- Email: [email protected]
Palliative Care in the Cardiac Intensive Care Unit
Palliative Care in the Cardiac Intensive Care Unit Tara Naib, MD, MPHa,*, Sopan Lahewala, MDa, Shilpkumar Arora, MD, MPHb, and Umesh Gidwani, MDa Patients admitted to today’s cardiac intensive care units (CICUs) have increasingly complex medical conditions; consequently, palliative care is becoming an integral component of their care. Although there is a robust body of literature emanating from other intensive care unit settings, there has been less discussion about the role of palliative care in the CICU. This study examined all admissions to the Mount Sinai Hospital CICU from January 1 through December 31, 2012. Of the 1,368 patients admitted, there were 117 CICU patient deaths. End-of-life discussions were carried out in 85 patients (72.6%) who died during that hospital admission; the primary CICU team led these discussions and helped with decision making in >1/2 of them. For the 85 patients who had goals of care (GOC) discussions, there was a higher rate of redirected GOC toward comfort care or no escalation of care (38.8% vs 3.1%, p <0.001) and withdrawal of life-sustaining treatments, such as mechanical ventilation and vasopressors (23.5% vs 6.3%, p [ 0.02) compared with patients for whom no GOC discussions were held. Among patients who had GOC discussions, there was no statistically significant difference for patients who had their mechanical circulatory support, defibrillator, or pacing therapies turned off compared with patients who were not involved in GOC discussions. With the exception of discontinuation of mechanical circulatory support which took place for 6 of the 7 patients in the CICU, end-of-life interventions were split evenly between the palliative care unit and the CICU. There was no difference in CICU length of stay or days to mortality from the time of CICU admission between the 2 groups. In conclusion, our study demonstrates the effect of palliative care and end-of-life decision making in the CICU. As such, we advocate for increased palliative care education and training among clinicians who are involved in cardiac critical care. Ó 2015 Elsevier Inc. All rights reserved. (Am J Cardiol 2015;115:687e690) With the development of advanced therapies, the coronary care unit has evolved over the last 5 decades to one now delivering complex critical care for cardiac patients, and oftentimes palliative care; as such, the unit is now more appropriately referred to as the cardiac intensive care unit (CICU).1e4 Mount Sinai Hospital (MSH) is a large, academic, 1,170-bed tertiary care hospital in Manhattan, New York. The CICU is a 14-bed unit that routinely manages cardiac patients with complex arrhythmias, advanced heart failure (HF), mechanical circulatory support (MCS), and postecardiac transplantation care. Its team consists of an attending cardiologist, an attending intensivist, a cardiology fellow, a house staff team, and specialized nurses. MSH is also home to an inpatient palliative care unit (PCU) and a multidisciplinary palliative care service that provides palliative care consultative services. The purpose of this study was to determine the effect of palliative care interventions in a typical tertiary CICU on outcomes such as length of stay (LOS), inpatient a Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York and bMount Sinai St Luke’seMount Sinai Roosevelt Hospital, New York, New York. Manuscript received August 26, 2014; revised manuscript received and accepted December 11, 2014. See page 690 for disclosure information. *Corresponding author: Tel: (212) 241-7243; fax: (212) 831-2195. E-mail address: [email protected] (T. Naib).
0002-9149/15/$ - see front matter Ó 2015 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.amjcard.2014.12.023
mortality, and redirection of goals of care (GOC) toward comfort measures or withdrawal of life-sustaining treatments (LSTs) such as mechanical ventilation or hemodynamic support. Methods A total of 1,368 patients admitted to the MSH CICU from January 1 through December 31, 2012, were screened by the electronic medical record (EMR). The study was approved by Mount Sinai’s Institutional Review Board. In an effort to identify patients who were most likely to have received a palliative care intervention, patients who died during the hospital stay (whether in the CICU, the PCU, or another inpatient unit) were selected for further review. One hundred seventeen patients admitted to the CICU died during their hospitalization. Patient information such as imaging and laboratory data for baseline characteristics, diagnoses pertaining to acute management, and GOC discussions were acquired by review of chart notes and the EMR. Respiratory failure was defined as the utilization of invasive positive pressure ventilation; cardiac failure as the use of inotropic support; severe sepsis as the development of hypotension requiring resuscitation with fluids or vasopressors in the setting of a documented or suspected infection requiring antibiotic treatment for >48 hours; acute kidney injury as an abrupt and persistent decrease in renal function, often requiring www.ajconline.org
688
The American Journal of Cardiology (www.ajconline.org)
Results
Figure 1. Breakdown of 117 patients who died in the CICU with respect to GOC discussions versus no GOC discussion.
