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Ethics in Cardiopulmonary Medicine |

Impact of a Proactive Approach to Improve End-of-Life Care in a Medical ICU*

Margaret L. Campbell, RN, MSN; Jorge A. Guzman, MD
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*From the Palliative Care Service, Detroit Receiving Hospital, and the Division of Pulmonary and Critical Care Medicine, Wayne State University, Detroit, MI.

Correspondence to: Jorge A. Guzman, MD, Room 3935, 3 Hudson, Harper University Hospital, 3990 John R, Detroit, MI 48201; e-mail: jguzman@intmed.wayne.edu.



Chest. 2003;123(1):266-271. doi:10.1378/chest.123.1.266
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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.

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