Assessment of consultation triggers to optimize the opportunity to access palliative care in the ICU
Keywords:
CRITICAL CARE, PALLIATIVE CARE, QUERY TRIGGER VALUATION
Abstract
Introduction: palliative care (PC) constitutes a marker of the quality of intensive care assistance. However, it has not been thoroughly assessed in Uruguay. Proactive detection of patients by means of “consultation triggers” should be considered a strategy to optimize access to PC. Objetives: to determine the prevalence and characteristics of Palliative Care consultation triggers in critical patients. To analyse the use of resources in these patients.
Method: retrospective cohort study of patients admitted in the ICU between March 2016 and February 2019. The following triggers were identified: a) a tumor with metastasis; length of stay at the ICU 50% over the average (14 days), c) >75 years old with multiple organic dysfunction and d) >80 years old with 2 or more severe comorbidities
Results: 2.850 patients were analysed. 26% (734) presented at least one consultation trigger with PC. Length of stay at the ICU 50% over average (18%). These patients presented higher average age 61 (43-75) versus 54 (36-65) years old (p < 0.001), and increased severity, SAPSIII of 60 (48-74) compared to 47 (35-61) points (p<0.001); 87% required mechanical ventilation compared to 55% (p <0.001), vasopressors 48% compared to 24% (p< 0.001) and hemodialysis 8% compared to 4% (p<0.001). 18 presented a longer stay (9-27) compared to 4 (2-8) days, (p<0.001) and time on mechanical ventilation 14 (7-23) compared to 3 (1- 6) days (p<0.001). Conclusions: 25 percent of patients in the ICU activated at least one criterion for PC, they were in a more severe condition and used more mechanical ventilation.
References
(1) Angus D, Truog R. Toward better ICU use at the end of life. JAMA 2016; 315(3):255-6. doi: 10.1001/jama.2015.18681.
(2) Ho A, Tsai D. Making good death more accessible: end-of-life care in the intensive care unit. Intensive Care Med 2016; 42(8):1258-60. doi: 10.1007/s00134-016-4396-2.
(3) Vincent J, Marshall J, Namendys-Silva S, François B, Martin-Loeches I, Lipman J, et al. Assessment of the worldwide burden of critical illness: the intensive care over nations (ICON) audit. Lancet Respir Med 2014; 2(5):380-6. doi: 10.1016/S2213-2600(14)70061-X
(4) World Health Organization. Palliative care. Geneva: WHO, 2016. Disponible en: www.who.int/cancer/palliative/definition/en/. (Consulta: 16 junio 2016).
(5) Teno J, Gozalo P, Bynum J, Leland N, Miller S, Morden N, et al. Change in end-of-life care for Medicare beneficiaries: site of death, place of care, and health care transitions in 2000, 2005, and 2009. JAMA 2013; 309(5):470-7. doi: 10.1001/jama.2012.207624.
(6) Teno J, Gozalo P, Trivedi A, Bunker J, Lima J, Ogarek J, et al. Site of death, place of care, and health care transitions among us medicare beneficiaries, 2000-2015. JAMA 2018; 320(3):264-71. doi: 10.1001/jama.2018.8981.
(7) Moreira E, Carámbula A, Barbato M, Alzugaray P, Cebey A, Baraibar J, et al. P428: Resource utilization among elderly ICU patients. Crit Care 2019; 23(Suppl 2):187. doi: 10.1186/s13054-019-2358-0.
(8) Walling A, Asch S, Lorenz K, Roth C, Barry T, Kahn K, et al. The quality of care provided to hospitalized patients at the end of life. Arch Intern Med 2010; 170(12):1057-63. doi: 10.1001/archinternmed.2010.175.
(9) Mercadante S, Gregoretti C, Cortegiani A. Palliative care in intensive care units: why, where, what, who, when, how. BMC Anesthesiol 2018; 18(1):106. doi: 10.1186/s12871- 018-0574-9.
(10) Myburgh J, Abillama F, Chiumello D, Dobb G, Jacobe S, Kleinpell R, et al. End-of-life care in the intensive care unit: Report from the Task Force of World Federation of Societies of Intensive and Critical Care Medicine. J Crit Care 2016; 34:125-30. doi: 10.1016/j.jcrc.2016.04.017.