Of the 117 patients who did not survive their hospitalization, 69 died in the CICU; 85 patients and/or surrogates had GOC discussions. The CICU team had these discussions with 48 patients/surrogates, whereas 37 patients/surrogates received a formal palliative care consultation. Thirty-two patients died without any end-of-life care discussions (Figure 1). Table 1 illustrates baseline characteristics of the study population. The median age of the overall cohort was 71.5 years, and 56% were men. There was no significant difference between patients with GOC and no GOC discussion for age or gender, and there was no statistical dif-
Table 1 Baseline characteristics of cardiac intensive care unit patients who died during the hospitalization Baseline Characteristics Variables Overall Deaths Age (years) (median,IQR) Male Female Blood urea nitrogen (mg/dL) (median, IQR) Serum creatinine (mg/dL) (median, IQR) Hemoglobin (g/dL) (median, IQR)
GOC Discussion 71 47 38 37 1.75 10
85 (61 to 86) (55.3%) (44.7%) (24 to 60) (1.11 to 2.71) (8.8 to 11.7)
No GOC Discussion 73 18 13 50 2.14 10.4
32 (62 to 79) (58.1%) (41.9%) (31 to 61) (1.2 to 3.64) (9.1 to 12)
Overall 71.5 65 51 39 1.81 10.2
117 (61 to 84) (56.0%) (44%) (25 to 60) (1.13 to 3.03) (8.85 to 11.7)
P-Value 0.46
0.35 0.15 0.30
GOC ¼ goals of care; IQR ¼ interquartile range.
consultation by a nephrologist; neurologic complications as a cerebrovascular accident or transient ischemic attack either confirmed with neurologic imaging or confirmed by a consulting neurologist. A GOC discussion was defined as a structured discussion with the patient and/or family regarding the patient’s end-of-life care that was documented as such in the patient chart. Specifically, GOC discussions that were held in our CICU were consistent with previously defined criteria and addressed at least one of the following: the lack of hope for cure, prolongation of life, quality of life, comfort, life goals, and family/caregiver support.5 This conversation could be initiated by either the primary CICU team or the palliative care consult team. Patients who had GOC discussions were then compared with those who did not with regards to LOS, discontinuation of MCS, discontinuation of implantable cardioverter-defibrillator/pacing therapies, redirected GOC (whether no escalation of care, comfort measures, withdrawal of LST, or palliative extubation), transfer to the PCU, and days from admission to death. Patients who received GOC discussions were also compared on the basis of baseline characteristics and diagnoses. Whereas differences between categorical variables were calculated according to the chi-square and Fisher’s exact tests, differences between continuous variables were tested using the Wilcoxon rank sum test. p Values were used, with a 2-sided value of <0.05 considered significant. Analyses were performed using SAS 9.3 (SAS Institute, Cary, North Carolina).
