Intensive Care Unit Palliative Care Shortens Hospital Stays

Abstract

SAN FRANCISCO – Palliative care in the intensive care unit reduces the length of stay in the hospital without changing mortality rates or family satisfaction, according to a review of the literature.Although measurements of family satisfaction overall didn't change much from palliative care of a loved one in the intensive care unit (ICU), some satisfaction indicators increased with palliative care, such as improved communication with the physician, better consensus around the goals of care, and decreased anxiety and depression in family members, reported Rebecca A. Aslakson, MD, of Johns Hopkins University, Baltimore. She originally reported the findings at a meeting of the Society of Critical Care Medicine.Dr. Aslakson and her associates were unable to perform a formal meta-analysis of the 37 published trials of palliative care in the ICU because of the heterogeneity of the studies, which looked at more than 40 different outcomes. Instead, their systematic review grouped results under four outcomes that commonly were measured, and the team assessed those either by the number of studies or by the number of patients studied.ICU length of stay decreased with palliative care in 13 of 21 studies (62%) that used this outcome and in 59% of 9,368 patients in those studies. Hospital length of stay decreased with palliative care in 8 of 14 studies (57%) and in 43% of 5,817 patients. Family satisfaction did not decrease in any study and increased in only 1 of 14 studies (7%) and in 2% of families of 4,927 patients, Dr. Aslakson reported.Mortality rates did not change with palliative care in 14 of 16 studies (88%) that assessed mortality and in 57% of 5,969 patients in those studies. Mortality increased in one small study (6%) and decreased in one larger study (6%).“Talking about big-picture issues and goals of care doesn't lead to people dying,” Dr. Aslakson said. “No harm came in any of these studies.” Some separate studies of palliative care outside of ICUs reported that this increases hope, “because people feel that they have more control over their choices and what's happening to their loved ones,” she added.Integrative vs. ConsultativeDr. Aslakson and her associates also reviewed studies based on whether the interventions used integrative or consultative models of palliative care.Generally, consultative models bring outsiders into the ICU to help provide palliative care, and integrative models train the ICU team to be the palliative care providers. In reality, the two models may overlap. For this review, the investigators applied mutually exclusive definitions to 36 of the studies. In 18 studies of integrative interventions, members of the ICU team were the only caregivers in face-to-face interactions with the patient and families. In 18 studies of consultative interventions, palliative care providers included others besides the ICU team.In the studies of integrative palliative care, ICU length of stay decreased with palliative care in 4 of 9 studies (44%) that measured this outcome and in 52% of 6,963 patients in those studies, she reported. Hospital length of stay decreased in 2 of 5 studies (40%) and in 24% of 3,812 patients. Family satisfaction changed in none of 15 studies, and mortality decreased in 1 of 5 studies (20%) and in 34% of 3,807 patients.In the studies of consultative care, ICU length of stay decreased with palliative care in 9 of 12 studies (75%) that measured this outcome and in 79% of 2,405 patients in those studies. Hospital length of stay decreased in 6 of 9 studies (67%) and in 79% of 2,005 patients. Family satisfaction increased in 1 of 4 studies (25%) and in 21% of 429 patients. Mortality increased in 1 of 11 studies (9%) and in 5% of 2,162 patients.One model isn't necessarily better than the other, Dr. Aslakson said. Integrative palliative care may work best in a closed ICU with perhaps 4 or 5 intensivists in a relatively small unit. An integrative approach can be much more difficult in open or semiopen ICUs that have “40 different doctors floating around,” she said. “We tried that in my unit, and it didn't work that well.”Different ICUs need palliative care models that fit them. “Look at your unit, the way it works, and who the providers are, then look at the literature and see what matches that and what might work for your unit,” she said.Improved CommunicationA previous, separate review of the medical literature identified 21 controlled trials of 16 interventions to improve communication in ICUs between families and care providers. Overall, the interventions improved emotional outcomes for families and reduced ICU length of stay and treatment intensity (Chest 2011;139[3]:543–54), Dr. Aslakson noted.Yet another prior review of the literature reported that interventions to promote family meetings, use empathetic communication