(11) O’Mahony S, McHenry J, Blank A, Snow D, Eti Karakas S, Santoro G, et al. Preliminary report of the integration of a palliative care team into an intensive care unit. Palliat Med 2010; 24(2):154-65. doi: 10.1177/026921630934654.
(12) Bradley C, Weaver J, Brasel K. Addressing access to palliative care services in the surgical intensive care unit. Surgery 2010; 147(6):871-7. doi: 10.1016/j.surg.2009.11.005.
(13) Hua M, Li G, Blinderman C, Wunsch H. Estimates of the need for palliative care consultation across united states intensive care units using a trigger-based model. Am J Respir Crit Care Med 2014; 189(4):428-36. doi: 10.1164/rccm. 201307-1229OC.
(14) Canale Cohe A, Broli Olaizola F. Prevalencia de los pacientes con necesidades paliativas en una unidad de cuidado intensivo de un hospital de agudos. Rev Urug Med Interna 2019; 4(1):169.
(15) Gómez-Batiste X, Martínez-Muñoz M, Blay C, Amblàs J, Vila L, Costa X. Identificación de personas con enfermedades crónicas avanzadas y necesidad de atención paliativa en servicios sanitarios y sociales: elaboración del instrumento NECPAL CCOMS-ICO. Med Clín (Barc) 2013;140(6): 241-5.
(16) Buchman T, Cassell J, Ray S, Wax M. Who should manage the dying patient?: Rescue, shame, and the surgical ICU dilemma. J Am Coll Surg 2002; 194(5):665-73. doi: 10.1016/s1072-7515(02)01157-2.
(17) Cook D, Rocker G. Dying with dignity in the intensive care unit. N Engl J Med 2014; 370(26):2506-14. doi: 10.1056/NEJMra1208795.
(18) Azoulay E, Chaize M, Kentish-Barnes N. Involvement of ICU families in decisions: fine-tuning the partnership. Ann Intensive Care 2014; 4:37. doi: 10.1186/s13613-014-0037-5.
(19) Lilly C, De Meo D, Sonna L, Haley K, Massaro A, Wallace R, et al. An intensive communication intervention for the critically ill. Am J Med 2000; 109(6):469-75. doi: 10.1016/s0002-9343(00)00524-6.
(20) Edwards J, Voigt L, Nelson J. Ten key points about ICU palliative care. Intensive Care Med 2017; 43(1):83-85. doi: 10.1007/s00134-016-4481-6.
(21) Frache B, Moreira E, Carámbula A, Pan C, Bárbato M, Alzugaray P, et al. Características de la limitación de terapia de soporte vital en pacientes fallecidos en unidades de medicina intensiva. Rev Méd Urug 2018; 34(4):193-200.
(22) Desbiens N, Wu A, Broste S, Wenger N, Connors AJr, Lynn J, et al. Pain and satisfaction with pain control in seriously ill hospitalized adults: findings from the SUPPORT research investigations. For the SUPPORT investigators. Study to understand prognoses and preferences for outcomes and risks of treatmentm. Crit Care Med 1996; 24(12):1953-61. doi: 10.1097/00003246-199612000-00005.
(23) Iwashyna T, Ely E, Smith D, Langa K. Long-term cognitive impairment and functional disability among survivors of severe sepsis. JAMA 2010; 304(16):1787-94. doi: 10.1001/ jama.2010.1553
(24) Swoboda S, Lipsett P. Impact of a prolonged surgical critical illness on patients’ families. Am J Crit Care 2002; 11(5):459-66.
(25) Nelson J, Meier D, Litke A, Natale D, Siegel R, Morrison R. The symptom burden of chronic critical illness. Crit Care Med 2004; 32(7):1527-34. doi: 10.1097/01.ccm.0000129485.08835.5a.
(26) Braus N, Campbell T, Kwekkeboom K, Ferguson S, Harvey C, Krupp A, et al. Prospective study of a proactive palliative care rounding intervention in a medical ICU. Intensive Care Med 2016; 42(1):54-62. doi: 10.1007/s00134-015-4098-1.
(27) Lecuyer L, Chevret S, Thiery G, Darmon M, Schlemmer B, Azoulay E. The ICU trial: a new admission policy for cancer patients requiring mechanical ventilation. Crit Care Med 2007; 35(3):808-14. doi: 10.1097/01.CCM.0000256846. 27192.7A.