ference in baseline laboratory values among patients who underwent GOC discussions compared with those who did not receive this intervention. Table 2 compares GOC with no GOC discussions for patients with specific diagnoses pertaining to end-organ failure. Sixty-seven patients were treated for HF, 26 for sepsis, 22 for respiratory failure, 6 for acute kidney injury, and 4 for transient ischemic attack or stroke. There was no significant difference among patients who received GOC discussions with respect to any of the single aforementioned diagnoses, although there was a trend toward GOC discussions for those patients with respiratory failure (p ¼ 0.06) or sepsis (p ¼ 0.06). Of note, 17 of the 67 patients with HF had at least 1 of the other 4 noncardiac diagnoses, and all but 1 of these patients had GOC discussions (p ¼ 0.04). Subjects involved in GOC discussions had a statistically significant higher rate of redirected GOC toward comfort measures or no escalation of care (38.8% vs 3.1%, p <0.001), withdrawal of LST vasopressors (23.5% vs 6.3%, p ¼ 0.02), and palliative extubation (21.2% vs 3.1%, p ¼ 0.01) compared with patients for whom no GOC discussions were held (Table 3 and Figure 2). Among patients who had GOC discussions, there was no statistically significant difference for patients who had their MCS or implantable cardioverter-defibrillator/pacing therapies turned off compared with those patients who were not involved in GOC discussions. Despite the greater degree of redirected end-of-life care among patients who received GOC discussions, there was no difference in CICU LOS or
Miscellaneous/Palliative Care in CICU Table 2 Diagnoses of patients with goals of care discussions versus no goals of care discussion Diagnosis Respiratory failure Heart failure Sepsis Acute kidney injury TIA or stroke Heart failure þ at least one of the above
GOC 19 45 22 4 3 16
No GOC
Overall
(22.4%) 3 (9.4%) 22 (52.9%) 22 (68.8%) 67 (25.9%) 4 (12.5%) 26 (4.7%) 2 (6.3%) 6 (3.5%) 1 (3.1%) 4 (18.8%) 1 (3.1%) 17
(18.8%) (57.3%) (22.2%) (5.1%) (3.4%) (14.5%)
P-Value 0.06 0.13 0.06 0.32 0.43 0.04
TIA ¼ transient ischemic attack.
Table 3 Outcomes of patients with and without goals of care discussions with respect to end of life interventions Outcomes
GOC No GOC Discussion Discussion
Discontinuation of MCS 6 (7.1%) Discontinuation of 4 (4.7%) ICD/pacing therapies Withdrawal of LST 20 (23.5%) 33 (38.8%) Redirected GOC (no escalation/ comfort care) Palliative extubation 18 (21.2%)
1 (3.1%) 1 (3.1%)
Overall 7 (6%) 5 (4.3%)
P-Value 0.28 0.39
2 (6.3%) 1 (3.1%)
22 (18.8%) 0.02 34 (29.1%) < 0.001
1 (3.1%)
19 (16.2%)
0.01
GOC ¼ goals of care; ICD ¼ implantable cardioverter defibrillator; LST ¼ life-sustaining treatments; MCS ¼ mechanical circulatory support.
689
days to mortality from the time of CICU admission between the 2 groups, and our results still did not reach statistical significance when mean values were used instead of median values (Table 4). Discussion In our study, end-of-life discussions were carried out for >70% of patients who died during their hospital admission, and the primary CICU team led these discussions for >1/2 of these patients. Our results show that GOC discussions had a significant effect on end-of-life care. Despite a significantly greater proportion of patients undergoing such discussions having GOC redirected toward comfort or no escalation of care, withdrawal of LST, or palliative extubation, there was no effect on CICU LOS or time to death. The reason for the unchanged LOS may have been due to the timing of the GOC discussions, which were held an average of 16 days from the time of admission to the CICU (median 8 days) and likely at an advanced stage of illness. Our study has several limitations. The first is that it was retrospective, and much of the information ascertained was dependent on whether these GOC discussions were documented as such in the chart notes and EMR. Although we did not identify evidence of end-organ damage to 1 organ system as a determinant of whether patients received GOC discussions, those patients with both HF and evidence of additional organ system failure were much more likely to receive GOC discussions, indicating that severity of illness and worse prognosis were likely the driving determinants of
Figure 2. Palliative care therapies in patients with and without GOC discussions.
