Elsevier

Journal of Critical Care

Volume 37, February 2017, Pages 24-29
Journal of Critical Care

Clinical Potpourri
Clinical significance of palliative care assessment in patients referred for urgent intensive care unit admission: A cohort study

https://doi.org/10.1016/j.jcrc.2016.08.018Get rights and content

Abstract

Purpose

To evaluate clinical characteristics of patients with palliative care (PC) and urgent intensive care unit (ICU) referrals in the same hospital admission.

Methods

All urgent ICU referrals at an academic, tertiary hospital, and the co-occurrence and timing of PC assessment were retrieved from a prospectively collected database.

Results

From May 2014 to May 2015, 2476 patients were analyzed and 179 (7%) had co-occurrence of PC assessment and urgent ICU referral in the same hospital admission. Hospital mortality was higher (odds ratio, 8.3; 95% confidence interval, 5.4-12.7) and ICU admission was lower (odds ratio, 0.54; 95% confidence interval, 0.40-0.74) in patients with PC assessment, compared with patients without concurrent PC and ICU referrals. Variables associated with PC assessment were older age, diagnosis of cancer, depressed level of consciousness, nonsurgical admission, lower performance status, physician's subjective prognosis of poor outcome, and length of hospitalization before ICU referral.

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.

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.

Section snippets

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.

References (20)

  • NK Adhikari et al.

    Critical care and the global burden of critical illness in adults

    Lancet

    (2010)
  • D Jones et al.

    Defining clinical deterioration

    Resuscitation

    (2013)
  • J Downar et al.

    Rapid response teams, do not resuscitate orders, and potential opportunities to improve end-of-life care: a multicentre retrospective study

    J Crit Care

    (2013)
  • DC Angus et al.

    Use of intensive care at the end of life in the United States: an epidemiologic study

    Crit Care Med

    (2004)
  • RD Piers et al.

    Perceptions of appropriateness of care among European and Israeli intensive care unit nurses and physicians

    JAMA

    (2011)
  • A controlled trial to improve care for seriously ill hospitalized patients. The study to understand prognoses and preferences for outcomes and risks of treatments (SUPPORT). The SUPPORT principal investigators

    JAMA

    (1995)
  • LJ Schneiderman et al.

    Effect of ethics consultations on nonbeneficial life–sustaining treatments in the intensive care setting: a randomized controlled trial

    JAMA

    (2003)
  • AK Hilton et al.

    Clinical review: the role of the intensivist and the rapid response team in nosocomial end-of-life care

    Crit Care

    (2013)
  • N Khandelwal et al.

    Estimating the effect of palliative care interventions and advance care planning on ICU utilization: a systematic review

    Crit Care Med

    (2015)
  • RL Smith et al.

    The medical emergency team call: a sentinel event that triggers goals of care discussion

    Crit Care Med

    (2014)
There are more references available in the full text version of this article.

Conflicts of interests: The authors declare no conflicts of interests.

View full text