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Comparative Study
. 2022 Jan 4;5(1):e2144093.
doi: 10.1001/jamanetworkopen.2021.44093.

Assessment of Clinical Palliative Care Trigger Status vs Actual Needs Among Critically Ill Patients and Their Family Members

Christopher E Cox  1   2 , Deepshikha Charan Ashana  1   2 , Krista L Haines  2   3 , David Casarett  4 , Maren K Olsen  5   6 , Alice Parish  5 , Yasmin Ali O'Keefe  7 , Mashael Al-Hegelan  1 , Robert W Harrison  8 , Colleen Naglee  7 , Jason N Katz  8 , Allie Frear  1   2 , Elias H Pratt  1   2 , Jessie Gu  1   2 , Isaretta L Riley  1 , Shirley Otis-Green  9 , Kimberly S Johnson  10 , Sharron L Docherty  11
Affiliations
Comparative Study

Assessment of Clinical Palliative Care Trigger Status vs Actual Needs Among Critically Ill Patients and Their Family Members

Christopher E Cox et al. JAMA Netw Open. .

Abstract

Importance: Palliative care consultations in intensive care units (ICUs) are increasingly prompted by clinical characteristics associated with mortality or resource utilization. However, it is not known whether these triggers reflect actual palliative care needs.

Objective: To compare unmet needs by clinical palliative care trigger status (present vs absent).

Design, setting, and participants: This prospective cohort study was conducted in 6 adult medical and surgical ICUs in academic and community hospitals in North Carolina between January 2019 and September 2020. Participants were consecutive patients receiving mechanical ventilation and their family members.

Exposure: Presence of any of 9 common clinical palliative care triggers.

Main outcomes and measures: The primary outcome was the Needs at the End-of-Life Screening Tool (NEST) score (range, 0-130, with higher scores reflecting greater need), which was completed after 3 days of ICU care. Trigger status performance in identifying serious need (NEST score ≥30) was assessed using sensitivity, specificity, positive and negative likelihood ratios, and C statistics.

Results: Surveys were completed by 257 of 360 family members of patients (71.4% of the potentially eligible patient-family member dyads approached) with a median age of 54.0 years (IQR, 44-62 years); 197 family members (76.7%) were female, and 83 (32.3%) were Black. The median age of patients was 58.0 years (IQR, 46-68 years); 126 patients (49.0%) were female, and 88 (33.5%) were Black. There was no difference in median NEST score between participants with a trigger present (45%) and those with a trigger absent (55%) (21.0; IQR, 12.0-37.0 vs 22.5; IQR, 12.0-39.0; P = .52). Trigger presence was associated with poor sensitivity (45%; 95% CI, 34%-55%), specificity (55%; 95% CI, 48%-63%), positive likelihood ratio (1.0; 95% CI, 0.7-1.3), negative likelihood ratio (1.0; 95% CI, 0.8-1.2), and C statistic (0.50; 95% CI, 0.44-0.57).

Conclusions and relevance: In this cohort study, clinical palliative care trigger status was not associated with palliative care needs and no better than chance at identifying the most serious needs, which raises questions about an increasingly common clinical practice. Focusing care delivery on directly measured needs may represent a more person-centered alternative.

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Conflict of interest statement

Conflict of Interest Disclosures: Dr Olsen reported receiving grants from the National Institutes of Health during the conduct of the study and grants from the Department of Veterans Affairs outside the submitted work. Dr Harrison reported receiving personal fees from Zoll outside the submitted work. Dr Docherty reported receiving grants from the National Institute of Aging during the conduct of the study. No other disclosures were reported.

Figures

Figure.
Figure.. Performance Characteristics of the Presence of Clinical Palliative Care Trigger Characteristics for Identifying Serious Needs
Performance characteristics of the presence of a clinical trigger characteristic are shown across a range of definitions for high levels of need based on Needs at the End-of-Life Screening Tool total scores. eTable 2 in the Supplement provides details on the calculation of values, and eTable 3 in the Supplement gives additional results.
See this image and copyright information in PMC

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