690
The American Journal of Cardiology (www.ajconline.org)
Table 4 Outcomes of patients with and without goals of care discussions with respect to length of stay and days to mortality Outcomes
GOC Discussion
No GOC Discussion
P-Value
CICU length of stay (days) (median IQR) Days to mortality (days) (median IQR) CICU length of stay (mean std err) Days to mortality (mean std err)
4 (2 to 8)
4 (2 to 10)
0.96
8 (3 to 16)
7 (3 to 31)
0.53
16.52.94
26.66.92
0.19
8.71.9
9.92.4
0.68
CICU ¼ cardiac intensive care unit; IQR ¼ interquartile range.
the decision to undergo these discussions. We also did not study GOC discussions among patients in CICU who survived their hospitalization, although anecdotal experience suggests that most GOC discussions were held for patients whom the CICU team believed were unlikely to survive their hospitalization. Identifying which patients should receive formal palliative care discussions and how early during the CICU stay these discussions should occur are areas for further study; such studies have already been conducted in other intensive care unit (ICU) settings. The Improving Palliative Care in the ICU project,6 a national initiative started by medical intensivists at MSH, has advocated for the integration of palliative care and critical care in the comprehensive management of patients in ICU and their families.7,8 The initiative emphasizes the early implementation of effective ICU palliative care initiatives to maximize the benefits to the patients and their families, as well as to shorten LOS and save costs.9 Education among patients, families, and the CICU team regarding the role of palliative care services is essential to the success of such a program. The cardiology leadership has also begun to focus on the emergence of the contemporary CICU and address the challenges faced with caring for patients in the CICU, as demonstrated by a recent scientific statement by the American Heart Association. Although emphasis was placed on the need for dedicated intensivist training, coordination of end-of-life care was determined to be a “central part of compassionate care in the CICU.”4 Challenges associated with, and ways in which to improve on, the integration and delivery of palliative care services specifically pertaining to the CICU setting were recently addressed by Swetz and Mansel.10 Ultimately, we envision a combined integrative and consultative approach to palliative care in the CICU in which the primary team addresses aspects of care pertaining to palliative care on a daily basis. The team would seek the assistance of a more formalized palliative care
consultation when additional expertise is requested to help with symptom management, conflict resolution, and aligning GOC between the primary team and the patient and family. Future prospective studies are needed to determine if the implementation of a structured and encompassing palliative care program in the CICU will in turn lead to decreased LOS and reduce the financial burden on health care delivery, as it has in the medical ICU.11
Disclosures The authors have no conflicts of interest to disclose. 1. Hollenberg SM. Intensive coronary care. Crit Care Med 2010;38: 685e686. 2. Katz JN, Shah BR, Volz EM, Horton JR, Shaw LK, Newby LK, Granger CB, Mark DB, Califf RM, Becker RC. Evolution of the coronary care unit: clinical characteristics and temporal trends in healthcare delivery and outcomes. Crit Care Med 2010;38:375e381. 3. Curtis JR, Rubenfeld GD. Improving palliative care for patients in the intensive care unit. J Palliat Med 2005;8:840e854. 4. Morrow DA, Fang JC, Fintel DJ, Granger CB, Katz JN, Kushner FG, Kuvin JT, Lopez-Sendon J, McAreavey D, Nallamothu B, Page RL 2nd, Parrillo JE, Peterson PN, Winkelman C; American Heart Association Council on Cardiopulmonary, Critical Care, Perioperative and Resuscitation, Council on Clinical Cardiology, Council on Cardiovascular Nursing, and Council on Quality of Care and Outcomes Research. Evolution of critical care cardiology: transformation of the cardiovascular intensive care unit and the emerging need for new medical staffing and training models: a scientific statement from the American Heart Association. Circulation 2012;126: 1408e1428. 5. Kaldjian LC, Curtis AE, Shinkunas LA, Cannon KT. Review article: goals of care toward the end of life: a structured literature review. Am J Hosp Palliat Med 2009;25:501e511. 6. The IPAL-ICU Project. Available at: http://www.capc.org/ipal-icu. Accessed on December 2, 2014. 