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Integrated palliative care: triggers for referral to palliative care in ICU patients

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Abstract

Introduction

Palliative care within intensive care units (ICU) benefits decision-making, symptom control, and end-of-life care. It has been shown to reduce the length of ICU stay and the use of non-beneficial and unwanted life-sustaining therapies. However, it is often initiated late or not at all. There is increasing evidence to support screening ICU patients using palliative care referral criteria or “triggers”. The aim of the project was to assess the need for palliative care referral during ICU admission using “trigger” tools.

Methods

Electronic record review of cancer patients who died in or within 30 days of discharge from oncology ICU, between 2016 and 2018. Patients referred to palliative care before or during ICU admission were identified. Three sets of palliative care referral “triggers” were applied: one that is being tested locally and two internationally derived tools. The proportion of patients who met any of these triggers during their final ICU admission was calculated.

Results

Records of 149 patients were reviewed: median age 65 (range 20–83). Most admissions (89%) were unplanned, with the most common diagnoses being haemato-oncology (31%) and gastrointestinal (16%) cancers. Most (73%) were unknown to palliative care pre-ICU admission; 44% were referred between admission and death. The median time from referral to death was 0 day (range 0–19). On ICU admission, 97–99% warranted referral to palliative care using locally and internationally derived triggers.

Conclusion

All “trigger” tools identified a high proportion of patients who may have warranted a palliative care referral either before or during admission to ICU. The routine use of trigger tools could help streamline referral pathways and underpin the development of an effective consultative model of palliative care within the ICU setting to enhance decision-making about appropriate treatment and patient-centred care.

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Data availability

The data came from a private repository, only accessible by members of Royal Marsden NHS Foundation Trust. The data can be made available upon reasonable request from the corresponding author.

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Author information

Authors and Affiliations

  1. Critical Care Unit, Anaesthetics Department, Royal Marsden NHS Foundation Trust, London, UK

    Yashna Nadkarni, Pascale Gruber & Shaman Jhanji

  2. University Hospital Centre Zagreb, Zagreb, Croatia

    Ivana Kukec

  3. Symptom Control and Palliative Care Team, Royal Marsden NHS Foundation Trust, London, UK

    Joanne Droney

Authors
  1. Yashna Nadkarni
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  2. Ivana Kukec
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  3. Pascale Gruber
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  4. Shaman Jhanji
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  5. Joanne Droney
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Contributions

Joanne Droney, Pascale Gruber, and Shaman Jhanji conceived the idea and planned the study. Yashna Nadkarni and Ivana Kukec collected the data, with supervision from Joanne Droney, Pascale Gruber, and Shaman Jhanji. Joanne Droney, Ivana Kukec, and Yashna Nadkarni analysed the data. All authors reviewed, discussed, and contributed to the interpretation of the results and writing of the manuscript. All authors agree on the final version of the manuscript.

Corresponding author

Correspondence to Yashna Nadkarni.

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Ethical approval was granted by the Royal Marsden NHS Foundation Trust Service Evaluation Department.

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The authors declare no competing interests.

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Appendix

Appendix

   

Before ICU admission

During ICU admission

Cancer diagnosis

Overall (N = 149)

Not referred to PC at all before death (N = 57)

Referred to PC before ICU admission (N = 37)

Previously known to PC and re-referred during ICU (N = 29)

New referral to PC during ICU (N = 55)

Haematological malignancy

46 (31)

19 (41)

12 (26)

8 (17)

15 (33)

Upper gastrointestinal cancer

24 (16)

10 (42)

6 (25)

6 (25)

8 (33)

Genitourinary

14 (9)

2 (14)

3 (21)

0

9 (64)

Gynaecological

6 (4)

3 (50)

0

0

3 (50)

Breast

10 (7)

3 (30)

2 (20)

2 (20)

5 (50)

Melanomas

6 (4)

0 (0)

2 (33)

2 (33)

4 (66)

Lower gastrointestinal

11 (7)

4 (36)

4 (36)

4 (36)

3 (17)

Lung carcinoma

10 (7)

6 (60)

2 (20)

2 (20)

2 (20)

CUP

4 (3)

1 (25)

2 (50)

1 (25)

1 (25)

Head and neck

4 (3)

2 (50)

1 (25)

1 (25)

1 (25)

Sarcoma

14 (9)

7 (50)

3 (21)

3 (21)

4 (29)

Reason for ICU admission

Respiratory

47 (32)

18 (38)

8 (17)

6 (13)

21 (45)

Renal

12 (8)

6 (50)

4 (33)

4 (33)

2 (17)

Cardiac

8 (5)

3 (37)

2 (25)

2 (25)

3 (38)

Sepsis

33 (22)

13 (40)

6 (18)

3 (9)

14 (42)

Neurological

6 (4)

3 (50)

2 (33)

2 (33)

1 (17)

Post-operative

43 (29)

14 (33)

15 (34)

12 (28)

14 (33)

 

Median (range)

    

Age

65 (20–83)

67 (20–83)

65 (28–81)

64 (25–83)

63(25–78)

Length of ICU admission

5 (0–70)

    

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Nadkarni, Y., Kukec, I., Gruber, P. et al. Integrated palliative care: triggers for referral to palliative care in ICU patients. Support Care Cancer 30, 2173–2181 (2022). https://doi.org/10.1007/s00520-021-06542-w

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