skills, and employ palliative care consultations improved family satisfaction and reduced ICU length of stay and the adverse effects of family bereavement (Curr. Opin. Crit. Care 2009;15[6]:569–77).Dr. Aslakson reported having no financial conflict of interest.Editor's NoteIt's nice when research and data confirm our intuitions. Palliative care makes sense on so many levels and in virtually every setting.Historically in the PA/LTC arena, we haven't embraced palliative care as much as we should, in part because of misalignment of incentives. Especially with the postacute (skilled) population, making palliation the primary goal of care often disqualifies a patient from Medicare Part A benefits, which markedly reduces the amount that a facility will be paid per diem.Unfortunately, many of us have seen dying patients who have no business being subjected to physical therapy that seems like torture to them. This can happen so a facility can get its RUG rates or so a family doesn't have to pay for custodial care. We can only hope that as more novel payment systems evolve, there will be provisions for palliative care in PA/LTC that make it a good option for all stakeholders.More and more nursing homes are able to provide formal palliative care consultations to their residents, and most of us provide palliation routinely, regardless of whether our patients are getting curative, skilled, or aggressive care. Symptom management and respect for a person's quality of life are what we are all about.—Karl Steinberg, MD, CMD Editor in Chief SAN FRANCISCO – Palliative care in the intensive care unit reduces the length of stay in the hospital without changing mortality rates or family satisfaction, according to a review of the literature. Although measurements of family satisfaction overall didn't change much from palliative care of a loved one in the intensive care unit (ICU), some satisfaction indicators increased with palliative care, such as improved communication with the physician, better consensus around the goals of care, and decreased anxiety and depression in family members, reported Rebecca A. Aslakson, MD, of Johns Hopkins University, Baltimore. She originally reported the findings at a meeting of the Society of Critical Care Medicine. Dr. Aslakson and her associates were unable to perform a formal meta-analysis of the 37 published trials of palliative care in the ICU because of the heterogeneity of the studies, which looked at more than 40 different outcomes. Instead, their systematic review grouped results under four outcomes that commonly were measured, and the team assessed those either by the number of studies or by the number of patients studied. ICU length of stay decreased with palliative care in 13 of 21 studies (62%) that used this outcome and in 59% of 9,368 patients in those studies. Hospital length of stay decreased with palliative care in 8 of 14 studies (57%) and in 43% of 5,817 patients. Family satisfaction did not decrease in any study and increased in only 1 of 14 studies (7%) and in 2% of families of 4,927 patients, Dr. Aslakson reported. Mortality rates did not change with palliative care in 14 of 16 studies (88%) that assessed mortality and in 57% of 5,969 patients in those studies. Mortality increased in one small study (6%) and decreased in one larger study (6%). “Talking about big-picture issues and goals of care doesn't lead to people dying,” Dr. Aslakson said. “No harm came in any of these studies.” Some separate studies of palliative care outside of ICUs reported that this increases hope, “because people feel that they have more control over their choices and what's happening to their loved ones,” she added. Integrative vs. ConsultativeDr. Aslakson and her associates also reviewed studies based on whether the interventions used integrative or consultative models of palliative care.Generally, consultative models bring outsiders into the ICU to help provide palliative care, and integrative models train the ICU team to be the palliative care providers. In reality, the two models may overlap. For this review, the investigators applied mutually exclusive definitions to 36 of the studies. In 18 studies of integrative interventions, members of the ICU team were the only caregivers in face-to-face interactions with the patient and families. In 18 studies of consultative interventions, palliative care providers included others besides the ICU team.In the studies of integrative palliative care, ICU length of stay decreased with palliative care in 4 of 9 studies (44%) that measured this outcome and in 52% of 6,963 patients in those studies, she reported. Hospital length of stay decreased in 2 of 5 studies (40%) and in 24% of 3,812 patients. Family satisfaction changed in none of 15 studies, and mortality decreased in 1 of 5 studies (20%) and in 34% of 3,807 patients.In the studies of consultative