Palliative Medicine Consultation Research Articles

Retrospective Analysis of the Integration of Palliative Care Into the Care of Stroke Patients Admitted to a Regional Stroke Center.

Background: Palliative care (PC) aims to enhance the quality of life for patients when confronted with serious illness. As stroke inflicts high morbidity and mortality, the integration of PC within acute stroke care remains an important aspect of quality inpatient care. However, there is a tendency to offer PC to stroke patients only when death appears imminent. We aim to understand why this may be by examining stroke patients admitted to a regional stroke centre who subsequently died and their provision of PC. Methods: We conducted a retrospective single-centre cohort study of patients who died during admission to the regional stroke centre at Sunnybrook Health Sciences Centre (SHSC) in Toronto, Ontario, Canada. Baseline demographics were assessed using means, standard deviations (SD), medians, interquartile ranges (IQR), and proportions. Descriptive statistics, univariate, and multivariate analyses were performed to ascertain relationships between collected variables. Results: Univariate modeling demonstrated that older age, being female, no stroke diagnosis at admission to hospital, ischemic stroke, and comorbidities of cancer or dementia were associated with a higher incidence of palliative medicine consultation (PMC), while admission from an acute care hospital and a Glasgow Coma Scale (GCS) coma classification were associated with a lower incidence of PMC. The multivariate model identified the GCS coma-related category as the only significant factor associated with a higher incidence of death but was non-significantly related to a lower incidence of PMC. Conclusion: These results highlight continued missed opportunities for PC in stroke patients and underscore the need to better optimize PMC.

New UK palliative medicine consultants: clinical and non-clinical preparedness after higher specialty training

ObjectivesHigher specialty trainees are expected to achieve clinical and non-clinical skills during training in preparation for a consultant role. However, evidence from many specialties from different countries suggests that new...

Social Determinants of Health Impacting the Experience of Young Adults With Cancer at a Single Community Urban Hospital: A Retrospective Cohort Study.

Adolescent and young adult (AYA) cancer patients receive palliative medicine consultation at a late stage and face diagnostic delays. Failure to address social determinants of health (SDOH) and AYA-specific needs can adversely impact patient experience. This retrospective observational cohort study used data from chart review to assess the frequency of SDOH impacting AYA patients and setting of initial diagnosis at a US urban safety-net hospital. The association of SDOH variables with delays in treatment, loss of follow-up, and no-shows was tested using Chi-square and t-tests. One hundred seventy five patient charts were reviewed. Sixty-two percent were diagnosed in acute care settings. Substance use disorders, financial, employment, and insurance issues were associated with delayed treatment, with weak to moderate effect sizes. Mental health diagnoses, substance use disorder, homelessness, and financial burdens were associated with patient no-shows, with moderate to large effect sizes. Twenty-five percent of patients received palliative medicine consultation; 70% of these occurred at end of life. This study demonstrates the impact of SDOH on AYA cancer care and the need for policy allowing for intervention on SDOH.

Prospective and Comprehensive Characterization of an Inpatient Radiation Oncology Consult Service: Examining Interdisciplinary Coordination of Palliative Radiation Access and Receipt

