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

Abstract

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. Comparative study of retrospective and prospective cohorts. Medical ICU of a university hospital. 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. 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. Proactive interventions from a palliative care consultant within this subset of patients decreased the use of nonbeneficial resources and avoided protracted dying.