ICU by Default: Consequences and Solutions to Deferred Palliative Care

Abstract

1.Describe barriers to palliative care consults in the acute-care setting through case report.2.Discuss effective solutions to upstream palliative care in advanced disease. I. Background. Intensive care unit (ICU) episodes for patients with advanced or terminal disease can occur if goals of care are not clearly defined or discussions of goals deferred entirely. These patients may experience symptom distress and ICU transfers that are not beneficial or consistent with their preferences. The competing priorities of comfort and cure and the misunderstanding about the benefits of palliative care are associated with inadequate use of palliative care. A solution to deferred palliative care and non-goal oriented ICU trials is a new model of integration used at our center, palliative care–acute care, or PAC rounds. The purpose of these weekly rounds is to identify patients with palliative care needs earlier in the hospital stay. Patients who meet specific screening criteria are presented to a multidisciplinary team. This case report affords an excellent opportunity to examine the consequences of deferral of palliative care and the impact of PAC rounds. II. Case Description. A 65-year-old female with severe systemic vasculitis underwent an extensive diagnostic evaluation. During this time, she had significant symptom burden including severe pain, delirium, dyspnea, constipation, and had extensive cutaneous involvement in both lower extremities. Renal, cardiology, and dermatology were consulted. The patient was transferred to the ICU after an episode of desaturation thought to be due to opioids. The patient remained a full code until the palliative care consult service coordinated a multidisciplinary meeting with the patient's spouse to clarify goals of care. The patient died within 2 days of ICU transfer on day 10 of hospitalization. III. Conclusion. Often the goal in acute illness is aggressive treatment or extensive diagnostic evaluation and palliative care goals may be perceived as conflicting. This case report illustrates the poor outcomes that can result if goals of care are not clearly elucidated but also an opportunity to upstream palliative care. Structure and Processes of Care