care, ICU length of stay decreased with palliative care in 9 of 12 studies (75%) that measured this outcome and in 79% of 2,405 patients in those studies. Hospital length of stay decreased in 6 of 9 studies (67%) and in 79% of 2,005 patients. Family satisfaction increased in 1 of 4 studies (25%) and in 21% of 429 patients. Mortality increased in 1 of 11 studies (9%) and in 5% of 2,162 patients.One model isn't necessarily better than the other, Dr. Aslakson said. Integrative palliative care may work best in a closed ICU with perhaps 4 or 5 intensivists in a relatively small unit. An integrative approach can be much more difficult in open or semiopen ICUs that have “40 different doctors floating around,” she said. “We tried that in my unit, and it didn't work that well.”Different ICUs need palliative care models that fit them. “Look at your unit, the way it works, and who the providers are, then look at the literature and see what matches that and what might work for your unit,” she said. Dr. Aslakson and her associates also reviewed studies based on whether the interventions used integrative or consultative models of palliative care. Generally, consultative models bring outsiders into the ICU to help provide palliative care, and integrative models train the ICU team to be the palliative care providers. In reality, the two models may overlap. For this review, the investigators applied mutually exclusive definitions to 36 of the studies. In 18 studies of integrative interventions, members of the ICU team were the only caregivers in face-to-face interactions with the patient and families. In 18 studies of consultative interventions, palliative care providers included others besides the ICU team. In the studies of integrative palliative care, ICU length of stay decreased with palliative care in 4 of 9 studies (44%) that measured this outcome and in 52% of 6,963 patients in those studies, she reported. Hospital length of stay decreased in 2 of 5 studies (40%) and in 24% of 3,812 patients. Family satisfaction changed in none of 15 studies, and mortality decreased in 1 of 5 studies (20%) and in 34% of 3,807 patients. In the studies of consultative care, ICU length of stay decreased with palliative care in 9 of 12 studies (75%) that measured this outcome and in 79% of 2,405 patients in those studies. Hospital length of stay decreased in 6 of 9 studies (67%) and in 79% of 2,005 patients. Family satisfaction increased in 1 of 4 studies (25%) and in 21% of 429 patients. Mortality increased in 1 of 11 studies (9%) and in 5% of 2,162 patients. One model isn't necessarily better than the other, Dr. Aslakson said. Integrative palliative care may work best in a closed ICU with perhaps 4 or 5 intensivists in a relatively small unit. An integrative approach can be much more difficult in open or semiopen ICUs that have “40 different doctors floating around,” she said. “We tried that in my unit, and it didn't work that well.” Different ICUs need palliative care models that fit them. “Look at your unit, the way it works, and who the providers are, then look at the literature and see what matches that and what might work for your unit,” she said. Improved CommunicationA previous, separate review of the medical literature identified 21 controlled trials of 16 interventions to improve communication in ICUs between families and care providers. Overall, the interventions improved emotional outcomes for families and reduced ICU length of stay and treatment intensity (Chest 2011;139[3]:543–54), Dr. Aslakson noted.Yet another prior review of the literature reported that interventions to promote family meetings, use empathetic communication skills, and employ palliative care consultations improved family satisfaction and reduced ICU length of stay and the adverse effects of family bereavement (Curr. Opin. Crit. Care 2009;15[6]:569–77).Dr. Aslakson reported having no financial conflict of interest.Editor's NoteIt's nice when research and data confirm our intuitions. Palliative care makes sense on so many levels and in virtually every setting.Historically in the PA/LTC arena, we haven't embraced palliative care as much as we should, in part because of misalignment of incentives. Especially with the postacute (skilled) population, making palliation the primary goal of care often disqualifies a patient from Medicare Part A benefits, which markedly reduces the amount that a facility will be paid per diem.Unfortunately, many of us have seen dying patients who have no business being subjected to physical therapy that seems like torture to them. This can happen so a facility can get its RUG rates or so a family doesn't have to pay for custodial care. We can only hope that as more novel payment systems evolve, there will be provisions for palliative care in PA/LTC that make it a good option for all stakeholders.More and more nursing homes are able to provide formal palliative care consultations to their residents, and most of us provide palliation routinely, regardless of whether our patients are getting curative, skilled, or aggressive care. Symptom management and respect for a person's quality of life are what we are all about.