Lessons Learned from an Embedded Palliative Care Model in the Medical Intensive Care Unit

ABSTRACT

Outcomes 1. Examine impact of an embedded model of palliative care delivery in the ICU 2. Brainstorm how to adapt this model of delivery into other ICU settings Background When palliative care is embedded in the medical intensive care unit (MICU), more critically ill patients with unmet palliative care needs can receive an earlier consultation and more value-aligned medical care. Aim Statement To describe an embedded physician (MD) + registered nurse (RN)-led palliative care consultation team in the MICU. To compare timing of consultation, goals of care documentation, and in-ICU mortality before and after the embedded team is implemented. Methods In a retrospective cohort study, we compared patients who received a referral-based MICU consult (pre-embedded) from 01/01/2019 to 06/30/2019, an MD/RN consult (embedded) from 09/01/2019 to 02/28/2020 and an adapted COVID MICU consult from 03/1/2020 to 8/31/2020. Using the electronic health record, we collected sociodemographic and clinical data to compare the consultation volume, patient sociodemographics, rates of documentation of medical decision makers and goals of care, and in-ICU deaths. Results The number of patients who received a MICU palliative care consult increased by 2.4 times (63 patients [pre] vs 169 patients [embedded]) As compared to pre-embedded, there was a significant increase in the documentation of medical decision makers (39% vs 90%, p < .001) and goals of care (34% vs. 90%, p < .001) during the embedded period. Patients were seen earlier in the hospitalization (median 9 days [pre-embedded] vs 3 days [embedded], p < .001);the rate of in-ICU death decreased (75% vs 43%, p < .001). During COVID, there was no change in documentation of decision makers (90% [embedded] vs 93% [COVID], p = .24), goals of care (98% vs 99%, p = 0.63), or time to consult (3 days vs 4 days, p = .08), yet, the rate of in-ICU death increased (43% vs 58%, p = .01). Conclusions and Implications The embedded model provided earlier consultation, increased medical decision maker and goals of care documentation, and decreased in-ICU mortality for MICU patients. Future work will examine how to adapt this model to other ICUs to improve palliative care access for critically ill patients.