7. Nelson JE, Curtis JR, Mulkerin C, Campbell M, Lustbader DR, Mosenthal AC, Puntillo K, Ray DE, Bassett R, Boss RD, Brasel KJ, Frontera JA, Hays RM, Weissman DE. Choosing and using screening criteria for palliative care consultation in the ICU: a report from the Improving Palliative Care in the ICU (IPAL-ICU) Advisory Board. Crit Care Med 2013;41:2318e2327. 8. Nelson JE, Bassett R, Boss RD, Brasel KJ, Campbell ML, Cortez TB, Curtis JR, Lustbander DR, Mulkerin C, Puntillo KA, Ray DE, Weissman DE. Models for structuring a clinical initiative to enhance palliative care in the intensive care unit: a report from the IPAL-ICU Project (Improving Palliative Care in the ICU). Crit Care Med 2010;38:1765e1772. 9. Nelson JE, Campbell ML, Cortez TB, Curtis JR, Lustbader DR, Mosenthal AC, Mulkerin C, Puntillo KA, Ray DE, Bassett R, Boss RD, Brasel KJ, Weissman DE. Organizing an ICU Palliative Care Initiative: A Technical Assistance Monograph from the IPAL-ICU Project. New York: Center to Advance Palliative Care; 2010. Available at: http://ipal.capc. org/downloads/ipal-icu-organizing-an-icu-palliative-care-initiative.pdf. Accessed on December 2, 2014. 10. Swetz KM, Mansel JK. Ethical issues and palliative care in the cardiovascular intensive care unit. Cardiol Clin 2013;31:657e668. 11. Campbell ML, Guzman JA. A proactive approach to improve endof-life care in a medical intensive care unit for patients with terminal dementia. Crit Care Med 2004;32:1839e1843.
0002-9149/15/$ - see front matter Ó 2015 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.amjcard.2014.12.023
mortality, and redirection of goals of care (GOC) toward comfort measures or withdrawal of life-sustaining treatments (LSTs) such as mechanical ventilation or hemodynamic support. Methods A total of 1,368 patients admitted to the MSH CICU from January 1 through December 31, 2012, were screened by the electronic medical record (EMR). The study was approved by Mount Sinai’s Institutional Review Board. In an effort to identify patients who were most likely to have received a palliative care intervention, patients who died during the hospital stay (whether in the CICU, the PCU, or another inpatient unit) were selected for further review. One hundred seventeen patients admitted to the CICU died during their hospitalization. Patient information such as imaging and laboratory data for baseline characteristics, diagnoses pertaining to acute management, and GOC discussions were acquired by review of chart notes and the EMR. Respiratory failure was defined as the utilization of invasive positive pressure ventilation; cardiac failure as the use of inotropic support; severe sepsis as the development of hypotension requiring resuscitation with fluids or vasopressors in the setting of a documented or suspected infection requiring antibiotic treatment for >48 hours; acute kidney injury as an abrupt and persistent decrease in renal function, often requiring www.ajconline.org
688
The American Journal of Cardiology (www.ajconline.org)
Results
Figure 1. Breakdown of 117 patients who died in the CICU with respect to GOC discussions versus no GOC discussion.
Of the 117 patients who did not survive their hospitalization, 69 died in the CICU; 85 patients and/or surrogates had GOC discussions. The CICU team had these discussions with 48 patients/surrogates, whereas 37 patients/surrogates received a formal palliative care consultation. Thirty-two patients died without any end-of-life care discussions (Figure 1). Table 1 illustrates baseline characteristics of the study population. The median age of the overall cohort was 71.5 years, and 56% were men. There was no significant difference between patients with GOC and no GOC discussion for age or gender, and there was no statistical dif-
Table 1 Baseline characteristics of cardiac intensive care unit patients who died during the hospitalization Baseline Characteristics Variables Overall Deaths Age (years) (median,IQR) Male Female Blood urea nitrogen (mg/dL) (median, IQR) Serum creatinine (mg/dL) (median, IQR) Hemoglobin (g/dL) (median, IQR)
GOC Discussion 71 47 38 37 1.75 10
85 (61 to 86) (55.3%) (44.7%) (24 to 60) (1.11 to 2.71) (8.8 to 11.7)
No GOC Discussion 73 18 13 50 2.14 10.4
32 (62 to 79) (58.1%) (41.9%) (31 to 61) (1.2 to 3.64) (9.1 to 12)
Overall 71.5 65 51 39 1.81 10.2
117 (61 to 84) (56.0%) (44%) (25 to 60) (1.13 to 3.03) (8.85 to 11.7)
P-Value 0.46
0.35 0.15 0.30
GOC ¼ goals of care; IQR ¼ interquartile range.
