Prospective study of a proactive palliative care rounding intervention in a medical ICU

Abstract

Purpose: To evaluate the effects of a palliative care intervention on clinical and family outcomes, and palliative care processes.

Methods: Prospective, before-and-after interventional study enrolling patients with high risk of mortality, morbidity, or unmet palliative care needs in a 24-bed academic intensive care unit (ICU). The intervention involved a palliative care clinician interacting with the ICU physicians on daily rounds for high-risk patients.

Results: One hundred patients were enrolled in the usual care phase, and 103 patients were enrolled during the intervention phase. The adjusted likelihood of a family meeting in ICU was 63% higher (RR 1.63, 95% CI 1.14-2.07, p = 0.01), and time to family meeting was 41% shorter (95% CI 52-28% shorter, p < 0.001). Adjusted ICU length of stay (LOS) was not significantly different between the two groups (6% shorter, 95% CI 16% shorter to 4% longer, p = 0.22). Among those who died in the hospital, ICU LOS was 19% shorter in the intervention (95% CI 33-1% shorter, p = 0.043). Adjusted hospital LOS was 26% shorter (95% CI 31-20% shorter, p < 0.001) with the intervention. Post-traumatic stress disorder (PTSD) symptoms were present in 9.1% of family respondents during the intervention versus 20.7% prior to the intervention (p = 0.09). Mortality, family depressive symptoms, family satisfaction and quality of death and dying did not significantly differ between groups.

Conclusions: Proactive palliative care involvement on ICU rounds for high-risk patients was associated with more and earlier ICU family meetings and shorter hospital LOS. We did not identify differences in family satisfaction, family psychological symptoms, or family-rated quality of dying, but had limited power to detect such differences.

Keywords: Communication; End-of-life care; Family ICU syndrome; Family meetings; ICU decision-making; Palliative care.

Fig 1

Association between intervention and hospital (left) and ICU (right) length of stay, with sensitivity analyses. Incidence rate ratios calculated from zero-truncated Poisson regression models are presented, with error bars representing 95% confidence intervals. The full model included the following potential confounders: patient age, sex, race and ethnicity, the presence of metastatic or incurable cancer, multimorbidity with age over 80, and admission from LTAC.

Fig 2

Adjusted change in family satisfaction scores (by FS-ICU) (top) and adjusted change in family assessment of the quality of death and dying (QODD-1) (middle, in blue), using multivariable linear regression. Adjusted association between the intervention and psychological outcomes (bottom). All models were adjusted for patient age, sex, and race, respondent sex, whether the patient and respondent were spouses, the presence of metastatic or incurable cancer, multimorbidity with age over 80, and (except for the QODD-1 model) the occurrence of death in the ICU