Patient-Centered Outcomes and Use of Palliative Care Among Seriously-Ill and Non-Surviving Mechanically Ventilated ICU Patients

Background: A considerable proportion of mechanically ventilated (MV) patients in the ICU are at high risk of dying or die during hospitalization. Patients face threats to comfort, social connectedness, and dignity as a result of experiencing pain, ICU-acquired pressure ulcers, heavy sedation, and physical restraint, all inconsistent with standards for high quality end-of-life (EOL) care. Receipt of palliative care consultation (PCC) services has been associated with improved outcomes for seriously-ill and dying individuals.\ud Objectives: 1) Describe patient-centered outcomes (unrelieved pain, ICU-acquired pressure ulcers, heavy sedation and days in restraint) among sampled patients who were seriously-ill or non-surviving; 2) Identify patient-level predictors of these outcomes; and 3) Explore the relationship between presence, timing and duration of PCC services and patient outcomes among sampled patients who were seriously-ill or non-surviving.\ud Methods: A retrospective cohort design was used to conduct an expanded secondary analysis of data from the parent study (SPEACS-2; RWJF INQRI #66633). Additional data on receipt of PCC services were abstracted from the electronic medical records of parent study subjects.\ud Results: Of the 1440 sampled patients, 773 were at high risk of dying or did not survive hospitalization. This cohort had a mortality rate of 29.8%; and of ICU days evaluated in the parent study, they spent on average 50% with unrelieved pain, 40% with some heavy sedation, and 40.8% with physical restraint. 12.3% experienced at least one ICU-acquired pressure ulcer. Being at EOL was independently associated with greater odds of experiencing heavy sedation (OR=2.64) and ICU-acquired pressure ulcer (OR=1.60); greater percentage of the ICU stay in heavy sedation (b=0.088; p< .001); and lower percentage of ICU days with unrelieved pain (b=-0.063; p=.002), after adjusting demographic and clinical covariates. Among those at EOL, 73 (9.4%) received PCC services, occurring on average, after 62% of the stay had elapsed. Compared to pre-consultation, subjects post consultation experienced a lower proportion of days in restraint (-0.17, p<.001), a higher proportion of days in heavy sedation (0.13, p=.015), and similar proportions of days with pain. \ud Conclusion: These findings suggest that seriously-ill and non-surviving MV adults in the ICU experience a high prevalence of poor outcomes on measures of patient-centered care.\u