(28) Mittel A, Hua M. Supporting the geriatric critical care patient: decision making, understanding outcomes, and the role of palliative care. Anesthesiol Clin 2019; 37(3):537-46. doi: 10.1016/j.anclin.2019.04.011.
(29) Biskup E, Cai F, Vetter M, Marsch S. Oncological patients in the intensive care unit: prognosis, decision-making, therapies and end-of-life care. Swiss Med Wkly 2017; 147:w14481. doi: 10.4414/smw.2017.14481.
(30) Firet L, Koekkoek W, Savelkoul C, Harringhuizen A, Tjan D. The acutely ill oncological patient: admit to ICU or not? Ned Tijdschr Geneeskd 2017; 161:D991.
(2) Ho A, Tsai D. Making good death more accessible: end-of-life care in the intensive care unit. Intensive Care Med 2016; 42(8):1258-60. doi: 10.1007/s00134-016-4396-2.
(3) Vincent J, Marshall J, Namendys-Silva S, François B, Martin-Loeches I, Lipman J, et al. Assessment of the worldwide burden of critical illness: the intensive care over nations (ICON) audit. Lancet Respir Med 2014; 2(5):380-6. doi: 10.1016/S2213-2600(14)70061-X
(4) World Health Organization. Palliative care. Geneva: WHO, 2016. Disponible en: www.who.int/cancer/palliative/definition/en/. (Consulta: 16 junio 2016).
(5) Teno J, Gozalo P, Bynum J, Leland N, Miller S, Morden N, et al. Change in end-of-life care for Medicare beneficiaries: site of death, place of care, and health care transitions in 2000, 2005, and 2009. JAMA 2013; 309(5):470-7. doi: 10.1001/jama.2012.207624.
(6) Teno J, Gozalo P, Trivedi A, Bunker J, Lima J, Ogarek J, et al. Site of death, place of care, and health care transitions among us medicare beneficiaries, 2000-2015. JAMA 2018; 320(3):264-71. doi: 10.1001/jama.2018.8981.
(7) Moreira E, Carámbula A, Barbato M, Alzugaray P, Cebey A, Baraibar J, et al. P428: Resource utilization among elderly ICU patients. Crit Care 2019; 23(Suppl 2):187. doi: 10.1186/s13054-019-2358-0.
(8) Walling A, Asch S, Lorenz K, Roth C, Barry T, Kahn K, et al. The quality of care provided to hospitalized patients at the end of life. Arch Intern Med 2010; 170(12):1057-63. doi: 10.1001/archinternmed.2010.175.
(9) Mercadante S, Gregoretti C, Cortegiani A. Palliative care in intensive care units: why, where, what, who, when, how. BMC Anesthesiol 2018; 18(1):106. doi: 10.1186/s12871- 018-0574-9.
(10) Myburgh J, Abillama F, Chiumello D, Dobb G, Jacobe S, Kleinpell R, et al. End-of-life care in the intensive care unit: Report from the Task Force of World Federation of Societies of Intensive and Critical Care Medicine. J Crit Care 2016; 34:125-30. doi: 10.1016/j.jcrc.2016.04.017.
(11) O’Mahony S, McHenry J, Blank A, Snow D, Eti Karakas S, Santoro G, et al. Preliminary report of the integration of a palliative care team into an intensive care unit. Palliat Med 2010; 24(2):154-65. doi: 10.1177/026921630934654.
(12) Bradley C, Weaver J, Brasel K. Addressing access to palliative care services in the surgical intensive care unit. Surgery 2010; 147(6):871-7. doi: 10.1016/j.surg.2009.11.005.
(13) Hua M, Li G, Blinderman C, Wunsch H. Estimates of the need for palliative care consultation across united states intensive care units using a trigger-based model. Am J Respir Crit Care Med 2014; 189(4):428-36. doi: 10.1164/rccm. 201307-1229OC.
(14) Canale Cohe A, Broli Olaizola F. Prevalencia de los pacientes con necesidades paliativas en una unidad de cuidado intensivo de un hospital de agudos. Rev Urug Med Interna 2019; 4(1):169.
(15) Gómez-Batiste X, Martínez-Muñoz M, Blay C, Amblàs J, Vila L, Costa X. Identificación de personas con enfermedades crónicas avanzadas y necesidad de atención paliativa en servicios sanitarios y sociales: elaboración del instrumento NECPAL CCOMS-ICO. Med Clín (Barc) 2013;140(6): 241-5.