Studies have increasingly demonstrated the benefit of dedicated palliative radiation therapy (PRT) models on care quality, coordination and cost-effectiveness. However, these studies are primarily retrospective and volume-based, limiting broad application of findings. Through prospective, comprehensive characterization of inpatient consults, we investigated trends in interdisciplinary coordination and PRT delivery. Inpatient consult pages at a single institution from 11/1/21-5/31/22 were prospectively tracked and characterized. Consult type, temporality and decision-making, and patient demographics, disease and treatment details, and mortality outcomes were recorded. Chi-square and logistic and linear regressions evaluated associations between consult and patient-specific features. Of 460 pages received, 131 (28.5%) were requests for further communication following initial consultation. For the 329 original consults, 20.1% related to care coordination for established on-treatment or recently treated patients who were hospitalized. RT was recommended for 57% of patients-81.3% with palliative intent. With a mean 1.85 vs. 0.8 consults per day for weekday vs. weekend, 52.6% and 34.0% of pages occurred from 7am-noon or noon-5pm respectively, with 13.4% received overnight. This distribution did not significantly differ between weekday vs. weekend. Consult type (RT consideration vs. care coordination) was not associated with day or time period. Concern regarding benefit and/or safety of radiation was the main reason for treatment deferral (31.3%). Neurologic compromise (38.7%), pain (33.8%) and obstruction (ex. airway, luminal; 11.6%) were the most frequent non-post-operative palliative indications. Median time from admission to consult was 2 days (range 0-70), with a median of 1 day for neurologic compromise, 2 days for pain and 4 days for obstruction. For PRT scenarios, patients treated or untreated with RT had no significant difference in 30 days (25.2% vs. 28.2%, respectively) or 60 days (39.6% vs. 46.3%, respectively) mortality. 53.5% of patients had either a palliative medicine consultation while an inpatient or one scheduled at the time of discharge. Prospective characterization at a tertiary-care institution reveals high-volume care coordination- and communication-related consults with temporal distribution similar to consults for RT consideration for new patients. Association of timing with palliative indication and the observed rate of palliative medicine involvement highlight opportunities for interdisciplinary education regarding early multidisciplinary engagement to ensure provision of comprehensive palliative oncologic care.

Palliative Medicine and End of Life Care Between Races in an Academic Intensive Care Unit.

Background: Although palliative medicine (PM) is more commonly being integrated into the intensive care unit (ICU), research on racial disparities in this area is lacking. Our objectives were to (a) identify racial disparities in utilization of PM consultation for patients who received ICU care and (b) determine if there were differences in the use of code status or PM consultation over time based on race. Materials and Methods: Retrospective analysis of 571 patients, 18 years and above, at a tertiary care institution who received ICU care and died during their hospital stay. We analyzed two timeframes, 2008-2009 and 2018-2019. Univariate analysis was utilized to evaluate baseline characteristics. A multivariate logistic regression model and interaction P values were employed to assess for differential use of PM consultation, do not resuscitate (DNR) orders, and comfort care (CC) orders between races in aggregate and for changes over time. Results: There was a notable increase in Black/African-American (AA) (54% to 61%) and Hispanic/Latino (2% to 3%) patients over time in our population. Compared to White patients, we found no differences between PM consultation and CC orders. There was a lower probability of DNR orders for Black/AA (adjusted odds ratio [aOR] 0.569; P = .049; confidence interval [CI]: 0.324-0.997) and other/unknown/multiracial patients (aOR: 0.389; P = .273; CI: 0.169-0.900). Comparing our earlier time period to the later time period, we found an increased usage of PM for all patients. Interaction P values suggest there were no differences between races regarding PM, DNR, and CC orders. Conclusions: PM use has increased over time at our institution. Contrary to the previous literature, there were no differences in the frequency of utilization of PM consultation between races. Further analysis to evaluate the usage of PM in the ICU setting in varying populations and geographic locations is warranted.

Qualified and motivated, but limited by specialty-specific barriers: a national survey of UK Palliative Medicine consultants research experience

ObjectivesProviding high-quality safe palliative care requires high-quality clinically driven research. Little is known about how to optimise clinical research capacity in this field.To understand interest and capacity to conduct clinical...

CT-019 Patient Perceptions of Palliative Care in the Process of Allogenic Stem Cell Transplantation

