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Early palliative care consultation in the medical ICU: A cluster randomized crossover trial.
Open accessAbstract
Objectives: To assess the impact of early triggered palliative care consultation on the outcomes of high-risk ICU patients. Design: Single-center cluster randomized crossover trial. Setting: Two medical ICUs at Barnes Jewish Hospital. Patients: Patients ( n = 199) admitted to the medical ICUs from August 2017 to May 2018 with a positive palliative care screen indicating high risk for morbidity or mortality. Interventions: The medical ICUs were randomized to intervention or usual care followed by washout and crossover, with independent assignment of patients to each ICU at admission. Intervention arm patients received a palliative care consultation from an interprofessional team led by board-certified palliative care providers within 48 hours of ICU admission. Measurements and Main Results: Ninety-seven patients (48.7%) were assigned to the intervention and 102 (51.3%) to usual care. Transition to do-not-resuscitate/do-not-intubate occurred earlier and significantly more often in the intervention group than the control group (50.5% vs 23.4%; p < 0.0001). The intervention group had significantly more transfers to hospice care (18.6% vs 4.9%; p < 0.01) with fewer ventilator days (median 4 vs 6 d; p < 0.05), tracheostomies performed (1% vs 7.8%; p < 0.05), and postdischarge emergency department visits and/or readmissions (17.3% vs 38.9%; p < 0.01). Although total operating cost was not significantly different, medical ICU ( p < 0.01) and pharmacy ( p < 0.05) operating costs were significantly lower in the intervention group. There was no significant difference in ICU length of stay (median 5 vs 5.5 d), hospital length of stay (median 10 vs 11 d), in-hospital mortality (22.6% vs 29.4%), or 30-day mortality between groups (35.1% vs 36.3%) ( p > 0.05). Conclusions: Early triggered palliative care consultation was associated with greater transition to do-not-resuscitate/do-not-intubate and to hospice care, as well as decreased ICU and post-ICU healthcare resource utilization. Our study suggests that routine palliative care consultation may positively impact the care of high risk, critically ill patients.
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In the citing paper
“However, prone position was associated with an increase in pressure sores (RR, 1.22; 95% CI, 1.05-1.41)(460, 461), and some patients have contraindications to the prone position (460, 461).”
From Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock 2021. (2021) · cites this paper as [461]
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“Studies have evaluated palliative care interventions in the ICU but not specifically in patients with sepsis [543, 545–548].”
From Surviving sepsis campaign: international guidelines for management of sepsis and septic shock 2021 (2021) · cites this paper as [548]
In the citing paper
“Palliative care interventions had no significant impact on family satisfaction with care, ICU length of stay [543, 545–548], hospital length of stay [543, 545, 548], or mortality [543, 545, 548].”
From Surviving sepsis campaign: international guidelines for management of sepsis and septic shock 2021 (2021) · cites this paper as [548]
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Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock 2021.
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Metadata
- Authors
- Ma, J., Chi, S., Buettner, B., Pollard, K., Muir, M., Kolekar, C., Al-Hammadi, N., Chen, L., Kollef, M., & Dans, M.
- Affiliations
- Duke University (US)
- Washington University in St. Louis (US)
- Venue
- Critical Care Medicine
- Published
- 2019-12
- Volume
- 47
- Issue
- 12
- Pages
- 1707-1715
- ISSN
- 0090-3493 (ISSN-L)
- PMC
- PMC6861688
- OpenAlex
- W2980544752
- Semantic Scholar
- ec6665a0529067c85c4be1d796ab72edd607512e
- Cited by
- 166
- References
- 49
- Citations by year
- 2026: 23 · 2025: 31 · 2024: 28 · 2023: 21 · 2022: 26 · 2021: 24 · 2020: 11 · 2019: 1
- FWCI
- 14.27
- Type
- journal article
- Language
- en
- Open access
- green
- www.ncbi.nlm.nih.gov
- Locations
- Critical Care Medicine (publishedVersion)
- PubMed (publishedVersion)
- PubMed Central (acceptedVersion)
- Funders
- National Institutes of Health (UL1TR002345)
- National Center for Advancing Translational Sciences
- Topics
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Palliative Care and End-of-Life Issues
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Palliative and Oncologic Care
- Health Sciences › Health Professions › General Health Professions › Ethics in medical practice
- Keywords
- medical intensive care unit, do-not-resuscitate orders, do-not-intubate orders, healthcare resource utilization, ventilator days, tracheostomy, post-discharge readmission, in-hospital mortality, operating costs, palliative care screening, end-of-life care
- MeSH terms
- Aged, Aged, 80 and over, Female, Humans, Intensive Care Units, Male, Middle Aged, Palliative Care, Prospective Studies, Referral and Consultation, Critical Illness, Cross-Over Studies, Early Medical Intervention
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