B14-02 Randomized Trial of Specialty Palliative Care Integrated With Critical Care for Critically Ill Older Adults at High Risk of Death or Severe Functional Impairment

Rationale

Specialty palliative care (SPC) is increasingly recommended for critically ill patients, yet evidence of efficacy remains limited. We sought to determine whether early, integrated SPC consultation improves patient- and family-centeredness of care and other key outcomes among critically ill older adults.

Methods

We conducted a multicenter, patient-randomized efficacy trial in 7 ICUs at 5 hospitals in Pittsburgh, PA. Eligible patients were ≥60 years old and were at high risk (>50%) of in-hospital death or severe functional impairment. Patients were randomized 1:1 to early integrated SPC consultation versus usual care. The intervention consisted of multidisciplinary SPC team consultation within 24 hours of enrollment, daily SPC visits during ICU stay, and joint SPC-ICU team family meetings within 2 days of enrollment and every 5-7 days thereafter. Control patients received routine ICU care, including family meetings within 72 hours and at least weekly thereafter. The primary outcome was patient- and family-centeredness of care, assessed by surrogates at 3 months using the modified Patient Perceived Patient-Centeredness of Care (PPPC) scale (range 1-4; lower scores indicate more patient-centered care). Other outcomes included surrogates’ ratings of goal concordance of care, and patients’ ICU and hospital LOS. We conducted a prespecified subgroup analysis among surrogates with high palliative care needs (NEST score ≥30).

Results

We enrolled 500 patients and 552 surrogates; 36% of surrogates had high palliative care needs at baseline. Intervention fidelity was high: 99.2% of intervention patients received SPC consultation within 24 hours of enrollment, and 85% of family meetings were attended by both SPC and ICU teams. There was no significant difference in the primary outcome across groups (mean PPPC score: intervention 1.5±0.6 vs. control 1.5±0.5, p = 0.81). Surrogate-assessed goal-concordant care was similar between groups (93.3% control vs. 90.3% intervention reported healthcare team discussed patient wishes, p = 0.31; agreement that care met patient wishes: 3.5±0.7 in both groups, p = 0.67). There were no significant differences in ICU length of stay (8.8±10.1 vs. 8.6±7.8 days, p = 0.53), hospital length of stay (18.0±17.2 vs. 16.9±16.2 days, p = 0.50), or in-hospital mortality (38.3% vs. 40.6%, p = 0.67). Among patients with high palliative care needs (NEST ≥30, n = 196) there was similarly no difference in patient-centeredness of care, goal-concordant care, or ICU length of stay.

Conclusions

Early, integrated SPC consultation did not improve patient- and family-centeredness of care, goal-concordant care, or healthcare utilization, including among surrogates with high baseline palliative care needs.

This abstract is funded by: NIA