Allogeneic hematopoietic stem cell transplantation (allo-HSCT) is associated with significant sequalae that affect patients' overall quality of life (QoL). Although studies have shown improvement in patient QoL with the involvement of palliative care in the allo-HSCT process, perceptions regarding palliative care often impact referrals to palliative care. We conducted a study to examine patient perceptions of palliative care during evaluation for allo-HSCT. Primary endpoint was to assess the change in patient pre-and post-questionnaire responses. Secondary endpoint was to assess for completion of advance care planning documentation. We conducted a prospective, single-center study, of adult patients who were referred for palliative care consultation as part of evaluation for allo-HSCT. Patients were administered a pre- and post-visit questionnaire to assess understanding and comfort level with palliative medicine. We enrolled 32 patients (male = 14) patients undergoing evaluation for allo-HSCT with a primary diagnosis of AML (n=8), NHL (n=8), MDS (n=7), ALL (n=2), and other (n=7). Our study showed that the majority (56%) of patients reported a below-average (poor or fair) knowledge of palliative medicine and understanding of the reason for palliative medicine consultation. Following consultation with palliative care there was a statistically significant increase in patient understanding of reason for the appointment, p= 0.0006. There was also a significant increase in patients' knowledge of palliative care, with only 28% describing their knowledge as "good" or "excellent" prior to consultation and 79.3% after consultation, p <0.0001. There was an observed positive trend in patient comfort level with palliative medicine and likelihood to utilize palliative medicine during allo-HSCT following consultation, although not statistically significant. There was a higher rate of completion of advance care planning documentation following consultation with palliative medicine 56.3% vs 71.4%, p= 0.042. The majority of patients undergoing allo-HSCT report a poor understanding of palliative medicine. A palliative care consultation prior to allo-HSCT increases a patient's understanding of the role of palliative medicine in his/her allo-HSCT. A positive trend was observed in patients' comfort with and interest in continuing to utilize palliative medicine following initial consultation.

Aspects of palliative medicine in intensive care units: A narrative review

Background: The perspective of palliative care has changed dynamically over the years, and palliative medicine, which was originally concerned with patients with advanced oncology diseases, has become an interdisciplinary area. Many societies have published guidelines for the use of palliative medicine in intensive care units. Methods: This article presents indications and methods for implementing the principles of palliative medicine in intensive care units. Particular attention is devoted to the consultations of palliative medicine for current medical trends — COVID-19 infection, oncological diseases, fragility syndrome, and end-stage circulatory failure. Conclusions: Elements of palliative medicine are necessary for everyday practices in the intensive care unit. The most important task in cooperation is to present classifications that can help in the objective identification of patients requiring palliative care. It seems that creating a checklist of the qualifications for a palliative medicine consultation can be the next step towards making decisions about this form of therapy.

Advance Care Planning in Patients With Metastatic Cancer: A Quality Improvement Initiative.

An initiative aimed to increase the rate of advance care planning (ACP) activities for outpatients with metastatic cancer, an essential step to achieving goal concordant care. Patients with metastatic cancer were identified by International Classification of Diseases-10 coding and later by oncologists' electronic health record documentation of metastatic tumor status. ACP activities were defined as either an ACP note, Advance Directive, Physician Orders for Life-Sustaining Therapy (POLST), or a Palliative Medicine (PM) consultation within the prior year. From 2017 to 2020, the initiative screened more than 5,000 total unique cancer patients per year. PM consultants were embedded in tumor boards, oncology care team meetings, and shared oncology clinic space. Quarterly reports were sent to 60 oncologists at three cancer care sites with data of their percentage of ACP activities for patients with metastatic cancer compared with their peers. Oncologists' identities were initially blinded, but later unblinded. Oncologists also received a monthly list of patients with metastatic cancer without ACP activities. The rate of ACP activities for patients with metastatic cancer increased from a baseline of 37% in July 2017 to 57% by the end of 2020. PM consultations increased from 12% to 39% and ACP notes increased from 16% to 29% during the same interval. There was no change in Advance Directive (17%-20%) or POLST completion (7%-6%). ACP activities are an essential step to achieve goal concordant care, and this initiative successfully increased ACP activities for patients with metastatic cancer. However, given that the main source of increased ACP activities during this initiative was PM referrals, further progress will depend upon strengthening the oncology care teams' ACP skills and motivation for completion.

Early Versus Usual Palliative Care Consultation in the Intensive Care Unit.

