Critical Care Documentation for the Dying Trauma Patient: Are We Recognizing Our Own Efforts?

2020 ◽  
pp. 000313482097298
Author(s):  
Samuel J. Zolin ◽  
Jasmin K. Bhangu ◽  
Brian T. Young ◽  
Sarah E. Posillico ◽  
Husayn A. Ladhani ◽  
...  
Keyword(s):  
Critical Care ◽  
Trauma Patients ◽  
Family Meeting ◽  
Comfort Care ◽  
Code Status ◽  
Family Meetings ◽  
Dying Patients ◽  
Palliative Care Consultation ◽  
Care Consultation ◽  
Poor Outcomes

Background Missed documentation for critical care time (CCT) for dying patients may represent a missed opportunity for physicians to account for intensive care unit (ICU) services, including end-of-life care. We hypothesized that CCT would be poorly documented for dying trauma patients. Methods Adult trauma ICU patients who died between December 2014 and December 2017 were analyzed retrospectively. Critical care time was not calculated for patients with comfort care code status. Critical care time on the day prior to death and day of death was collected. Logistic regression was used to determine factors associated with documented CCT. Results Of 147 patients, 43% had no CCT on day prior to death and 55% had no CCT on day of death. 82% had a family meeting within 1 day of death. Family meetings were independently associated with documented CCT (OR 3.69, P = .008); palliative care consultation was associated with decreased documented CCT (OR .24, P < .001). Conclusions Critical care time is not documented in half of eligible trauma patients who are near death. Conscious (time spent in family meetings and injury acuity) and unconscious factors (anticipated poor outcomes) likely affect documentation.

571 Palliative Care Utilization in Burn Patients

2021 ◽  
Vol 42 (Supplement_1) ◽  
pp. S136-S136
Author(s):  
Marcus Geffre ◽  
Frederick W Endorf ◽  
Rachel M Nygaard
Keyword(s):  
Palliative Care ◽  
Inhalation Injury ◽  
Comfort Care ◽  
Code Status ◽  
Factors Associated ◽  
Care Services ◽  
Palliative Care Consultation ◽  
Palliative Care Services ◽  
Care Consultation ◽  
Multiple Variables

Abstract Introduction The morbidity and mortality of the severely burned patient can be affected by multiple variables. Many of these variables are also associated with an increased likelihood of withdrawal of care. Palliative care services can aid families in difficult decision making during this time and improve the process of transition to comfort cares. Despite this, palliative care services may be underutilized. The aim of our study is to assess factors associated with palliative care consultation in the setting of severe burns. Methods We analyzed 191 patients with a burn TBSA of ≥30% at our institution from 2007 to 2019. Univariate and multivariate analysis was performed to identify factors associated with consultation to palliative care. Results 17 of the 191 (8.9%) patients received a palliative care consultation. The average time to consultation was 10.3 days. On univariate analysis, age, inhalation injury, multiple comorbid conditions, and code status were associated with consultation to palliative care. Independent predictors of palliative care consult included inhalation injury, non-white race, code status, and ventilator days. Conclusions Palliative care consultation appears to be seldomly requested at our facility. The presence of an inhalation injury and comorbidities increase the likelihood of consultation. These factors correspond to the same factors that increase likelihood of transition to comfort care. Consult to palliative care on patients with these factors can help improve patient and family care.

scholarly journals Palliative Care in Patients With High-Grade Gliomas in the Neurological Intensive Care Unit

2019 ◽  
Vol 10 (3) ◽  
pp. 163-167
Author(s):  
Jon Rosenberg ◽  
Allie Massaro ◽  
James Siegler ◽  
Stacey Sloate ◽  
Matthew Mendlik ◽  
...  
Keyword(s):  
Quality Of Life ◽  
Intensive Care Unit ◽  
Palliative Care ◽  
High Grade ◽  
Neurological Intensive Care Unit ◽  
Code Status ◽  
Neurological Intensive Care ◽  
Palliative Care Consultation ◽  
Care Consultation

