Abstract
Dear Editor:
Historically, palliative care involvement in the cardiac intensive care unit (CICU) was less than in other intensive care units (ICUs). 1 With advances in technology, the CICU manages many more complex and severely ill patients with high risk of morbidity and mortality compared to years prior. 2 There have been various articles published supporting the role of palliative care in patients who are critically ill in the CICU.1–4 However, little guidance exists on how to structure resources to meet the clinical needs of these patients in a limited workforce environment.
Pilot Model of Palliative Care Delivery in the CICU
We present a retrospective cohort study in which we pilot tested a model that included the identification of appropriate patients for palliative care consultation. To screen in patients who may benefit from palliative care consultation, the CICU team, particularly the cardiology attendings and fellows, used existing health system-wide ICU triggers for palliative care consultation. These triggers were ICU length of stay ≥5 days, cardiac arrest, or metastatic malignancy. Additional unit-specific triggers were added, including >4 hospitalizations in the past 12 months or requiring extracorporeal membrane oxygenation. For those who met at least one trigger criterion, the palliative care heart failure nurse practitioner (NP), with over five years of cardiac palliative care experience, did a second screen of these patients’ electronic medical records using the same trigger criteria. Then these cases were discussed face-to-face during interdisciplinary team rounds with the CICU team in order to prioritize which patients should be seen by specialty palliative care consultation in light of staffing limitations. We compared patients who received a palliative care consult six months prior to this trigger model and those who received a consult for six months after the implementation of the trigger model in November of 2024. We use descriptive statistics to compare patients’ sociodemographic and clinical characteristics (e.g., age, gender, race, and primary language) and compare outcomes of health care utilization (e.g., hospital length of stay and in-hospital mortality). This study was approved by the Icahn School of Medicine Institutional Review Board.
Pilot Results
In comparison to the six-month period before the trigger pilot began, during which patients received a specialty palliative care consultation by attending referral only, there was a 56% increase in the number of consultations (54 vs. 84 patients) during the pilot period. There were no significant differences in patient sociodemographics or health care utilization. In comparison to the pre-pilot period, more patients seen during the pilot had a higher functional status as measured by the Karnofsky Performance Status >80% (e.g., normal activity with effort, some signs of symptoms of disease) 5 (19 patients [35%] vs. 35 patients [41%]), and yet more patients were transferred to the hospital’s inpatient palliative care unit (8 [15%] vs. 20 [24%]). However, these findings did not reach statistical significance (p > 0.05).
Future of Palliative Care Delivery in the ICUs
Despite not showing statistically significant results in the measured outcomes, this model was very effective for cultural change. Frequent interactions with the same palliative care nurse practitioner (NP) allowed for trust building between palliative care and CICU teams, and a higher consultation volume led to more exposure to palliative care skills for the primary cardiology team. With an enhanced value of palliative care understood by the clinical team, there were more opportunities for education, both bedside and didactic. Multiple communication courses were given to all levels of learners and faculty in the CICU along with a grand rounds around palliative care. This model allows for the identification of highest-needs patients using one, consistent specialty-trained palliative care clinician, while exposing more cardiac clinicians to core palliative care skills that they can apply themselves for those patients with fewer or less urgent needs. These nontangibles are hard to capture with metrics and therefore are often overlooked. Though not commonly linked, the CICU is a place that benefits from partnership with palliative care and requires more focus to operationalize the most effective models. Further studies need to be done in order to determine outcomes that accurately capture the impact of these models.
Footnotes
Author Disclosure Statement
No competing financial interests exist.
Funding Information
No funding was received for this article.