consultation by a nephrologist; neurologic complications as a cerebrovascular accident or transient ischemic attack either confirmed with neurologic imaging or confirmed by a consulting neurologist. A GOC discussion was defined as a structured discussion with the patient and/or family regarding the patient’s end-of-life care that was documented as such in the patient chart. Specifically, GOC discussions that were held in our CICU were consistent with previously defined criteria and addressed at least one of the following: the lack of hope for cure, prolongation of life, quality of life, comfort, life goals, and family/caregiver support.5 This conversation could be initiated by either the primary CICU team or the palliative care consult team. Patients who had GOC discussions were then compared with those who did not with regards to LOS, discontinuation of MCS, discontinuation of implantable cardioverter-defibrillator/pacing therapies, redirected GOC (whether no escalation of care, comfort measures, withdrawal of LST, or palliative extubation), transfer to the PCU, and days from admission to death. Patients who received GOC discussions were also compared on the basis of baseline characteristics and diagnoses. Whereas differences between categorical variables were calculated according to the chi-square and Fisher’s exact tests, differences between continuous variables were tested using the Wilcoxon rank sum test. p Values were used, with a 2-sided value of <0.05 considered significant. Analyses were performed using SAS 9.3 (SAS Institute, Cary, North Carolina).
ference in baseline laboratory values among patients who underwent GOC discussions compared with those who did not receive this intervention. Table 2 compares GOC with no GOC discussions for patients with specific diagnoses pertaining to end-organ failure. Sixty-seven patients were treated for HF, 26 for sepsis, 22 for respiratory failure, 6 for acute kidney injury, and 4 for transient ischemic attack or stroke. There was no significant difference among patients who received GOC discussions with respect to any of the single aforementioned diagnoses, although there was a trend toward GOC discussions for those patients with respiratory failure (p ¼ 0.06) or sepsis (p ¼ 0.06). Of note, 17 of the 67 patients with HF had at least 1 of the other 4 noncardiac diagnoses, and all but 1 of these patients had GOC discussions (p ¼ 0.04). Subjects involved in GOC discussions had a statistically significant higher rate of redirected GOC toward comfort measures or no escalation of care (38.8% vs 3.1%, p <0.001), withdrawal of LST vasopressors (23.5% vs 6.3%, p ¼ 0.02), and palliative extubation (21.2% vs 3.1%, p ¼ 0.01) compared with patients for whom no GOC discussions were held (Table 3 and Figure 2). Among patients who had GOC discussions, there was no statistically significant difference for patients who had their MCS or implantable cardioverter-defibrillator/pacing therapies turned off compared with those patients who were not involved in GOC discussions. Despite the greater degree of redirected end-of-life care among patients who received GOC discussions, there was no difference in CICU LOS or
Miscellaneous/Palliative Care in CICU Table 2 Diagnoses of patients with goals of care discussions versus no goals of care discussion Diagnosis Respiratory failure Heart failure Sepsis Acute kidney injury TIA or stroke Heart failure þ at least one of the above
GOC 19 45 22 4 3 16
No GOC
Overall
(22.4%) 3 (9.4%) 22 (52.9%) 22 (68.8%) 67 (25.9%) 4 (12.5%) 26 (4.7%) 2 (6.3%) 6 (3.5%) 1 (3.1%) 4 (18.8%) 1 (3.1%) 17
(18.8%) (57.3%) (22.2%) (5.1%) (3.4%) (14.5%)
P-Value 0.06 0.13 0.06 0.32 0.43 0.04
TIA ¼ transient ischemic attack.
