Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
Randomized Controlled Trial
. 2025 Feb 1;185(2):173-183.
doi: 10.1001/jamainternmed.2024.6838.

Mobile App-Facilitated Collaborative Palliative Care Intervention for Critically Ill Older Adults: A Randomized Clinical Trial

Christopher E Cox  1   2 , Deepshikha C Ashana  1   2 , Katelyn Dempsey  1   2 , Maren K Olsen  3   4 , Alice Parish  3 , David Casarett  5 , Kimberly S Johnson  6   7 , Krista L Haines  8 , Colleen Naglee  9 , Jason N Katz  10 , Mashael Al-Hegelan  1 , Isaretta L Riley  1   2 , Sharron L Docherty  11
Affiliations
Randomized Controlled Trial

Mobile App-Facilitated Collaborative Palliative Care Intervention for Critically Ill Older Adults: A Randomized Clinical Trial

Christopher E Cox et al. JAMA Intern Med. .

Abstract

Importance: Few person-centered, scalable models of collaborative intensive care unit (ICU) clinician-palliative care specialist care exist.

Objective: To evaluate the effect of a collaborative palliative care intervention compared to usual care among family members of patients in the ICU.

Design, setting, and participants: This parallel-group randomized clinical trial with patient-level randomization was conducted between April 2021 and September 2023. The study was set at 6 medical and surgical ICUs in 1 academic hospital and 1 community hospital. The study participants included critically ill older adult patients with 1 of 11 poor outcome phenotypes, their family members with elevated palliative care needs, and their attending ICU physicians.

Intervention: An automated electronic health record-integrated, mobile application-based communication platform that displayed family-reported needs over 7 days, coached ICU attending physicians on addressing needs, and prompted palliative care consultation if needs were not reduced within 3 study days.

Main outcomes and measures: The primary outcome was change in the family-reported Needs at the End-of-Life Screening Tool (NEST) score between study days 1 and 3. The 13-item NEST score is a number between 0 and 130, with higher scores indicating a greater need. Secondary outcomes included quality of communication and goal of care concordance, as well as 3-month psychological distress.

Results: Of 151 family members, the mean (SD) age was 57.4 (12.9) years, and 110 (72.9%) were female. Of 151 patients, the mean (SD) age was 69.8 (9.7) years, and 86 (57.0%) were male. Thirty-five ICU physicians were male (68.6%). Seventy-six patients were randomized to the intervention group and 75 to the control group. Treatment group differences in estimated mean NEST scores were similar at 3 days between the intervention and control groups (-3.1 vs -2.0, respectively; estimated mean difference in differences, -1.3 points [95% CI, -6.0 to 3.5]) and 7 days (-2.3 vs -2.2, respectively; estimated mean difference in differences, 0 points [95% CI, -6.2 to 6.2]). Median (IQR) need scores were lower among individuals who remained in the ICU at day 3 for intervention participants vs controls (24.5 [16.5-34.5] vs 27.5 [13.0-40.0], respectively); median (IQR) need scores were also lower among those who remained in the ICU at day 7 for intervention vs controls (22.0 [11.0-35.0] vs 28.0 [14.0-35.0], respectively). Goal concordance, quality of communication, and psychological distress symptoms did not differ. Twenty-nine intervention participants (38.2%) had palliative care consultations, compared to only 3 (4.0%) among controls, (P < .001); 66 intervention participants (87.0%) had a family meeting, compared to 48 (64.0%) among controls (P = .001).

Conclusions and relevance: In this randomized clinical trial, a collaborative, person-centered, ICU-based palliative care intervention had no effect on palliative care needs or psychological distress compared to usual care despite a higher frequency of palliative care consultations and family meetings among intervention participants.

Trial registration: ClinicalTrials.gov Identifier: NCT04414787.

PubMed Disclaimer

Conflict of interest statement

Conflict of Interest Disclosures: Dr Ashana reported grants from the National Institutes of Health (NIH; grant 5K23HL164968-03) outside the submitted work. Dr Olsen reported grants from Duke University during the conduct of the study and grants from the Department of Veterans Affairs outside the submitted work. Dr Casarett reported personal fees from and investing in Curio Wellness, holding equity in SoFi and DisposeRx, and investing and holding equity in CareYaya outside the submitted work. Dr Katz reported speaker fees from Zoll, nonfinancial research support from Abbott, and consulting fees from Abiomed outside the submitted work. Dr Riley reported grants from NIH (grant K01 HL159043) during the conduct of the study. No other disclosures were reported.

Comment on

References

    1. Gentzler ER, Derry H, Ouyang DJ, et al. . Underdetection and undertreatment of dyspnea in critically ill patients. Am J Respir Crit Care Med. 2019;199(11):1377-1384. doi:10.1164/rccm.201805-0996OC - DOI - PMC - PubMed
    1. White DB, Ernecoff N, Buddadhumaruk P, et al. . Prevalence of and factors related to discordance about prognosis between physicians and surrogate decision-makers of critically ill patients. JAMA. 2016;315(19):2086-2094. doi:10.1001/jama.2016.5351 - DOI - PubMed
    1. Cook D, Rocker G. Dying with dignity in the intensive care unit. N Engl J Med. 2014;370(26):2506-2514. doi:10.1056/NEJMra1208795 - DOI - PubMed
    1. Sullivan DR, Iyer AS, Enguidanos S, et al. . Palliative care early in the care continuum among patients with serious respiratory illness: an official ATS/AAHPM/HPNA/SWHPN policy statement. Am J Respir Crit Care Med. 2022;206(6):e44-e69. doi:10.1164/rccm.202207-1262ST - DOI - PMC - PubMed
    1. Wysham NG, Hua M, Hough CL, et al. . Improving ICU-based palliative care delivery: a multicenter, multidisciplinary survey of critical care clinician attitudes and beliefs. Crit Care Med. 2017;45(4):e372-e378. doi:10.1097/CCM.0000000000002099 - DOI - PMC - PubMed

Associated data