—Karl Steinberg, MD, CMD Editor in Chief A previous, separate review of the medical literature identified 21 controlled trials of 16 interventions to improve communication in ICUs between families and care providers. Overall, the interventions improved emotional outcomes for families and reduced ICU length of stay and treatment intensity (Chest 2011;139[3]:543–54), Dr. Aslakson noted. Yet another prior review of the literature reported that interventions to promote family meetings, use empathetic communication skills, and employ palliative care consultations improved family satisfaction and reduced ICU length of stay and the adverse effects of family bereavement (Curr. Opin. Crit. Care 2009;15[6]:569–77). Dr. Aslakson reported having no financial conflict of interest. Editor's NoteIt's nice when research and data confirm our intuitions. Palliative care makes sense on so many levels and in virtually every setting.Historically in the PA/LTC arena, we haven't embraced palliative care as much as we should, in part because of misalignment of incentives. Especially with the postacute (skilled) population, making palliation the primary goal of care often disqualifies a patient from Medicare Part A benefits, which markedly reduces the amount that a facility will be paid per diem.Unfortunately, many of us have seen dying patients who have no business being subjected to physical therapy that seems like torture to them. This can happen so a facility can get its RUG rates or so a family doesn't have to pay for custodial care. We can only hope that as more novel payment systems evolve, there will be provisions for palliative care in PA/LTC that make it a good option for all stakeholders.More and more nursing homes are able to provide formal palliative care consultations to their residents, and most of us provide palliation routinely, regardless of whether our patients are getting curative, skilled, or aggressive care. Symptom management and respect for a person's quality of life are what we are all about.—Karl Steinberg, MD, CMD Editor in Chief It's nice when research and data confirm our intuitions. Palliative care makes sense on so many levels and in virtually every setting.Historically in the PA/LTC arena, we haven't embraced palliative care as much as we should, in part because of misalignment of incentives. Especially with the postacute (skilled) population, making palliation the primary goal of care often disqualifies a patient from Medicare Part A benefits, which markedly reduces the amount that a facility will be paid per diem.Unfortunately, many of us have seen dying patients who have no business being subjected to physical therapy that seems like torture to them. This can happen so a facility can get its RUG rates or so a family doesn't have to pay for custodial care. We can only hope that as more novel payment systems evolve, there will be provisions for palliative care in PA/LTC that make it a good option for all stakeholders.More and more nursing homes are able to provide formal palliative care consultations to their residents, and most of us provide palliation routinely, regardless of whether our patients are getting curative, skilled, or aggressive care. Symptom management and respect for a person's quality of life are what we are all about.—Karl Steinberg, MD, CMD Editor in Chief It's nice when research and data confirm our intuitions. Palliative care makes sense on so many levels and in virtually every setting. Historically in the PA/LTC arena, we haven't embraced palliative care as much as we should, in part because of misalignment of incentives. Especially with the postacute (skilled) population, making palliation the primary goal of care often disqualifies a patient from Medicare Part A benefits, which markedly reduces the amount that a facility will be paid per diem. Unfortunately, many of us have seen dying patients who have no business being subjected to physical therapy that seems like torture to them. This can happen so a facility can get its RUG rates or so a family doesn't have to pay for custodial care. We can only hope that as more novel payment systems evolve, there will be provisions for palliative care in PA/LTC that make it a good option for all stakeholders. More and more nursing homes are able to provide formal palliative care consultations to their residents, and most of us provide palliation routinely, regardless of whether our patients are getting curative, skilled, or aggressive care. Symptom management and respect for a person's quality of life are what we are all about. —Karl Steinberg, MD, CMD Editor in Chief