Triggers For Palliative Care Consultation Research Articles

Standardized Triggers for Palliative Care Consultation in Patients with End-Stage Liver Disease Improves Utilization and Outcomes (SCI909)

Standardized Triggers for Palliative Care Consultation in Patients with End-Stage Liver Disease Improves Utilization and Outcomes (SCI909)

Introduction of triggers for palliative care consultation improve utilization and and satisfaction within a level 4 NICU

Introduction of triggers for palliative care consultation improve utilization and and satisfaction within a level 4 NICU

Introduction of triggers for palliative care consultation improves utilization and satisfaction within a level four NICU.

We sought to explore the beliefs regarding palliative care team utilization, as well as increase consultation and awareness of the palliative care team's role in the NICU. The study design in this Level 4 NICU included observational time series with multiple planned sequential interventions. Medical chart review was conducted to determine eligibility, and statistical process control charts were used to show performance over time. Prior to implementation of the triggers, 26% received consultation, which increased to 46% after implementation. There was an increase in level of understanding, knowledge of team's role, and improved utilization. The time until initial consultation decreased from ~1.5 months to 1 week. We observed a 20% increase in consultations. Key interventions included continual education, reminders, and clear postage of the trigger list. Written guidelines increase awareness of a palliative care team's role within a NICU, and provider satisfaction.

Derivation of data-driven triggers for palliative care consultation in critically ill patients

PurposeTo examine the ability of existing triggers for intensive care unit (ICU) palliative care consultation to predict 6-month mortality, and derive new triggers for consultation based on risk factors for 6-month mortality. Materials and methodsRetrospective cohort study of NY state residents who received intensive care, 2008–2013. We examined sensitivity and specificity of existing triggers for predicting 6-month mortality and used logistic regression to generate patient subgroups at high-risk for 6-month mortality as potential novel triggers for ICU palliative care consultation. ResultsOf 1,019,849 patients, 195,847 (19.2%) died within 6 months of admission. Existing triggers were specific but not sensitive for predicting 6-month mortality, (sensitivity 0.3%–11.1%, specificity 96.5–99.9% for individual triggers). Using logistic regression, patient subgroups with the highest predicted probability of 6-month mortality were older patients admitted with sepsis (age 70–79 probability 49.7%, [49.5–50.0]) or cancer (non-metastatic cancer, age 70–79 probability 51.5%, [51.1–51.9]; metastatic cancer, age 70–79 probability 60.3%, [59.9–60.6]). Sensitivity and specificity of novel triggers ranged from 0.05% to 9.2% and 98.6% to 99.9%, respectively. ConclusionsExisting triggers for palliative care consultation are specific, but insensitive for 6-month mortality. Using a data-driven approach to derive novel triggers may identify subgroups of patients at high-risk of 6-month mortality.

Introduction of Triggers for Palliative Care Consultation Improve Utilization and Satisfaction within a Level IV NICU (SA508D)

•Identify three key elements that influence successful implementation of triggers for palliative care consultation within a NICU setting.•Recall the four major trigger domains that qualify for pediatric palliative care consultation within a NICU setting. The use of a palliative care guideline, such as a trigger list for palliative care consultation (PCC), remains controversial in the NICU. Despite knowledge that a palliative team is present at our institution, the level of utilization of their services, and the NICU providers’ attitudes and beliefs regarding neonatal palliative care, are unknown. We sought to increase awareness of the palliative care team’s role and the criteria in which a consultation is appropriate, with a SMART aim to increase the number of PCCs within our level four NICU by 20% by the end of December 2016. The setting is in a Level four NICU at an academic urban pediatric hospital. The study design included observational time series with multiple planned sequential interventions, which include but not limited to surveys and education. Medical chart review screened for eligibility for PCC. Statistical process control charts show performance over time. Many providers noted a need for a guideline for PCC. Prior to implementation of the triggers, of those who qualified for PCC, 26% received consultation, which increased to 46% after implementation. There was also an increase in the percentage of survey respondents who understand what the team's role is, know when they should be consulted, and noticed a positive difference since their utilization. Lastly, the time until initial consultation decreased from approximately 1.5 months to one week. We achieved our goal of increasing the number of PCC by 20%, and decreased time to initial consultation. The triggers helped establish prompt and proactive referral. Not only can a written guideline increase awareness of a palliative care team’s role within a NICU, but it also enhances the satisfaction amongst providers of the care they are giving. Early integration of palliative care within the NICU can help guide revision of treatment goals, improve communication, and provide continuity of comprehensive care to families.

Emerging Triggers for Palliative Care Consultation in Surgery: Interdisciplinary Strategies to Identify and Meet Palliative Care Needs in the Elective and Inpatient Settings (TH313)

Emerging Triggers for Palliative Care Consultation in Surgery: Interdisciplinary Strategies to Identify and Meet Palliative Care Needs in the Elective and Inpatient Settings (TH313)

Critical Care at the End of Life.

