​​Early Palliative Care Consultation in the Medical ICU

Jeff Sung, MD 

​​At my current job, we are routinely consulted from the ICU and it’s beginning to feel like we are seeing all the patients in the ICU.  My intuition is that this is a good thing, as many patients are critically ill and there are many medical decisions to be made.  I wondered if there was any data on routine palliative care consultation in the ICU and whether it changes outcomes.​ 

​​I found a single-center cluster randomized crossover trial in which 199 patients admitted to the medical ICUs at Barnes Jewish Hospital (St. Louis, MO) from August 2017 to May 2018 with a positive palliative care screen indicating high risk of morbidity and mortality were randomized to intervention or usual care. The intervention group received a palliative care consultation from an interdisciplinary team led by a board-certified palliative care provider within 48 hours of ICU admission.  97 patients (48.7%) were assigned to the intervention group and 102 (51.3%) to usual care.  The primary measured outcome was change in code status from full code to DNR.  Secondary outcomes were transfer to hospice care, duration of mechanical ventilation, placement of tracheostomy, hospital mortality, 30-day mortality, ICU length of stay, hospital length of stay, post discharge revisits, and total operating cost per patient.​ 

​​Transition to DNR/DNI occurred earlier and significantly more often in the intervention group (50.5%) vs the control group (23.4%).  Transfer to hospice care was significantly increased in the intervention group (18.6%) vs the control group (4.9%).  The intervention group had fewer ventilator days (4d vs 6d), fewer tracheostomies performed (1% vs 7.8%), and fewer post discharge ER visits and/or readmissions (17.3% vs 38.9%).  Total operating cost was lower in the intervention group by 18.5%, but this was not statistically significant.  Medical ICU and pharmacy operating costs were lower with statistical significance (37% and 41%, respectively) in the intervention group.  There was no significant difference between the groups in ICU length of stay (5 vs 5.5 days), hospital length of stay (10 vs 11 days), in-hospital mortality (22.6% vs 29.4%), or 30-day mortality (35.1% vs 36.3%).​ 

​​Intuitively, this study makes sense.  Research shows over and over that early palliative care consultation in the outpatient, ED, and hospital settings leads to improved patient outcomes, increased patient satisfaction, decreased resource utilization, and decreased costs.  This study suggests similar results in the ICU setting.  I found it interesting that the primary measured outcome was a change in code status from full code to DNR.  I would be concerned that this leads the palliative care team to focus only on that metric.  However, overall resource utilization was also decreased with fewer ventilator days, fewer trachs, and fewer readmissions.  This study was performed at a single academic institution which limits the generalizability of the results to different hospitals and settings.  In addition, as the enrollment process was limited by the staffing on the PC team, not all potentially eligible patients were included in the study and this could be a source of bias.  Future research should focus on the optimal conditions for palliative care consultation in the ICU setting that includes clinical outcomes as well as patient and family satisfaction.​ 

The bottom line: ​Early triggered palliative care consultation for high risk critically ill patients in the ICU may positively impact care. ​ 

Source: ​Ma J, Chi S, Buettner B, Pollard K, Muir M, Kolekar C, Al-Hammadi N, Chen L, Kollef M, Dans M. Early Palliative Care Consultation in the Medical ICU: A Cluster Randomized Crossover Trial. Crit Care Med. 2019 Dec;47(12):1707-1715. doi: 10.1097/CCM.0000000000004016. PMID: 31609772; PMCID: PMC6861688.​