Palliative Medicine involvement in MICU patients have improved length of stay and mortality, but with varying effects on specific patient decision outcomes, such as, advance care planning. These studies have utilized Palliative Medicine later in the hospital or ICU course, with some evidence showing that earlier involvement resulted in better results. The purpose of this study was to evaluate the benefits of early (within 24hours) palliative care consultation in medical ICU (MICU) patients to clinical and satisfaction outcomes. An unblinded randomized study performed in the MICU in one academic hospital in the USA. Ninety-one adult patients admitted to MICU received a Palliative care medicine consultation within 24hours as the intervention. Ninety-one patients admitted to the MICU underwent randomization with 50 patients randomly assigned to receive Palliative Medicine consultation and 41 patients randomly assigned to receive standard-of-care based on predefined criteria. The median satisfaction score was 23 points higher for the patients in the intervention group (P < .001). The median length of MICU stay was 5 days shorter in the intervention group compared to the control group (95% CI; 1 day to 18days, P = .018). Advance care planning was completed in the hospital for 34% of patients in the intervention arm and 12% of patients in the controls arm (absolute risk difference 22%, 95% CI 4% to 37%, P = .016). Early Palliative Medicine consultation within 24hours of MICU admission showed significant benefits to patients by improving satisfaction and decreasing length of stay. This study provides evidence that Palliative Medicine involvement earlier in the course of severe disease is important. Further studies in other types of intensive care units (neurological and Cardiovascular) are necessary to determine their impact.

Current status of academic palliative medicine in Poland: a nationwide study

AimTo assess the current status of palliative medicine (PM) education in medical students in Poland.MethodsData on PM teaching were obtained from a 16–item questionnaire sent to the heads of PM and palliative care (PC) departments at universities or university authorities. In cases in which there was no PM or PC department, the questionnaire was sent to authorities of a given University.ResultsEleven PM and PC departments were included in the analysis; 7 at the medical universities, and four at collegium medicum at universities. Among these there were two chairs of PM (at the Medical University of Poznań and the Collegium Medicum at the University of Zielona Góra) and one chair of PC (in Bydgoszcz). Most of the Departments were part of faculties of medicine, and a minority were part of faculties of health sciences. There were no PM or PC departments at 2 medical universities, three at collegium medicum at universities, and 6 at faculties of medicine; two at public universities and 4 at non–public universities. All programs of PM teaching included the philosophy of PC, and pain management. The majority included management of other symptoms, emergencies, communication, ethical issues and psychological issues in PC. Of 12 programs, 9 included practical (bedside) teaching. The numbers of hours allocated to PM ranged from 15 to 45 (median 20).ConclusionsHalf of the universities that educate medical students in Poland had PM departments and provided obligatory PM teaching. Establishing departments of PM and PC at all medical universities, collegium medicum at universities, and faculties of medicine at universities with a common PM program as an integral part of undergraduate education is suggested through including PM as a separate subject to the Regulation of the Ministry of Education and Science and initiatives of National and Provincial Consultants in PM.

Palliative Care Consultation is Associated with Decreased Rates of In-Hospital Mortality Among Patients Undergoing Major Amputation

Despite advancements in medical care and surgical techniques, major amputation continues to be associated with risks for morbidity and mortality. Palliative care programs may help alleviate symptoms and align patients' goals and the care they receive with their treatment plan. Access to specialty palliative medicine among vascular surgery patients is limited. Here, we aim to describe utilization and impact of formal palliative care consultation for patients receiving major amputations. This is a retrospective, secondary data analysis project examining the records of patients who received major amputations by the vascular surgery team between 2016 and 2021. Demographics, operative, and postoperative outcomes were recorded. The primary outcome variable was palliative care consultation during index admission (the admission in which the patient received their first major amputation). Secondary outcomes were in-hospital mortality and code status at the time of death, if death occurred during the index admission, location of death, and discharge destination. The cohort comprised of 292 patients (39% female, 53% Black, mean age 63), who received a lower extremity major amputation. Most patients (65%) underwent amputation for limb ischemia. One-year mortality after first major amputation was 29%. Average length of stay was 20days. Thirty-five (12%) patients received a palliative care consultation during the hospitalization in which they received their first major amputation. On multivariable analysis, patients were more likely to receive a palliative care consult during their index admission if they had undergone a thorough knee amputation (OR=2.89, P=0.039) or acute limb ischemia (OR=4.25, P=0.005). A formal palliative care consult was associated with lower likelihood of in-hospital death and increased likelihood of discharge to hospice (OR=0.248, P=0.0167, OR=1.283, P<0.001).There were no statistically significant differences in the code status of patients who received a palliative care consultation. In a large academic medical center, palliative medicine consultation was associated with lower in-hospital mortality among patients with advanced vascular disease and major limb amputation. These data will hopefully stimulate much needed prospective research to develop and test tools to identify patients in need and derive evidence about the impact of palliative care services.

