Feasibility and economic impact of dedicated hospice inpatient units for terminally ill ICU patients.

OBJECTIVES: End-of-life care is frequently provided in the ICU because patients receiving life-sustaining treatments are often unsuitable for transfer to home or community hospices. In-hospital dedicated hospice inpatient units are a novel option. This study was designed to 1) demonstrate the feasibility of ICU to dedicated hospice inpatient unit transfer in critically ill terminal patients; 2) describe the clinical characteristics of those transferred and compare them to similar patients who were not transferred; and 3) assess the operational and economic impact of dedicated hospice inpatient units. DESIGN: Retrospective chart review. SETTING: ICUs and dedicated hospice inpatient units at two southeast urban university hospitals. INTERVENTIONS: Charts of ICU and dedicated hospice inpatient unit deaths over a 6-month period were reviewed. PATIENTS: Dedicated hospice inpatient unit transfers were identified from hospice administrator records. Missed opportunities were patients admitted to the hospital for more than 48 hours who either adopted a comfort care course or had a planned termination of life-sustaining therapy. Patients were excluded if they were declared brain dead, were organ donors, required high-frequency ventilation, or if there was insufficient information in the medical record to make a determination. MEASUREMENTS AND MAIN RESULTS: We identified 167 transfers and 99 missed opportunities; 37% of appropriate patients were not transferred. Transfers were older (66.9 vs 60.4 yr; p < 0.05), less likely to use mechanical ventilation (71.9% vs 90.9%) and vasopressors (70.9% vs 95.0%; p < 0.05), and less likely to receive a palliative care consult (70.4% vs 43.4%; p < 0.05) than missed opportunities. Transfers saved 585 ICU bed days. CONCLUSIONS: Dedicated hospice inpatient units are a feasible way to provide care for terminal ICU patients, but barriers including lack of knowledge of the units and provider or family comfort with leaving the ICU remain. Dedicated hospice inpatient units are potentially significant sources of bed days and cost savings for hospitals and the healthcare system overall.

Identifying family members who may struggle in the role of surrogate decision maker.

UNLABELLED: Although acting as a surrogate decision maker can be highly distressing for some family members of intensive care unit patients, little is known about whether there are modifiable risk factors for the occurrence of such difficulties. OBJECTIVES: To identify: 1) factors associated with lower levels of confidence among family members to function as surrogates and 2) whether the quality of clinician-family communication is associated with the timing of decisions to forego life support. METHODS: We conducted a prospective study of 230 surrogate decision makers for incapacitated, mechanically ventilated patients at high risk of death in four intensive care units at University of California San Francisco Medical Center from 2006 to 2007. Surrogates completed a questionnaire addressing their perceived ability to act as a surrogate and the quality of their communication with physicians. We used clustered multivariate logistic regression to identify predictors of low levels of perceived ability to act as a surrogate and a Cox proportional hazard model to determine whether quality of communication was associated with the timing of decisions to withdraw life support. RESULTS: There was substantial variability in family members' confidence to act as surrogate decision makers, with 27% rating their perceived ability as 7 or lower on a 10-point scale. Independent predictors of lower role confidence were the lack of prior experience as a surrogate (odds ratio 2.2, 95% confidence interval [1.04-4.46], p=.04), no prior discussions with the patient about treatment preferences (odds ratio 3.7, 95% confidence interval [1.79-7.76], p<.001), and poor quality of communication with the ICU physician (odds ratio 1.2, 95% confidence interval [1.09-1.35] p<.001). Higher quality physician-family communication was associated with a significantly shorter duration of life-sustaining treatment among patients who died (ß=0.11, p=.001). CONCLUSIONS: Family members without prior experience as a surrogate and those who had not engaged in advanced discussions with the patient about treatment preferences were at higher risk to report less confidence in carrying out the surrogate role. Better-quality clinician-family communication was associated with both more confidence among family members to act as surrogates and a shorter duration of use of life support among patients who died.