Wednesday, July 30, 2008
The Journal of Trama has an article about changing the culture around end of life care in the trauma ICU. This is a before-and-after comparison of communication and end of life care practices in a single trauma ICU after a structured palliative care program was integrated into this ICU's standard care practices. The program (described in detail here) is summarized as follows:
Because trauma patients admitted to an ICU have a significant mortality risk (15–20%), and families have consequent, immediate psychosocial needs, the intervention was designed to apply to all trauma patients and their families regardless of their prognosis. Because of the nature of trauma, its sudden onset and rapid trajectory from well to life-threatening illness, the intervention was designed to begin at admission to the ICU, with early communication and family support. The program consisted of five clinical steps grouped into parts I and II in a timed sequence from admission.... In part I, within 24 hours of admission, each patient had a palliative care assessment by physician and nurse. Each family received psychosocial or bereavement support. The palliative care assessment encompassed prognosis, advance directives, family support, and surrogate decision maker, and pain and symptoms. To assess prognosis, physician and nurse were asked the most likely outcome using a score 1-5 similar to the Glasgow Outcome Score, with 1 = death and 5 = independent functional recovery. In part II, within 72 hours, an interdisciplinary family meeting was held regardless of prognosis; during the meeting, likely outcomes, treatments, and goals of care were discussed. These meetings were assessed subjectively by counselors for discussion of goals of care, family understanding of information, and conflict. When the goals of care transitioned from curative to a completely palliative approach, a palliative care order set was implemented.This paper compares aspects of care between the ~280 admissions in the baseline year with the ~370 in the year after implementation. About 70% of patients completed both steps 1 and 2 of the program.
Many outcomes didn't change: total mortality was the same in both years (15%); rates of DNR orders (~43%) and family meetings were similar (~60%) as was the timing of family meetings (nearly all within 72 hours of admission).
What did change were: rates of withdrawal of life-prolonging treatments were higher after the program started (37% of deaths vs 24% - again, however, overall mortality was the same); timing of DNR orders and withdrawals of life prolonging treatment were earlier; overall length of stay in the ICU and hospital was shorter in those patients who died after the program was implemented (mean hospital stay went from 14 days to 6.5 days in those who died).
Essentially, then, what this intervention did was accelerate the decision-making process between families and ICU staff about transition care goals to comfort in a dying patient - and this happened without any demonstrable effect on overall mortality. What's really interesting here is that even before the intervention this ICU team were having early family meetings at a high rate, suggesting that these were not responsible for the changes in care. Instead one wonders if it was the rapid and structured identification of patients very likely to die along with immediate opening of discussions about prognosis and patient/family values/goals. That, and a general culture shift that attended this formalization of 'palliative care' principles into the care of this population (for instance, the discussion notes that this group also introduced end of life peer review into their morbidity and mortality conference).
I think that these formal, deliberate changes in standards of care/expected practice are one of the best ways in improving end of life care in hospitals, and are particularly suitable to ICU situations where mortality rates are very high compared to the rest of the hospital (so the likelihood of measurable impact is so much higher than, say, a general medical ward). One caveat here is that group is clearly one which already had a culture (and presumably leadership) which was open to examining and improving end of life practice - this isn't something which could be foisted onto an unwilling group. Given the changes that are happening with the Joint Commission regarding end of life care in the hospital, it's possible that hospitals in the near future will be 'incentivized' into 'willingness' in the not-too-distant future. We'll see....
Mosenthal, A.C., Murphy, P.A., Barker, L.K., Lavery, R., Retano, A., Livingston, D.H. (2008). Changing the Culture Around End-of-Life Care in the Trauma Intensive Care Unit. The Journal of Trauma: Injury, Infection, and Critical Care, 64(6), 1587-1593. DOI: 10.1097/TA.0b013e318174f112