The Impact of Palliative Medicine Consultation on Readmission Rates and Hospital Costs in Surgical Patients Requiring Prolonged Mechanical Ventilation.

The use of palliative care for critically ill hospitalized patients has expanded. However, it is still underutilized in surgical specialties. Postsurgical patients requiring prolonged mechanical ventilation have increased mortality and costs of care; outcomes from adding palliative care services to this population have been poorly investigated. The objective of this study was to determine the impact of palliative medicine consultation on readmission rates and hospitalization costs in postsurgical patients requiring prolonged mechanical ventilation. The Nationwide Readmissions Database was queried for adults (> 18 years) between the years 2010 and 2014 who underwent a major operation (Healthcare Cost and Utilization Project [HCUP] data element ORPROC = 1), required mechanical ventilation for ≥96 consecutive hours (ICD-9-CM V46.1), and survived until discharge. Among these, patients who received a palliative medicine consultation during hospitalization were identified using the ICD-9-CM diagnosis code V66.7. Of 53,450 included patients, 3.4% received a palliative care consultation. Compared to patients who did not receive a palliative care consultation, patients who did receive a consultation had a lower readmission rate (14.8% vs. 24.8%, p < 0.001) and lower average cost of hospitalization during the initial admission ($109,007 vs. $124,218, p < 0.001), findings that persisted after multivariable logistic regression. Utilization of palliative care in surgical patients remains low. Palliative care consultation in postsurgical patients requiring prolonged mechanical ventilation was associated with lower cost and rate of readmission. Further work is needed to integrate palliative care services with surgical care.

Organizational standards for specialist palliative care for adult patients: Recommendations of the Expert Group of National Consultants in Palliative Medicine and Palliative Care Nursing

Introduction: The study aimed to develop organizational standards for specialist palliative care for adult patients (OSSPCAP) in Poland. Methods: The National Consultants in Palliative Medicine and Palliative Care Nursing appointed an Expert Group consisting of three physicians — independent researchers, two nurses and a lawyer to develop the OSSPCAP. The work was done in three stages. 1. Literature analysis (Scopus and PubMed databases) and legislation on palliative care. 2. Questionnaire development using Google Forms and survey of 120 respondents in two rounds using the Delphi method. 3. Analysis of the results by the Expert Group during remote meetings and determination of the final version of the OSSPCAP. Results: The response rate in the first round of the survey was 71 (59.17%) and in the second 58 (48.33%). The first round yielded 73 positive responses (at least 70% criterion) to 97 questions; the second round yielded 21 positive responses to 31 questions. For the remaining ten questions, the Expert Group members discussed the results obtained with at least 50% criterion of positive responses. The results of both rounds were analyzed, and the final version of the document was accepted by all members of the Expert Group. Conclusions: Palliative care was divided into two types (levels): palliative care elements (palliative care approach) and specialist palliative care. In the latter home, inpatient and outpatient care was distinguished with ensuring public funding for all their organizational units by the State, including the integration into the guaranteed benefits. Requirements and procedures for all organizational units of specialist palliative care were depicted. Three specialist inpatient palliative care referral levels were offered taking into account complexity of services for patients, under- and postgraduate education. Principles of qualifying patients for palliative care, the development of research and education in palliative medicine and palliative care nursing were presented.