Table 3 Outcomes of patients with and without goals of care discussions with respect to end of life interventions Outcomes
GOC No GOC Discussion Discussion
Discontinuation of MCS 6 (7.1%) Discontinuation of 4 (4.7%) ICD/pacing therapies Withdrawal of LST 20 (23.5%) 33 (38.8%) Redirected GOC (no escalation/ comfort care) Palliative extubation 18 (21.2%)
1 (3.1%) 1 (3.1%)
Overall 7 (6%) 5 (4.3%)
P-Value 0.28 0.39
2 (6.3%) 1 (3.1%)
22 (18.8%) 0.02 34 (29.1%) < 0.001
1 (3.1%)
19 (16.2%)
0.01
GOC ¼ goals of care; ICD ¼ implantable cardioverter defibrillator; LST ¼ life-sustaining treatments; MCS ¼ mechanical circulatory support.
689
days to mortality from the time of CICU admission between the 2 groups, and our results still did not reach statistical significance when mean values were used instead of median values (Table 4). Discussion In our study, end-of-life discussions were carried out for >70% of patients who died during their hospital admission, and the primary CICU team led these discussions for >1/2 of these patients. Our results show that GOC discussions had a significant effect on end-of-life care. Despite a significantly greater proportion of patients undergoing such discussions having GOC redirected toward comfort or no escalation of care, withdrawal of LST, or palliative extubation, there was no effect on CICU LOS or time to death. The reason for the unchanged LOS may have been due to the timing of the GOC discussions, which were held an average of 16 days from the time of admission to the CICU (median 8 days) and likely at an advanced stage of illness. Our study has several limitations. The first is that it was retrospective, and much of the information ascertained was dependent on whether these GOC discussions were documented as such in the chart notes and EMR. Although we did not identify evidence of end-organ damage to 1 organ system as a determinant of whether patients received GOC discussions, those patients with both HF and evidence of additional organ system failure were much more likely to receive GOC discussions, indicating that severity of illness and worse prognosis were likely the driving determinants of
Figure 2. Palliative care therapies in patients with and without GOC discussions.
690
The American Journal of Cardiology (www.ajconline.org)
Table 4 Outcomes of patients with and without goals of care discussions with respect to length of stay and days to mortality Outcomes
GOC Discussion
No GOC Discussion
P-Value
CICU length of stay (days) (median IQR) Days to mortality (days) (median IQR) CICU length of stay (mean std err) Days to mortality (mean std err)
4 (2 to 8)
4 (2 to 10)
0.96
8 (3 to 16)
7 (3 to 31)
0.53
16.52.94
26.66.92
0.19
8.71.9
9.92.4
0.68
CICU ¼ cardiac intensive care unit; IQR ¼ interquartile range.
the decision to undergo these discussions. We also did not study GOC discussions among patients in CICU who survived their hospitalization, although anecdotal experience suggests that most GOC discussions were held for patients whom the CICU team believed were unlikely to survive their hospitalization. Identifying which patients should receive formal palliative care discussions and how early during the CICU stay these discussions should occur are areas for further study; such studies have already been conducted in other intensive care unit (ICU) settings. The Improving Palliative Care in the ICU project,6 a national initiative started by medical intensivists at MSH, has advocated for the integration of palliative care and critical care in the comprehensive management of patients in ICU and their families.7,8 The initiative emphasizes the early implementation of effective ICU palliative care initiatives to maximize the benefits to the patients and their families, as well as to shorten LOS and save costs.9 Education among patients, families, and the CICU team regarding the role of palliative care services is essential to the success of such a program. The cardiology leadership has also begun to focus on the emergence of the contemporary CICU and address the challenges faced with caring for patients in the