DOI: 10.1097/CCM.0b013e31819bb858
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PMID: 19237941
Issn Print: 0090-3493
Publication Date: 2009/03/01
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Excerpt
Despite the rapid growth, many doctors are unclear about which patients might benefit from a palliative care consult (4). Much of the early attention focused on the medical intensive care unit, where the high cost, morbidity, and symptom load (5) made case finding seem reasonable. For example, Norton et al. (6) identified a medical intensive care unit population at high risk for a poor outcome based largely on age, comorbidities, diagnosis, and length of stay. Palliative care consultation in this group was shown to shorten medical intensive care unit length of stay without increasing mortality, suggesting a more rapid triage to a comfort approach in appropriate patients. Similar results were found by Campbell and Guzman (7) for medical intensive care unit patients with multisystem organ failure or global cerebral ischemia.
Palliative care’s entry into the surgical intensive care unit (SICU), on the other hand, has been slower, despite calls for better integration (8). One early promising study by Mosenthal et al. (9) showed a decreased length of stay using a structured palliative intervention for all patients with trauma in the intensive care unit (ICU). The intervention, however, was largely provided by ICU staff and did not involve a formal palliative care consultation. In addition, by involving all patients with trauma, it provided no guidance about the patient groups, which may benefit the most from palliative interventions.
The article by Bradley and Brasel (10) in this issue of Critical Care Medicine describes the first set of selective patient-specific triggers for palliative care consultation in the SICU. The authors used a modified Delphi technique with a group of six local (Milwaukee, WI) and national experts in surgery, surgical intensive care, and palliative care to answer the question, “Which patients in the SICU should receive a palliative care consultation?” The responses were refined over a series of e-mail–based circulations with a larger group of 19 experts until a list of ten criteria achieved consensus. The ten criteria for triggering a SICU palliative care consultation were as follows: 1) family request, 2) futility considered or declared by medical team, 3) family disagreement with team, advance directive, or each other lasting >7 days, 4) death expected during same SICU stay, 5) SICU stay >1 month, 6) a diagnosis with median survival of <6 months, 7) more than three SICU admissions during same hospitalization, 8) Glasgow Coma Scale score <8 for >1 week in a patient older than 75 years, 9) Glasgow Coma Scale score <3 (i.e., persistent vegetative state), and 10) multisystem organ failure with more than three systems.
Although clearly limited by its small sample size, potential local bias, and lack of any link to direct patient outcomes, this study represents an important first step in integrating palliative care into the SICU. There are reasons to believe that palliative care consultation in the SICU can provide both patient and institutional benefits. First, the SICU has a high mortality rate. For example, a 2000 study of 128 patients in SICU with a duration of stay of 7 days or more found that 40% died in the hospital and another 13% died within the year (11).