Development of a research-based classification of approaches to paediatric palliative medicine service provision within children’s and young adults’ hospices: A mixed methods study

Background: Globally, pioneers in children’s palliative care influenced this speciality’s development through individual initiatives leading to diverse models of care. Children’s and young adults’ hospices have now been established around the world. However, service provision varies widely leading to inequities both within countries and internationally. Aim: To describe and classify existing approaches to paediatric palliative medicine in children’s and young adults’ hospices across the UK. Design: A mixed methods study conducted by telephone interview. Setting/participants: Thirty-one leaders of children’s hospice care, representing 28 services, 66% of UK children’s and young adults’ hospice organisations. Results: A geographic-specialist classification was developed through integration of findings, enabling hospices to be classified as Regional specialist, Regional non-specialist, Local specialist and Local non-specialist. Both qualitative and quantitative data demonstrated diversity and inequity in paediatric palliative medicine provision. Of 159 doctors (63.5% of whom were general practitioners) working in participating hospices only 27.5% had specialist training in paediatric palliative medicine. The majority of participating hospices (67.9%) did not have involvement from a paediatric palliative medicine consultant. Conclusions: Internationally, the integration of specialist children’s palliative care teams with existing services is a current challenge. Despite differing approaches to children’s palliative care world-wide, models of care which facilitate integration of specialist children’s palliative care could benefit a range of countries and contexts. The geographic-specialist classification could be used to inform recommendations for a networked approach to paediatric palliative medicine within children’s and young adults’ hospices to promote equity for children with life-limiting and life-threatening conditions.

Palliative medicine trainees be should learn about frailty: meta-synthesis and Delphi study to establish curriculum content

ObjectivesFrailty is common and highly associated with morbidity and mortality, a fact that has been highlighted by COVID-19. Understanding how to provide palliative care for frail individuals is an international...

Advance care planning in metastatic cancer patients: A quality improvement initiative.

22 Background: The initiative aimed to increase the rate of advance care planning (ACP) activities for outpatients with metastatic cancer. Methods: The project was sponsored by the institution’s Quality Committee in collaboration with the Cancer Quality Committee, Oncology Division, Tumor Boards, and Medical Group. Metastatic cancer patients were identified by ICD-10 coding and later by oncologist electronic health record (EHR) documentation of metastatic status. ACP activities were defined as either an ACP note, Advance Directive, Physician’s Order for Life Sustaining Therapy, or a palliative medicine (PM) consultation. The EHR was revised to include a section for ACP documentation. Quarterly reports were sent to oncologists with data comparing their rate of ACP activities for patients with metastatic cancer with peers. Oncologists’ identities were initially blinded and later unblinded. Oncologists received a monthly list of their metastatic patients without any ACP activities. Results: The study covered 5201 unique cancer patients cared for by 60 oncologists each year. The rate of ACP activities for metastatic cancer patients increased from 37% in 2017 to 57% at the end of 2020. Data on individual ACP activities are pending analysis. The ACP activities were driven most by PM consultations, which rose from 12% to 39%. Conclusions: This initiative successfully increased ACP activities for patients with metastatic cancer. ACP activities are an essential step to achieve goal concordant care. Given that the main driver of increased ACP activities was PM referrals, further work will be required to strengthen oncologist’s ACP skills and improve access to PM.

Trends in palliative medicine and aggressive care at the end of life for women with gynecologic malignancies: a 15-year single institutional experience

Objectives: For over a decade palliative medicine in conjunction with disease modifying therapy has been recommended for women with metastatic, recurrent and symptomatic malignancies. The objective of this study was to compare the prevalence of palliative care consultations as well as aggressive care at the end of life (ACE) scores between women who died from gynecologic malignancies from 2005-2010 verse 2015-2020 as stratified by timely verses no/untimely consultation. We hypothesize that in the past fifteen years there has been an increase in palliative medicine consultation. Methods: After IRB approval data including patient demographics, histopathology, treatment and metrics of quality palliative care were abstracted from patients who died from gynecologic malignancies between 2005-2010 and 2015-2020 at a tertiary care medical center. Timely palliative consultation was defined as ≥to 30 days before death. Metrics contributing one point each to the ACE scores were 1) admission to ICU within 30 days of death, 2) hospital admission more than 14 days in the last 30 days of life, 3) more than one hospital admission during the past 30 days of life,4) more than one emergency room visit during the last 30 days of life,5) death in an acute care setting, 6) initiation of a new chemotherapy during the last 30 days of life, 7)last chemotherapy within 14 days of death, and 8) hospice admission less than 3 days before death. Data were reported in a descriptive fashion and analyzed using Student's T test, Wilcoxon Scores, and chi-square analysis with Stata 14.2. Results: Of 147 women in 2015-2020 cohort, 59(40%) had timely referral to palliative medicine compared to 18(18%) of the 2005-2010 cohort (p Download : Download high-res image (142KB) Download : Download full-size image Conclusions: There has been an increased consultation frequency and proportion of timely referrals to palliative medicine comparing contemporary to historical deaths from gynecologic malignancies. In both time periods overall ACE scores and some component scores were improved for women who received timely referral to palliative medicine. These data should be interpreted with caution secondary to baseline differences in cohorts who received timely palliative consultation verses untimely/no consultation

