1 Supplemental Digital Content – Appendix A: Palliative care interventions in the ICU
Intervention Trial Population Results
Improved communication by
ICU team
Lilly et al, 2000 (102); pre-post study at a single institution
530 medical ICU patients
Patients receiving proactive communication had reduced non-consensus between their ICU clinicians (65 to 4 days/1000 patient-days; p<0.001), reduced non- consensus between their ICU clinicians and families (171 to 16 days/1000 patient- days; p<0.001), and a shorter ICU length-of-stay (4 to 3 days; p=0.01). There was no significant difference in ICU mortality.
Lilly et al, 2003 (103); pre-post study at a single institution over 4 years
2495 medical ICU patients
Patients receiving proactive communication had reduced ICU length-of-stay (4 to 3 days; p=0.01) and reduced ICU mortality (31% to 18%; p<0.001).
Daly et al, 2010 (112); pre-post study at five different ICUs at two different medical centers
481 surgical, medical, and neuroscience ICU patients
Patients receiving proactive communication were more likely to receive family meetings within 72 hours (19% to 74%; p<0.0001). There was no significant difference in ICU length-of-stay, ICU mortality, ventilator days, or treatment limitation orders.
Lautrette et al, 2007 (106); randomized controlled trial at 22 ICUs in France
110 family members of 126 patients dying in a medical, surgical, or combined medical-surgical ICU
Family members in the intervention group had longer conferences (30 vs. 20 minutes; p<0.001) and less post-traumatic stress disorder, depression, and anxiety (Impact of Event scores of 27 vs. 39 with p=0.02; Hospital Anxiety and Distress scores of 11 vs. 17 with p=0.004, anxiety prevalence of 45% vs. 67% with p=0.02;
depression prevalence of 29% vs. 56% with p=0.003).
Ethics consultation
Dowdy et al, 1998 (109); pre-post study at a single institution
99 ICU patients after 96 hours of mechanical ventilation who received proactive ethics consultation (n=31), optional ethics consult (n=31), or no ethics consult (n=37).
Patients receiving proactive ethics consults were more likely to declare do-not- resuscitate status (61% versus 39% in optional ethics consult group vs. 32% in unavailable ethics consult group; p<0.05) or to have life-sustaining treatments withdrawn/withheld (p<0.05), and had lower hospital costs (no p value given), shorter ICU lengths-of-stay (p<0.01), a higher proportion of deaths (68% vs. 48% in optional ethics consult group vs. 43% in unavailable ethics consult group; p<0.05)
2 Schneiderman et al,
2000 (1); randomized controlled trial at a single institution
74 medical and pediatric ICU patients amongst whom values- based treatments conflicts arose
Decedents in the group randomized to ethics consults had a reduced ICU length-of- stay (13.2 to 4.2 days; p=0.03) and fewer ventilator days (11.4 to 3.7 days; p=0.05) and artificial nutrition-hydration days (12.0 to 4.1 days; p=0.05). There was no significant change in mortality or the percentage of patients choosing do-not- resuscitate status
Andereck et al, 2014 (113); randomized controlled trial at a single institution
384 medical- surgical ICU patients with ICU length-of-stay of 5 days or greater
There were no significant differences in ICU length-of-stay, hospital length-of-stay, mortality, days on life-sustaining treatments, days receiving artificial nutrition and hydration, cost, or patient or providers perceptions of quality of care.
Schneiderman et al, 2003 (104);
randomized controlled trial in ICUs at 7 different hospitals from variable geographic regions
551 adult ICU patients amongst whom values- based treatments conflicts arose
Decedents in the group randomized to ethics consults had a reduced ICU length-of- stay (decreased 1.44 days; p=0.03), a reduced hospital length-of-stay (decreased 2.95 days; p=0.01), and fewer ventilator days (decreased 1.7 days; p=0.03). There was no significant change in mortality or artificial nutrition-hydration days.
