hospital admission. These patients were older, were more likely to have previous diagnosis of cancer and nonsurgical admission, were like to present with depressed level of consciousness, were hospitalized for longer periods before ICU admission request, had lower performance status, and were judged by the
Conclusion
In this cohort of patients with urgent ICU referral, clinical characteristics at the moment of ICU referral were associated with co-occurrence of PC assessment in the same hospital admission. These characteristics might guide the development of instruments to enhance early referral of high-risk patients to PC services.
Authors' contributions
JGRR, MDTC, RTC, and DNF contributed to the designing, acquisition, analysis and interpretation of data, and drafting and revising the manuscript. DJ contributed to interpretation of results, drafting, and critically revising the manuscript. All authors have approved the final version of this manuscript.
This work has no funding.
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Palliative Care Consult among Older Adult Patients in Intensive Care Units: An Integrative Review
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Conflicts of interests: The authors declare no conflicts of interests.