Background: Palliative care improves quality of life in patients with malignancy; however, it may be underutilized in patients with high-grade gliomas (HGGs). We examined the practices regarding palliative care consultation (PCC) in treating patients with HGGs in the neurological intensive care unit (NICU) of an academic medical center. Methods: We conducted a retrospective cohort study of patients admitted to the NICU from 2011 to 2016 with a previously confirmed histopathological diagnosis of HGG. The primary outcome was the incidence of an inpatient PCC. We also evaluated the impact of PCC on patient care by examining its association with prespecified secondary outcomes of code status amendment to do not resuscitate (DNR), discharge disposition, 30-day mortality, and 30-day readmission rate, length of stay, and place of death. Results: Ninety (36% female) patients with HGGs were identified. Palliative care consultation was obtained in 16 (18%) patients. Palliative care consultation was associated with a greater odds of code status amendment to DNR (odds ratio [OR]: 18.15, 95% confidence interval [CI]: 5.01-65.73), which remained significant after adjustment for confounders (OR: 27.20, 95% CI: 5.49-134.84), a greater odds of discharge to hospice (OR: 24.93, 95% CI: 6.48-95.88), and 30-day mortality (OR: 6.40, 95% CI: 1.96-20.94). Conclusion: In this retrospective study of patients with HGGs admitted to a university-based NICU, PCC was seen in a minority of the sample. Palliative care consultation was associated with code status change to DNR and hospice utilization. Further study is required to determine whether these findings are generalizable and whether interventions that increase PCC utilization are associated with improved quality of life and resource allocation for patients with HGGs.

Early Palliative Care Consultation in the Burn Unit: A Quality Improvement Initiative to Increase Utilization

2021 ◽  
Author(s):  
Heather Carmichael ◽  
Hareklia Brackett ◽  
Maurice C Scott ◽  
Margaret M Dines ◽  
Sarah E Mather ◽  
...  
Keyword(s):  
Palliative Care ◽  
Small Sample ◽  
Quality Improvement Initiative ◽  
Comfort Care ◽  
Early Palliative Care ◽  
Palliative Care Consultation ◽  
Before And After ◽  
Care Consultation ◽  
Patient Values ◽  
The Impact

Abstract Despite significant morbidity and mortality for major burns, palliative care consultation (PCC) is underutilized in this population. The purpose of this study is to examine the impact of a protocol using recommended “triggers” for PCC at a single academic burn center. This is a retrospective review of patient deaths over a four-year period. Use of life-sustaining treatments, comfort care (de-escalation of one or more life-sustaining treatments) and do not attempt resuscitation (DNAR) orders were determined. Use of PCC was compared during periods before and after a protocol establishing recommended triggers for early (&lt;72 hrs of admission) PCC was instituted in 2019. A total of 33 patient deaths were reviewed. Most patients were male (n=28, 85%) and median age was 62 years [IQR 42-72]. Median revised Baux score was 112 [IQR 81-133]. Many patients had life-sustaining interventions such as intubation, dialysis, or cardiopulmonary resuscitation, often prior to admission. Amongst patients who survived &gt;24 hrs, 67% (n=14/21) had PCC. Frequency of PCC increased after protocol development, with 100% vs. 36% of these patients having PCC before death (p=0.004). However, even during the later period, less than half of patients had early PCC despite meeting criteria at admission. In conclusion, initiation of life-sustaining measures in severely injured burn patients occurs prior to or early during hospitalization. Thus, value-based early goals of care discussions are valuable to prevent interventions that do not align with patient values and assist with de-escalation of life-sustaining treatment. In this small sample, we found that while there was increasing use of PCC overall after developing a protocol of recommended triggers for consultation, many patients who met criteria at admission did not receive early PCC. Further research is needed to elucidate reasons why providers may be resistant to PCC.