CICU, as demonstrated by a recent scientific statement by the American Heart Association. Although emphasis was placed on the need for dedicated intensivist training, coordination of end-of-life care was determined to be a “central part of compassionate care in the CICU.”4 Challenges associated with, and ways in which to improve on, the integration and delivery of palliative care services specifically pertaining to the CICU setting were recently addressed by Swetz and Mansel.10 Ultimately, we envision a combined integrative and consultative approach to palliative care in the CICU in which the primary team addresses aspects of care pertaining to palliative care on a daily basis. The team would seek the assistance of a more formalized palliative care
consultation when additional expertise is requested to help with symptom management, conflict resolution, and aligning GOC between the primary team and the patient and family. Future prospective studies are needed to determine if the implementation of a structured and encompassing palliative care program in the CICU will in turn lead to decreased LOS and reduce the financial burden on health care delivery, as it has in the medical ICU.11
Disclosures The authors have no conflicts of interest to disclose. 1. Hollenberg SM. Intensive coronary care. Crit Care Med 2010;38: 685e686. 2. Katz JN, Shah BR, Volz EM, Horton JR, Shaw LK, Newby LK, Granger CB, Mark DB, Califf RM, Becker RC. Evolution of the coronary care unit: clinical characteristics and temporal trends in healthcare delivery and outcomes. Crit Care Med 2010;38:375e381. 3. Curtis JR, Rubenfeld GD. Improving palliative care for patients in the intensive care unit. J Palliat Med 2005;8:840e854. 4. Morrow DA, Fang JC, Fintel DJ, Granger CB, Katz JN, Kushner FG, Kuvin JT, Lopez-Sendon J, McAreavey D, Nallamothu B, Page RL 2nd, Parrillo JE, Peterson PN, Winkelman C; American Heart Association Council on Cardiopulmonary, Critical Care, Perioperative and Resuscitation, Council on Clinical Cardiology, Council on Cardiovascular Nursing, and Council on Quality of Care and Outcomes Research. Evolution of critical care cardiology: transformation of the cardiovascular intensive care unit and the emerging need for new medical staffing and training models: a scientific statement from the American Heart Association. Circulation 2012;126: 1408e1428. 5. Kaldjian LC, Curtis AE, Shinkunas LA, Cannon KT. Review article: goals of care toward the end of life: a structured literature review. Am J Hosp Palliat Med 2009;25:501e511. 6. The IPAL-ICU Project. Available at: http://www.capc.org/ipal-icu. Accessed on December 2, 2014. 7. Nelson JE, Curtis JR, Mulkerin C, Campbell M, Lustbader DR, Mosenthal AC, Puntillo K, Ray DE, Bassett R, Boss RD, Brasel KJ, Frontera JA, Hays RM, Weissman DE. Choosing and using screening criteria for palliative care consultation in the ICU: a report from the Improving Palliative Care in the ICU (IPAL-ICU) Advisory Board. Crit Care Med 2013;41:2318e2327. 8. Nelson JE, Bassett R, Boss RD, Brasel KJ, Campbell ML, Cortez TB, Curtis JR, Lustbander DR, Mulkerin C, Puntillo KA, Ray DE, Weissman DE. Models for structuring a clinical initiative to enhance palliative care in the intensive care unit: a report from the IPAL-ICU Project (Improving Palliative Care in the ICU). Crit Care Med 2010;38:1765e1772. 9. Nelson JE, Campbell ML, Cortez TB, Curtis JR, Lustbader DR, Mosenthal AC, Mulkerin C, Puntillo KA, Ray DE, Bassett R, Boss RD, Brasel KJ, Weissman DE. Organizing an ICU Palliative Care Initiative: A Technical Assistance Monograph from the IPAL-ICU Project. New York: Center to Advance Palliative Care; 2010. Available at: http://ipal.capc. org/downloads/ipal-icu-organizing-an-icu-palliative-care-initiative.pdf. Accessed on December 2, 2014. 10. Swetz KM, Mansel JK. Ethical issues and palliative care in the cardiovascular intensive care unit. Cardiol Clin 2013;31:657e668. 11. Campbell ML, Guzman JA. A proactive approach to improve endof-life care in a medical intensive care unit for patients with terminal dementia. Crit Care Med 2004;32:1839e1843.