EARLY VS USUAL PALLIATIVE CARE CONSULTATION IN THE ICU: AUGMENTING THE CRITICAL CARE PHYSICIAN TO DECREASE IN-HOSPITAL MORTALITY

Abstract

SESSION TITLE: Palliative Care and End-of-Life SESSION TYPE: Original Investigations PRESENTED ON: 10/20/2019 2:15 PM - 3:15 PM PURPOSE: Around 1/5 of all deaths in the USA occur in or around an Intensive Care Unit (ICU) admission. This admission may result in changing goals of care from cure to comfort, but sometimes too late. Palliative care medicine’s (PCM) role as defined by Institute of Medicine is to “prevent, relieve, reduce, or soothe the symptoms of disease or disorder without effecting a cure” so they are a specialty that would assist with this transition. Researchers have shown a decreased length of stay and costs when PCM was involved early in the ICU stay. Other studies have tried to show an improvement in patient and family member/caregiver satisfaction scores, but have failed due to low sample sizes. There have been no studies to compare if an early palliative care consult (within 24 hours) improves mortality or decreases hospital deaths when compared to usual palliative care consultation (whenever the treating team deems is appropriate). METHODS: We performed a randomized controlled trial in a medical ICU (MICU) from 10/1/2018 to 11/30/2018. Adult patients were included if they met just one of these criteria 1) age>80 years, 2> APACHE II score >14, 3) SOFA score >9, 4) Pre-existing functional dependency, 5) late stage dementia, 6) metastatic cancer, 7) consideration to place a permanent feeding tube or tracheostomy, 8) recurrent ICU admissions, 9) post-cardiac arrest, or 10) end stage organ failure. Patients were excluded if they have already seen palliative care medicine. Once included in the study, the patients were randomized to either group by a random number generator. The patients randomized to the treatment group had a palliative care consultation within 24 hours of MICU admission. RESULTS: A total of 29 patients were randomized (14 in the early and 15 in the usual palliative care group). Baseline patient characteristics were not different between groups. The early palliative care group had a lower hospital mortality when compared to the usual care group (0 vs 6; p=0.04). More patients were discharged to hospice in the early group (4 vs 0; p=0.01). There also were more healthcare surrogates chosen in the hospital in the early group (7 vs 0; p<0.01). There was no difference in ICU or hospital length of stay or code status changes. CONCLUSIONS: This is the only study that has been performed to evaluate early palliative care consultation as defined as within 24 hours of ICU admission and its impact in patient care. We have shown in this study that patients who receive an early palliative care consultation have a lower in-hospital mortality resulting in more discharges to hospice. Also, this study shows that more healthcare surrogates are chosen in the hospital when palliative care medicine is involved earlier. CLINICAL IMPLICATIONS: Palliative care is able to augment the Critical Care physician's ability to take care of end-of-life patients when involved early resulting in a lower ICU and hospital mortality. DISCLOSURES: No relevant relationships by Rebecca Burnside, source=Web Response No relevant relationships by Scott Helgeson, source=Web Response No relevant relationships by John Moss, source=Web Response No relevant relationships by Maisha Robinson, source=Web Response