Impact of a Proactive Approach to Improve End-of-Life Care in a Medical ICU

doi:10.1378/chest.123.1.266

Chest

Volume 123, Issue 1, January 2003, Pages 266-271

https://doi.org/10.1378/chest.123.1.266 Get rights and content

Study objectives

To assess the impact of a proactive case finding approach to end-of-life care for critically ill patients experiencing global cerebral ischemia (GCI) after cardiopulmonary resuscitation and multiple organ system failure (MOSF) in comparison to historical control subjects.

Design

Comparative study of retrospective and prospective cohorts.

Setting

Medical ICU of a university hospital.

Interventions

Patterns of end-of life care for patients with MOSF and GCI obtained through a retrospective chart review were compared to proactive case finding facilitated by the inpatient palliative care service. Interventions included identification of patient's advance directives or preferences about end-of life care, if any; assistance with discussion of the prognosis and treatment options with patients or their surrogates; and implementation of palliative care strategies when treatment goals changed to a focus on comfort measures.

Results

Although our retrospective data demonstrated a high percentage of do-not-resuscitate decisions for the patients under investigation, a considerable time lag elapsed between identification of the poor prognosis and the establishment of end-of-life treatment goals (4.7 ± 2.4 days and 3.5 ± 0.5 days for patients with MOSF and GCI, respectively [mean ± SE]). The proactive case finding approach decreased hospital length of stay (mean, 20.6 ± 4.1 days vs 15.1 ± 2.5 days and 8.6 ± 1.6 days vs 4.7 ± 0.6 days for MOSF and GCI patients, respectively; p = 0.063 and < 0.001, respectively). More importantly, a proactive palliative care intervention decreased the time between identification of the poor prognosis and the establishment of comfort care goals (7.3 ± 2.9 days vs 2.2 ± 0.8 days and 6.3 ± 1.2 days vs 3.5 ± 0.4 days for MOSF and GCI patients, respectively; p < 0.05 for both), decreased the time dying patients with MOSF remained in the ICU, and reduced the use of nonbeneficial resources, thus reducing the cost of care.

Conclusions

Proactive interventions from a palliative care consultant within this subset of patients decreased the use of nonbeneficial resources and avoided protracted dying.

Section snippets

Materials and Methods

The Human Investigation Committee of Wayne State University approved the study protocol. The study consisted of two cohorts. A retrospective cohort, which served as a historical control group, obtained by chart analysis of patients with GCI after cardiac arrest or MOSF admitted to the Detroit Receiving Hospital medical ICU (MICU), and a prospective cohort consisting of the same patient populations subjected to proactive palliative care interventions. Since the prospective phase was conducted as

Results

There were 1,972 admissions to the Detroit Receiving Hospital MICU during the period of July 1, 1998, to June 30, 1999. Four hundred four medical records were identified by the medical records searching method previously described. After careful review of the identified charts, 18 patients with CGI and 22 patients with MOSF met inclusion criteria and were included in the retrospective analysis. The proactive cohort consisted of 20 patients with GCI and 21 patients with MOSF enrolled

Discussion

Outcome measures for evaluating end-of-life care of patients with diagnoses known to have a poor outcome such as GCI after cardiac arrest and persistent MOSF are scarce. In spite of a well-established palliative care practice at our institution,¹³¹⁴¹⁵²⁹³⁰ the program was underutilized by the MICU team, in that the palliative care consultants saw only approximately 30% of the study patients, as demonstrated by the retrospective data analysis. However, our data shows that a dedicated team

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Chest

Ethics in Cardiopulmonary MedicineImpact of a Proactive Approach to Improve End-of-Life Care in a Medical ICU

Study objectives

Design

Setting

Interventions

Results

Conclusions

Section snippets

Materials and Methods

Results

Discussion

Chest

Electroencephalogr Clin Neurophysiol

Neurol Clin

Death in two Canadian intensive care units: institutional difference and changes over time

Crit Care Med

Increasing incidence of withholding and withdrawal of life support from the critically ill

Am J Respir Crit Care Med

A national survey of end-of-life care for critically ill patients

Am J Respir Crit Care Med

The use and implications of do not resuscitate orders in intensive care units

JAMA

Decisions about resuscitation: inequities among patients with different diseases but similar prognoses

Ann Intern Med

Patient preferences for communication with physicians about end-of-life decisions

Ann Intern Med

Patient attitudes to discussing life-sustaining treatment

Arch Intern Med

Decisions to limit or continue life-sustaining treatment by critical care physicians in the United States: conflicts between physicians' practices and patients' wishes

Am J Respir Crit Care Med

Short-term mortality predictions for critically ill hospitalized adults: science and ethics

Science

Accurate prognostication of death: opportunities and challenges for clinicians

West J Med

A controlled trial to improve care for seriously ill hospitalized patients: the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatment (SUPPORT)

JAMA

Development of a comprehensive supportive care team for the hopelessly ill on a university medical service

JAMA

Impact of a comprehensive supportive care team on management of hopelessly ill patients with multiple organ failure

Chest

Experience with an end-of-life practice at a university hospital

Crit Care Med

Ethics in Cardiopulmonary Medicine
Impact of a Proactive Approach to Improve End-of-Life Care in a Medical ICU