Palliative care in cardiac intensive care units (CICUs): Insights from the Critical Care Cardiology Trials Network (CCCTN) registry

Abstract

Abstract Funding Acknowledgements Type of funding sources: None. OnBehalf Critical Care Cardiology Trials Network (CCCTN) registry Introduction Palliative care is a practice focused on providing relief of symptoms of illness, while optimizing the quality of life for patients and families. We aimed to quantify palliative care (PC) practices and end-of-life decision-making in critically ill cardiac patients in contemporary CICUs. Methods The CCCTN Registry is a network of tertiary care CICUs in the United States and Canada. Between 2017 and 2020, up to 26 centers contributed an annual 2-month snapshot of all consecutive admissions to the CICU. We captured code status, rates of palliative care consultation, and decisions for comfort measures only (CMO) before all deaths in the CICU. Results Of 8231 admissions, 10% ended with death in the CICU and 2.6% were discharges to hospice. Of deceased patients, 68% were CMO before death. The median age of CMO patients was 70y (25th-75th: 59-78) vs. 67 (56-77) among deaths without CMO. In the CMO group, only 13% were DNR/DNI at admission, and the remainder were full code. Respiratory insufficiency and non-cardiogenic shock were the CICU indications most frequently associated with CMO. The median time from CICU admission to CMO decision was 3.4 days (25th-75th: 1.2-7.7) and was ≥7 days in 27% (Figure). Time from CMO decision to death was <24h in 88%, with a median of 3.8h (25th-75th 1.0-10.3). Before a CMO decision, 73% received mechanical ventilation and 25% mechanical circulatory support. Of total deaths, 34% of intubated patients were palliatively extubated. Formal PC services were engaged in only 28% of deaths. Conclusions In contemporary CICUs, CMO preceded death in 2/3 of cases. The high use of advanced ICU therapies, lengthy times to a CMO decision, and the very short time from CMO to death, highlight a potential opportunity for greater PC consultation, as well as training programs to build skills in PC for practitioners in the CICU. Abstract Figure