(16) Buchman T, Cassell J, Ray S, Wax M. Who should manage the dying patient?: Rescue, shame, and the surgical ICU dilemma. J Am Coll Surg 2002; 194(5):665-73. doi: 10.1016/s1072-7515(02)01157-2.
(17) Cook D, Rocker G. Dying with dignity in the intensive care unit. N Engl J Med 2014; 370(26):2506-14. doi: 10.1056/NEJMra1208795.
(18) Azoulay E, Chaize M, Kentish-Barnes N. Involvement of ICU families in decisions: fine-tuning the partnership. Ann Intensive Care 2014; 4:37. doi: 10.1186/s13613-014-0037-5.
(19) Lilly C, De Meo D, Sonna L, Haley K, Massaro A, Wallace R, et al. An intensive communication intervention for the critically ill. Am J Med 2000; 109(6):469-75. doi: 10.1016/s0002-9343(00)00524-6.
(20) Edwards J, Voigt L, Nelson J. Ten key points about ICU palliative care. Intensive Care Med 2017; 43(1):83-85. doi: 10.1007/s00134-016-4481-6.
(21) Frache B, Moreira E, Carámbula A, Pan C, Bárbato M, Alzugaray P, et al. Características de la limitación de terapia de soporte vital en pacientes fallecidos en unidades de medicina intensiva. Rev Méd Urug 2018; 34(4):193-200.
(22) Desbiens N, Wu A, Broste S, Wenger N, Connors AJr, Lynn J, et al. Pain and satisfaction with pain control in seriously ill hospitalized adults: findings from the SUPPORT research investigations. For the SUPPORT investigators. Study to understand prognoses and preferences for outcomes and risks of treatmentm. Crit Care Med 1996; 24(12):1953-61. doi: 10.1097/00003246-199612000-00005.
(23) Iwashyna T, Ely E, Smith D, Langa K. Long-term cognitive impairment and functional disability among survivors of severe sepsis. JAMA 2010; 304(16):1787-94. doi: 10.1001/ jama.2010.1553
(24) Swoboda S, Lipsett P. Impact of a prolonged surgical critical illness on patients’ families. Am J Crit Care 2002; 11(5):459-66.
(25) Nelson J, Meier D, Litke A, Natale D, Siegel R, Morrison R. The symptom burden of chronic critical illness. Crit Care Med 2004; 32(7):1527-34. doi: 10.1097/01.ccm.0000129485.08835.5a.
(26) Braus N, Campbell T, Kwekkeboom K, Ferguson S, Harvey C, Krupp A, et al. Prospective study of a proactive palliative care rounding intervention in a medical ICU. Intensive Care Med 2016; 42(1):54-62. doi: 10.1007/s00134-015-4098-1.
(27) Lecuyer L, Chevret S, Thiery G, Darmon M, Schlemmer B, Azoulay E. The ICU trial: a new admission policy for cancer patients requiring mechanical ventilation. Crit Care Med 2007; 35(3):808-14. doi: 10.1097/01.CCM.0000256846. 27192.7A.
(28) Mittel A, Hua M. Supporting the geriatric critical care patient: decision making, understanding outcomes, and the role of palliative care. Anesthesiol Clin 2019; 37(3):537-46. doi: 10.1016/j.anclin.2019.04.011.
(29) Biskup E, Cai F, Vetter M, Marsch S. Oncological patients in the intensive care unit: prognosis, decision-making, therapies and end-of-life care. Swiss Med Wkly 2017; 147:w14481. doi: 10.4414/smw.2017.14481.
(30) Firet L, Koekkoek W, Savelkoul C, Harringhuizen A, Tjan D. The acutely ill oncological patient: admit to ICU or not? Ned Tijdschr Geneeskd 2017; 161:D991.
Published
2021-03-31
How to Cite
1.
Moreira E, Lamas L, Píriz Álvarez G, Barbato M, Burghi G. Assessment of consultation triggers to optimize the opportunity to access palliative care in the ICU. Rev. Méd. Urug. [Internet]. 2021Mar.31 [cited 2024Dec.18];37(1):e37105. Available from: https://www2.rmu.org.uy/ojsrmu311/index.php/rmu/article/view/674
Section
Original Articles
This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.