Incorporating Early Palliative Medicine Consultation Into Daily Morning Huddle in the ICU.

OBJECTIVES:Early palliative medicine consult in the ICU can significantly improve outcomes in high-risk patients. We describe a pilot study of including a recommendation for palliative medicine consult in the ICU morning huddle.DESIGN:A prospective, observational, quality improvement study.PATIENTS AND SETTING:Adult patients (age above 18 yr) admitted with cardiac arrest, stage IV cancer, admission from a long-term acute care facility, and circulatory shock on mechanical ventilation to the medical ICU.INTERVENTIONS:We aim to assess the effect of an early palliative medicine consultation in selected high-risk patients on change in code status, referral to hospice, tracheostomy, and or percutaneous gastrostomy tube placement.MEASUREMENTS AND MAIN RESULTS:There were 83 patients who triggered an early palliative medicine consult. Palliative medicine consultation occurred in 44 patients (53%); 23 patients (28%) had a palliative medicine consult within the first 48 hours, 21 (25%) had a palliative medicine consult afterwards. There was a significantly higher number of patients who de-escalated their code status in the palliative medicine consult group compared with the no palliative medicine consult group (63.6% vs 7.7%); however, the number was higher in the late palliative medicine consult group (71.4% vs 56.5%). There were more patients referred to hospice in the palliative medicine consult group. No difference in length of stay was observed.CONCLUSIONS:Early palliative medicine consultation in the daily ICU morning huddle is achievable, can produce a palliative medicine consultation in most cases, and results in a significant change in code status toward less aggressive measures.

Place of Death Trends and Utilization of Outpatient Palliative Care at the End of Life—Analysis of Death Certificates (2001, 2011, 2017) and Pseudonymized Data From Selected Palliative Medicine Consultation Services (2017) in Westphalia, Germany.

The largest German study on place of death was performed for deaths in selected regions of Westphalia in the years 2001 and 2011. In the period thereafter, provision of palliative care was regionally expanded. This upgrade included the establishment of palliative medicine consultation services (PMCS), combining general and specialized palliative care on an outpatient basis. A follow-up place of death survey took place in 2017. The aim was to depict the trends in place of death between 2001 and 2017. A second goal was to determine how often outpatient PMCS were used by persons who died in 2017. Descriptive analysis of place of death as specified in all death certificates (2001, 2011, 2017) issued in the cities of Bochum and Münster and the districts of Borken and Coesfeld. Comparison of pseudonymized data on deceased patients (2017) treated by the PMCS of Münster and Coesfeld with the place of death database to ascertain the rate of PMCS care at the end of life. A total of 38 954 death certificates were analyzed, and 5887 deaths were compared with PCMS data. The distribution of place of death was as follows: (2001, 2011, 2017; age standardized; %): own residence 27.8; 23.3; 21.3; hospital: 55.8; 51.8; 51.8; palliative care unit: 0.0; 1.0; 6.2; hospice: 1.9; 4.5; 4.8; nursing home: 13.1; 18.6; 20.4; other: 1.2; 1.2; 1.5. The rate of PMCS use was 28.8% (1694/5887). Over the period 2001-2017, the proportion of people who died at home or in the hospital went down, while the number who died in a palliative care unit, hospice, or nursing home increased. In the city of Münster and the district of Coesfeld, one fourth of the people who died in 2017 received PMCS care at the end of life.