Intensive care unit (ICU) admission is common among patients approaching the end of their lives from acute as well as chronic life-limiting conditions. ICU providers are expected to have basic palliative care skills integrated into their routine practice. Palliative care skills can be applied to all ICU patients, regardless of prognosis, and may improve patient- and family-centered end of life (EOL) care in the ICU. Consultative palliative care models may be required for more complex palliative care needs including symptom management, medical decision making, and bereavement. This review discusses integrative and consultative palliative care models and the role of triggers for palliative care consultation, particularly when they are tailored to the needs of individual ICUs. We then review the evidence for providing several palliative care domains in the ICU and some of the ethical considerations surrounding EOL care in the ICU. Finally, we highlight the importance of self-care and peer support groups to mitigate the risk of burnout for clinicians providing EOL care in the ICU.

Prevalence and Outcomes of Patients Meeting Palliative Care Consultation Triggers in Neurological Intensive Care Units.

Palliative care needs among patients in the neurological intensive care unit (neuroICU) are poorly characterized. Our aim was to explore the prevalence and type of potential palliative care consultation triggers in neuroICUs. We conducted a retrospective cohort study of neuroICU admissions in Project IMPACT from 2001 to 2008. We assessed the prevalence of neuroICU admissions meeting one or more of five validated palliative care consultation triggers and compared the percentage of admissions meeting these triggers in other ICUs from the same hospitals. Among 1268 admissions to 2 neuroICUs, 200 (15.8%) met one or more triggers for palliative care consultation. Among 13,694 admissions to non-neuroICUs in the same hospitals, 1909 (13.9%) met one or more palliative care triggers (p=0.44). The most common trigger in the neuroICU was intracerebral hemorrhage with mechanical ventilation (n=92; 7.3%). The most common trigger in non-neuroICUs was ICU admission following ≥10-day hospital stay (n=805; 5.9%). Although ICU mortality was not significantly higher in neuroICU vs. non-neuroICU patients meeting triggers (23.4 vs 19.9%, p=0.46), neuroICU patients were significantly more likely to have withdrawal of life-sustaining therapies (19.4 vs 8.0%, p<0.001). Among neuroICU patients, 15.8% met triggers for palliative care consultation. Although prevalence of admissions meeting any trigger was similar amongst all ICUs, neuroICU admissions met different types of triggers and were more likely to have withdrawal of life-sustaining therapy. These data suggest that palliative care needs are common among neuroICU patients and discussions with patients and families regarding limitation of life-sustaining therapy may differ in this setting.

Implementation of clinical triggers for palliative care consultation on a gynecologic oncology inpatient service: A pilot study

51 Background: Our objectives were to (1) Assess the feasibility of creating clinical triggers for Palliative Care (PC) consultation on a large gynecologic oncology service and (2) Use triggers to increase PC consultation rates among trigger positive patients. Methods: Clinical triggers for PC consultation are listed below. Over a six month period, patients meeting triggers were prospectively identified and PC consultation was requested for those patients. Retrospective chart review was used to identify patients meeting triggers and gather clinical information. PC consultation rates were compared for patients meeting triggers in the 6 months pre and post trigger implementation. Statistical analysis utilized χ2 test, Fisher’s exact test and independent samples t-tests. Results: There was no difference in PC consultation rates among patients meeting triggers between the pre and post-triggers periods (see table). There was also no change in time from admission to PC consult (median time to PC consultation 1....

Implementation of clinical triggers for palliative care consultation on a gynecologic oncology inpatient service: A pilot study.

51 Background: Our objectives were to (1) Assess the feasibility of creating clinical triggers for Palliative Care (PC) consultation on a large gynecologic oncology service and (2) Use triggers to increase PC consultation rates among trigger positive patients. Methods: Clinical triggers for PC consultation are listed below. Over a six month period, patients meeting triggers were prospectively identified and PC consultation was requested for those patients. Retrospective chart review was used to identify patients meeting triggers and gather clinical information. PC consultation rates were compared for patients meeting triggers in the 6 months pre and post trigger implementation. Statistical analysis utilized χ2 test, Fisher’s exact test and independent samples t-tests. Results: There was no difference in PC consultation rates among patients meeting triggers between the pre and post-triggers periods (see table). There was also no change in time from admission to PC consult (median time to PC consultation 1.56d vs. 2.24d, p=0.28) and no change in overall PC consultation volume (mean 17.3 new PC consults per 100 admissions/month vs. 18.5, p=0.67). Of the 38 patients in the post-triggers period who were not seen by PC, 50% (n=19) were inaccurately deemed trigger negative during their admission and 13% (n=5) were not screened at all. Conclusions: Creation of clinical triggers for PC consultation was feasible in terms of investment from relevant stakeholders. Trigger implementation was not associated with increased rates of PC consultation for those patients. High baseline rates of PC consultation and screening process issues contributed significantly to the lack of change in PC consultation rates. Use of clinical triggers may still hold promise as a strategy for standardizing PC consultation patterns and capturing subgroups of patients with high needs. Next steps include modifying our clinical triggers and screening process and expanding into the outpatient setting. [Table: see text]

Estimates of the Need for Palliative Care Consultation across United States Intensive Care Units Using a Trigger-based Model

