Impact of a proactive approach to improve end-of-life care in a medical ICU

被引:247
作者
Campbell, ML
Guzman, JA
机构
[1] Detroit Receiving Hosp & Univ Hlth Ctr, Palliat Care Serv, Detroit, MI USA
[2] Wayne State Univ, Div Pulm & Crit Care Med, Detroit, MI USA
关键词
anoxic encephalopathy; critical care; multiple organ system failure; palliative care;
D O I
10.1378/chest.123.1.266
中图分类号
R4 [临床医学];
学科分类号
1002 ; 100602 ;
摘要
Study objectives: To assess the impact of a proactive case finding approach to end-of-life care for critically ill patients experiencing global cerebral ischemia (GCI) after cardiopulmonary resuscitation and multiple organ system failure (MOSF) in comparison to historical control subjects. Design: Comparative study of retrospective and prospective cohorts. Setting: Medical ICU of a university hospital. Interventions: Patterns of end-of life care for patients with MOSF and GCI obtained through a retrospective chart review were compared to proactive case finding facilitated by the inpatient palliative care service. Interventions included identification of patient's advance directives or preferences about end-of life care, if any; assistance with discussion of the prognosis and treatment options with patients or their surrogates; and implementation of palliative care strategies when treatment goals changed to a focus on comfort measures. Results: Although our retrospective data demonstrated a high percentage of do-not-resuscitate decisions for the patients under investigation, a considerable time lag elapsed between identification of the poor prognosis and the establishment of end-of-life treatment goals (4.7 +/- 2.4 days and 3.5 +/- 0.5 days for patients with MOSF and GCI, respectively [mean SE]). The proactive case finding approach decreased hospital length of stay (mean, 20.6 +/- 4.1 days vs 15.1 +/- 2.5 days and 8.6 +/- 1.6 days vs 4.7 +/- 0.6 days for MOSF and GCI patients, respectively; p = 0.063 and < 0.001, respectively). More importantly, a proactive palliative care intervention decreased the time between identification of the poor prognosis and the establishment of comfort care goals (7.3 +/- 2.9 days vs 2.2 +/- 0.8 days and 6.3 +/- 1.2 days vs 3.5 +/- 0.4 days for MOSF and GCI patients, respectively; p < 0.05 for both), decreased the time dying patients with MOSF remained in the ICU, and reduced the use of nonbeneficial resources, thus reducing the cost of care. Conclusions: Proactive interventions from a palliative care consultant within this subset of patients decreased the use of nonbeneficial resources and avoided protracted dying.
引用
收藏
页码:266 / 271
页数:6
相关论文
共 34 条
[1]   DECISIONS TO LIMIT OR CONTINUE LIFE-SUSTAINING TREATMENT BY CRITICAL CARE PHYSICIANS IN THE UNITED-STATES - CONFLICTS BETWEEN PHYSICIANS PRACTICES AND PATIENTS WISHES [J].
ASCH, DA ;
HANSENFLASCHEN, J ;
LANKEN, PN .
AMERICAN JOURNAL OF RESPIRATORY AND CRITICAL CARE MEDICINE, 1995, 151 (02) :288-292
[2]  
Campbell M L, 1994, Am J Crit Care, V3, P202
[3]  
Campbell M L, 1996, AACN Clin Issues, V7, P159, DOI 10.1097/00044067-199602000-00015
[4]   Experience with an end-of-life practice at a university hospital [J].
Campbell, ML ;
Frank, RR .
CRITICAL CARE MEDICINE, 1997, 25 (01) :197-202
[5]   DEVELOPMENT OF A COMPREHENSIVE SUPPORTIVE CARE TEAM FOR THE HOPELESSLY ILL ON A UNIVERSITY HOSPITAL MEDICAL-SERVICE [J].
CARLSON, RW ;
DEVICH, L ;
FRANK, RR .
JAMA-JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION, 1988, 259 (03) :378-383
[6]   Relationship between TISS and ICU cost [J].
Dickie, H ;
Vedio, A ;
Dundas, R ;
Treacher, DF ;
Leach, RM .
INTENSIVE CARE MEDICINE, 1998, 24 (10) :1009-1017
[7]   A study of proactive ethics consultation for critically and terminally ill patients with extended lengths of stay [J].
Dowdy, MD ;
Robertson, C ;
Bander, JA .
CRITICAL CARE MEDICINE, 1998, 26 (02) :252-259
[8]   Do-not-resuscitate decisions in the medical ICU - Comparing physician and nurse opinions [J].
Eliasson, AH ;
Howard, RS ;
Torrington, KG ;
Dillard, TA ;
Philips, YY .
CHEST, 1997, 111 (04) :1106-1111
[9]   IMPACT OF A COMPREHENSIVE SUPPORTIVE CARE TEAM ON MANAGEMENT OF HOPELESSLY ILL PATIENTS WITH MULTIPLE ORGAN FAILURE [J].
FIELD, BE ;
DEVICH, LE ;
CARLSON, RW .
CHEST, 1989, 96 (02) :353-356
[10]  
Frank RR, 1996, JAMA-J AM MED ASSOC, V275, P1228