Reduction in Potentially Inappropriate Interventions in Trauma Patients following a Palliative Care Consultation

2020 ◽  
Author(s):  
Joanna Wycech ◽  
Alexander A. Fokin ◽  
Jeffrey K. Katz ◽  
Alexander Tymchak ◽  
Richard L. Teitzman ◽  
...  
Keyword(s):  
Palliative Care ◽  
Trauma Patients ◽  
Palliative Care Consultation ◽  
Care Consultation

Palliative Care Consultation Affects How and Where Heart Failure Patients Die

2020 ◽  
pp. 104990912096356
Author(s):  
Richard Pham ◽  
Casey McQuade ◽  
Alex Somerfeld ◽  
Sandra Blakowski ◽  
Gavin W. Hickey
Keyword(s):  
Heart Failure ◽  
Palliative Care ◽  
Chi Square ◽  
Code Status ◽  
Heart Failure Patients ◽  
Palliative Care Consultation ◽  
Care Consultation ◽  
Dying At Home ◽  
The Impact ◽  
At Home

Objective: Determine the role of palliative care on terminal code status and setting of death for those with heart failure. Background: Although palliative care consultation (PCC) has increased for many conditions, PCC has not increased in those with cardiovascular disease. While it has been shown that the majority of those with heart failure die in medical facilities, the impact of PCC on terminal code status and setting of death requires further analysis. Methods: Patients admitted with heart failure between 2014-2015 at an academic VA Healthcare System were reviewed. Primary outcome was terminal code status. Secondary outcomes included setting of death, hospice utilization, and mortality scores. Student t-testing and Chi-square testing were performed where appropriate. Results: 334 patients were admitted with heart failure and had a median follow up time of 4.3 years. 196 patients died, with 122 (62%) receiving PCC and 74 (38%) without PCC. Patients were more likely to have terminal code statuses of comfort measures with PCC (OR = 4.6, p = 0.002), and less likely to be full code (OR = 0.09, p < 0.001). 146 patients had documented settings of death and were more likely to receive hospice services with PCC (OR 6.76, p < 0.001). A patient’s chance of dying at home was not increased with PCC (OR 0.49, p = 0.07), but they were more likely to die with inpatient hospice (OR = 17.03; p < 0.001). Conclusion: Heart failure patients who received PCC are more likely to die with more defined care preferences and with hospice services. This does not translate to dying at home.

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

2021 ◽  
Vol 10 (Supplement_1) ◽  
Author(s):  
A Fagundes Junior ◽  
DD Berg ◽  
EA Bohula ◽  
VM Baird-Zars ◽  
J Guo ◽  
...  
Keyword(s):  
Palliative Care ◽  
Critical Care ◽  
Tertiary Care ◽  
The United States ◽  
Circulatory Support ◽  
Code Status ◽  
Funding Sources ◽  
Palliative Care Consultation ◽  
End Of Life Decision ◽  
Short Time

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 &lt;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

Overcoming Barriers to Palliative Care Consultation

2015 ◽  
Vol 35 (5) ◽  
pp. 44-52 ◽  
Author(s):  
Kathleen Ouimet Perrin ◽  
Mary Kazanowski
Keyword(s):  
Health Care ◽  
Palliative Care ◽  
Critical Care ◽  
Health Care Team ◽  
Critical Care Units ◽  
Palliative Care Consultation ◽  
Life Threatening ◽  
Care Consultation ◽  
To Receive

Palliative care consultations for patients with life-threatening illnesses provide benefits for the patients and their families as well as for the health care team. Patients have better quality of life and live longer but cost the health care system less. Still, many patients are not offered the opportunity to receive a palliative care consultation. Barriers to palliative care consultation for patients in critical care units include misunderstandings about palliative care and not having agreed upon criteria for referral. Critical care nurses can assist in overcoming these barriers.

Life-Sustaining Procedures, Palliative Care Consultation, and Do-Not Resuscitate Status in Dying Patients With COPD in US Hospitals

2018 ◽  
Vol 33 (3) ◽  
pp. 159-166 ◽  
Author(s):  
Jay J. Shen ◽  
Eunjeong Ko ◽  
Pearl Kim ◽  
Sun Jung Kim ◽  
Yong-Jae Lee ◽  
...  
Keyword(s):  
Palliative Care ◽  
Statistical Significance ◽  
Cohort Analysis ◽  
Temporal Trends ◽  
Care Utilization ◽  
Do Not Resuscitate ◽  
Dying Patients ◽  
Palliative Care Consultation ◽  
Care Consultation ◽  
The Impact