Use of triggers for palliative care consultation has been advocated in intensive care units (ICUs) to ensure appropriate specialist involvement for patients at high risk of unmet palliative care needs. The volume of patients meeting these triggers, and thus the potential workload for providers, is unknown. To estimate the prevalence of ICU admissions who met criteria for palliative care consultation using different sets of triggers. Retrospective cohort study of ICU admissions from Project IMPACT for 2001-2008. We assessed the prevalence of ICU admissions meeting one or more primary palliative care triggers, and prevalence meeting any of multiple sets of triggers. Overall, 53,124 (13.8%) ICU admissions met one or more primary triggers for palliative care consultation. Variation in prevalence was minimal across different types of units (mean 13.3% in medical ICUs to 15.8% in trauma/burn ICUs; P = 0.41) and individual units (mean 13.8%, median 13.0%, interquartile range, 10.2-16.5%). A comprehensive model combining multiple sets of triggers identified a total of 75,923 (19.7%) ICU admissions requiring palliative care consultation; of them, 85.4% were captured by five triggers: (1) ICU admission after hospital stay greater than or equal to 10 days, (2) multisystem organ failure greater than or equal to three systems, (3) stage IV malignancy, (4) status post cardiac arrest, and (5) intracerebral hemorrhage requiring mechanical ventilation. Approximately one in seven ICU admissions met triggers for palliative care consultation using a single set of triggers, with an upper estimate of one in five patients using multiple sets of triggers; these estimates were consistent across different types of ICUs and individual units. These results may inform staffing requirements for providers to ensure delivery of specialized palliative care to ICU patients nationally.

New Drugs and Drug News: The 411 and Implications for Palliative Care (TH313)

describe the role of the palliative care consultant caring for patients with kidney disease, provide prognostic tools, and provide a framework for engaging in discussions of treatment decisions. Content. The session includes an overview of the kidney disease trajectory and describes common triggers for palliative care consultation. Three common triggers for palliative care involvement along this trajectory will be explored and discussed: (a) discussions of dialysis initiation and withholding in seriously ill patients, (b) symptom management and medication strategies for patients both receiving and not receiving dialysis, and (c) end-of-life issues including dialysis withdrawal and dialysis access failure. We present a framework to elicit patient values and goals specifically addressing kidney disease treatment plans. This framework includes communicating the risks and benefits of dialysis in seriously ill patients and negotiating a care plan which may include withholding dialysis, withdrawing dialysis, or a time-limited treatment trial. Conclusion. By the end of the session, the palliative care provider will have gained new tools and understanding in caring for seriously ill patients with kidney disease. Participants will have an understanding of the unique challenges in treatment decision making; be able to list common symptoms patients experience, including treatment-related issues specific to certain symptoms; and gain an understanding of the prognostic factors and outcomes for different treatment paths. The palliative care provider will have the skill set to communicate care goals and treatment decisions with seriously ill patients with kidney disease.

The ABCs of Renal Palliative Care: Tools for Decision-Making and Symptom Management in Kidney Disease (TH312)

1.Describe role of the palliative care consult in the decision making and symptom management of seriously ill patients with kidney disease.2.Discuss the role of prognostication to guide renal providers and patients in decisions of dialysis initiation, withdrawal, and withholding in seriously ill patients.3.Describe a communication framework for the palliative care consultant to assist renal providers, seriously ill patients, and family members in treatment decisions and goals of care. Kidney disease is common among patients facing serious illness. The kidney disease trajectory is unique to other chronic illnesses and carries a high mortality rate which rivals many cancers. The palliative care provider is tasked with caring for this complex population, presenting unique challenges involving symptom management and treatment decision making. The purpose of this session is to describe the role of the palliative care consultant caring for patients with kidney disease, provide prognostic tools, and provide a framework for engaging in discussions of treatment decisions. The session includes an overview of the kidney disease trajectory and describes common triggers for palliative care consultation. Three common triggers for palliative care involvement along this trajectory will be explored and discussed: (a) discussions of dialysis initiation and withholding in seriously ill patients, (b) symptom management and medication strategies for patients both receiving and not receiving dialysis, and (c) end-of-life issues including dialysis withdrawal and dialysis access failure. We present a framework to elicit patient values and goals specifically addressing kidney disease treatment plans. This framework includes communicating the risks and benefits of dialysis in seriously ill patients and negotiating a care plan which may include withholding dialysis, withdrawing dialysis, or a time-limited treatment trial. By the end of the session, the palliative care provider will have gained new tools and understanding in caring for seriously ill patients with kidney disease. Participants will have an understanding of the unique challenges in treatment decision making; be able to list common symptoms patients experience, including treatment-related issues specific to certain symptoms; and gain an understanding of the prognostic factors and outcomes for different treatment paths. The palliative care provider will have the skill set to communicate care goals and treatment decisions with seriously ill patients with kidney disease.

How can we be helpful? Triggers for palliative care consultation in the surgical intensive care unit*

How can we be helpful? Triggers for palliative care consultation in the surgical intensive care unit*