A Descriptive Study of Palliative Care Team Use in the Intensive Care Unit

Abstract

Objective: The cost of an ICU stay is over two and a half times more expensive than a regular inpatient admission, taxing healthcare systems nationwide (Barrett, Smith, Exlixhauser, Honigman, & Pines, 2014). Palliative care consults can lead to decreased costs by facilitating de-escalation of care, limiting futile treatments, and decreasing total length of stay (Enguidanos, Housen, Penido, Mejia, & Miller, 2014). The purpose of this descriptive study is to review the medical records of patients admitted to the ICU with pre-existing advance directives and to whether goals of care discussion occurred, signified by the initial palliative care consult visit date, so that care could be guided towards the goals pre-described. Methods: This retrospective chart review was conducted to identify the total number of adult patients admitted to the ICU at a level one trauma, stroke, and academic healthcare facility in Scottsdale, Arizona from January 1, 2017 to December 31, 2017 with pre-existing advance directives. It will also identify whether or not a palliative care consult was ordered, and if so, how long after admission the goals of care discussion occurs, signified by the initial palliative care visit date. Finally, it will assess the discharge disposition of these patients. Findings: One hundred forty-two patients that met inclusion criteria for 2017 had a pre-existing DNR status. Of those 142 patients, 40 had a documented palliative care consultation order. Zero patients had a palliative care initial visit date on the day of or one day after admission. Five patients had a palliative care initial visit date of 2 to 3 days after admission, and three patients had a palliative care initial visit date of 4 to 5 days after admission. Finally, there were 5 patients that had a palliative care initial visit date that occurred more than 5 days after admission. Of the 40 patients that received a palliative care consult, 10 expired. Of those patients discharged to the morgue, 10 received a palliative care consultation, and 4 did not. Conclusion: A gap in care is present in those admitted to the ICU with a pre-existing DNR status because 71% of patients admitted to the ICU with a pre-existing DNR status did not receive a palliative care consultation. Four patients with a pre-existing DNR status died in the ICU without receiving a palliative care consultation. A palliative care consultation would ensure that all healthcare providers are in alignment with the patient and their family regarding the healthcare goals and treatment plan. The results and information obtained from this project can be used to guide quality improvement projects championed by the AGACNP aimed at creating a protocol requiring a palliative care consultation to be ordered within 24 hours of admission to the ICU in those with a pre-existing DNR status so that goals and plan of care can be in alignment.