Aim: Little is known regarding the extent to which dying patients with chronic obstructive pulmonary disease (COPD) receive life-sustaining procedures and palliative care in US hospitals. We examined temporal trends and the impact of palliative care on the use of life-sustaining procedures in this population. Materials and Methods: A retrospective nationwide cohort analysis was performed using weighted National Inpatient Sample (NIS) data obtained from 2010 to 2014. Decedents ≥18 years of age at the time of death and with a principal diagnosis of COPD were included. We examined the receipt of life-sustaining procedures, defined as1 ventilation (intubation, mechanical ventilation, and noninvasive ventilation),2 vasopressor use (infusion and intravascular monitoring),3 nutrition (enteral and parenteral infusion of concentrated nutrition),4 dialysis, and5 cardiopulmonary resuscitation as well as palliative care consultation and do not resuscitate (DNR). We used compound annual growth rates (CAGRs) and the Rao-Scott correction of the χ2 statistic to determine the statistical significance of temporal trends of life-sustaining procedures, palliative care utilization, and DNR status. Results: Among 37 312 324 hospitalizations, 38 425 patients were examined. The CAGRs of life-sustaining procedures were 6.61% and −9.73% among patients who underwent multiple procedures and patients who did not undergo any procedure, respectively (both P < .001). The CAGRs of palliative consultation and DNR were 5.25% and 36.62%, respectively (both P < .001). Conclusions: Among adults with COPD dying in US hospitals between 2010 and 2014, the utilization of life-sustaining procedures, palliative care, and DNR status increased.

Palliative Care Consultations in Trauma Patients and Role of Do-Not-Resuscitate Orders: Propensity-Matched Study

2020 ◽  
Vol 37 (12) ◽  
pp. 1068-1075
Author(s):  
Alexander A. Fokin ◽  
Joanna Wycech ◽  
Jeffrey K. Katz ◽  
Alexander Tymchak ◽  
Richard L. Teitzman ◽  
...  
Keyword(s):  
Mechanical Ventilation ◽  
Palliative Care ◽  
Length Of Stay ◽  
Trauma Patients ◽  
Trauma Centers ◽  
Do Not Resuscitate ◽  
Palliative Care Consultation ◽  
Care Consultation ◽  
Do Not Resuscitate Orders

Objective: To delineate characteristics of trauma patients associated with a palliative care consultation (PCC) and to analyze the role of do-not-resuscitate (DNR) orders and related outcomes. Methods: Retrospective study included 864 patients from 2 level one trauma centers admitted between 2012 and 2019.  Level 1 trauma centers are designated for admission of the most severe injured patients. Palliative care consultation group of 432 patients who received PCC and were compared to matched control (MC) group of 432 patients without PCC. Propensity matching covariates included Injury Severity Score, mechanism of injury, gender, and hospital length of stay (HLOS). Analysis included patient demographics, injury parameters, intensive care unit (ICU) admissions, ICU length of stay (ICULOS), duration of mechanical ventilation, timing of PCC and DNR, and mortality. Palliative care consultation patients were further analyzed based on DNR status: prehospital DNR, in-hospital DNR, and no DNR (NODNR). Results: Palliative care consultation compared to MC patients were older, predominantly Caucasian, with more frequent traumatic brain injury (TBI), ICU admissions, and mechanical ventilation. The average time to PCC was 5.3 days. Do-not-resuscitate orders were significantly more common in PCC compared to MC group (71.5% vs 11.1%, P < .001). Overall mortality was 90.7% in PCC and 6.0% in MC ( P < .001). In patients with DNR, mortality was 94.2% in PCC and 18.8% in MC. In-hospital DNR-PCC compared to NODNR-PCC patients had shorter ICULOS (5.0 vs 7.3 days, P = .04), HLOS (6.2 vs 13.2 days, P = .006), and time to discharge (1.0 vs 6.3 days, P = .04). Conclusions: Advanced age, DNR order, and TBI were associated with a PCC in trauma patients and resulted in significantly higher mortality in PCC than in MC patients. Combination of DNR and PCC was associated with shorter ICULOS, HLOS, and time from PCC to discharge.

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