Palliative care consultation
Campbell et al, 2003 (105); pre-post study at a single institution
81 medical ICU patients with either cerebral ischemia or multi- system organ failure
Patients with cerebral ischemia who received proactive palliative care had a reduced ICU length-of-stay (7.1 to 3.7 days; p<0.01) and reduced hospital length-of- stay (8.6 to 4.7 days; p<0.001). There was no significant change in ICU or hospital length-of-stay amongst patients with multi-system organ failure who did or did not receive proactive palliative care.
1Schneiderman LJ, Gilmer T, Teetzel HD: Impact of ethics consultations in the intensive care setting: a randomized controlled trial. Crit Care Med 2000;28:3920- 3924
3 Campbell et al, 2004
(2); pre-post study at a single institution
52 medical ICU patients with late stage dementia
Patients who received proactive palliative care had a reduced ICU length-of-stay (12.1 to 7.4 days; p<0.007), hospital length-of-stay(6.8 to 3.5 days; p<0.004), and use of resources after do-not-resuscitate status was declared (Therapeutic Intervention Scoring System 16.89 to 8.65; p<0.001).
Norton et al, 2007 (107); pre-post study at a single institution
191 medical ICU patients with high risk of death due to advanced age, prolonged hospital stay, stage IV cancer diagnosis, recent cardiac arrest, and/or intracerebral hemorrhage requiring mechanical ventilation
Patients receiving proactive palliative care had a reduced ICU length-of-stay (16.28 to 8.96 days; p=0.001). There was no significant change in hospital length-of-stay or mortality.
Informational brochures
Azoulay et al, 2002 (116); randomized controlled trial amongst 45 ICUs in France
175 family members (86 in intervention group and 87 in control group) of adult ICU patients with expected ICU stay of >48 hours
Family member with baseline poor comprehension of diagnosis, prognosis, or treatment and who received a brochure had reduced poor comprehension (41% to 12%; p<0.0001). Family members with baseline good comprehension who received the brochure were more satisfied (p=0.04). There were no significant changes in overall satisfaction, mortality, or comprehension of prognosis.
ICU diaries
Jones et al, 2010 (129); randomized controlled trial amongst 12 ICUs in 6 European countries
352 patients who were ventilated >
24 hours and in the ICU for > 72 hours
Patients randomized to ICU diaries received the diaries one month after ICU discharge and had lower 3 month incidence of post-traumatic stress disorder (5%
versus 13%; p=0.02).
2Campbell ML, Guzman JA: A proactive approach to improve end-of-life care in a medical intensive care unit for patients with terminal dementia. Crit Care Med 2004;32:1839-1843
4 Multi-faceted
quality improvement
intervention
Curtis et al, 2008 (133); pre-post study at a single institution
590 patients who died in the ICU or within 24 hours of transfer out of the ICU
Patients who received the quality improvement intervention had a reduced ICU LOS (3.86 to 2.9 days; p=0.03), a reduced hospital LOS (5 to 4 days; p=0.02), and an improved nurse-reported Quality of Death and Dying score (p=0.01). There were no significant changes in family-reported Quality of Death and Dying and Family Satisfaction in the ICU scores.
Curtis et al, 2011 (134); cluster randomized
controlled trial at 12 hospitals in the Seattle-Tacoma region
2318 patients who died in the ICU or within 30 hours of transfer out of the ICU
There were no significant changes in ICU length-of-stay, family-reported Quality of Death and Dying scores, or nurse-reported Quality of Death and Dying scores.
Care
protocols/pathways
Treece et al, 2004 (130); pre-post study at a single institution
117 patients who died in the ICU after withdrawal of life-sustaining treatments and survey results from 143 ICU nurses and 61 ICU physicians
After implementation of the withdrawal of life-sustaining treatment care protocol, the total narcotics and benzodiazepines doses increased before and after ventilator withdrawal and just prior to death (p < 0.03). There were no significant changes in time from withdrawal of life-sustaining treatments to death. Clinician satisfaction with the order protocol was high.
