Variability in Frequency of Consultation and Needs Assessed by Palliative Care Services

Variability in frequency of consultation and needs assessed by palliative care services across multiple specialty ICUs - Electronic Supplementary Material

Contents

Methods page 2

Table 1 page 4

Table 2 page 5

Figure 1 page 7

Methods

Study Setting

The study protocol was reviewed and approved by Columbia University Medical Center (CUMC) (IRB-AAAP2112 New York, NY). Written informed consent was waived. Data for this retrospective study came from the Clinical Data Warehouse, a repository of electronic medical records, at CUMC in New York, NY. CUMC is a 745-bed tertiary care academic medical center that contains multiple specialty ICUs with a total of 117 ICU beds. We included all adult patients (age > 18) who were admitted to any ICU from August 2013 to August 2015.

Data Collection

We obtained demographic and clinical variables from the medical record via an electronic data extraction performed by the Clinical Data Warehouse at CUMC. At CUMC, palliative care consults are obtained via phone call from a member of the ICU team to the palliative care team. The primary intensivist team is responsible for calling palliative care consultation within all ICUs, although the decision to do so may have been made in conjunction with other primary providers (e.g. surgeons, cardiologists). We obtained information about palliative care consultation directly from palliative care notes written in the medical record. Within the initial consultation note, the “reason for consultation” is a non-mutually exclusive check box field at the top of the note. The palliative care provider fills out this information based on the reason for consult, as specified by the primary team during the initial request for consultation. Options include “Patient/family support,” “Hospice referral,” “Prognostication,” “Pain management,” “Symptom management,” “Withholding/withdrawing of life-sustaining treatments,” “Discharge planning,” “Goals of care,” and “Advanced directives”. Specifically, “Symptom management” refers to the management of non-pain symptoms (e.g. nausea, vomiting, dyspnea, thirst, anxiety, depression), and “Advanced directives” refers to discussions regarding directives for future treatment including living wills, do-not-resuscitate orders, and appointment of health care agents/proxies. The reason for consultation is documented in every initial consultation note, multiple reasons may be enumerated and the field must be completed in order to finalize the note. We refer to these specific reasons for palliative care involvement as “palliative care needs” in this manuscript.

Chart review

To gain a more detailed understanding of the burden of palliative care needs for patients and the breadth of services provided by the palliative care team, we performed a chart review on a random sample of 125 patients who received a palliative care consultation (25 from each ICU). Abstractors were trained to examine both initial consultation and follow-up notes to determine whether a specific palliative care need was addressed based on the use of specific keywords or phrases (see Table 1 in the Electronic Supplementary Material). Data was collected using a standardized form, and abstractors’ performance was monitored. Charts were reviewed by two abstractors; inter-rater reliability was calculated for all variables. Adjudication was performed by a third abstractor for any variable with a κ < 0.8, until all variables had an inter-rater reliability > 0.8. For the initial consultation, we examined the difference between the reason(s) for consultation and what palliative care needs were actually addressed; for the follow-up notes, we abstracted any additional palliative care needs that were attended to for the patients’ entire hospitalization.

Table 1. Description of Consult Reasons and Key Terms for Abstraction for Chart Review

Descriptive Definition / Coding Criteria and Key Terms /
PC Consult Request variables / Explicit request in note for a given need is listed under “Reasons for Consult” by referring team.
PC Assessment variables / Reasons (e.g. “Symptom management”) must be mentioned in the consult note assessment with new observations or recommendations made by the palliative care team. Key terms that must be explicitly listed for specific needs are enumerated below.
PC Assessment - Symptom Management / The term "Symptom management" or related terms (e.g. evaluation on symptoms such as nausea, delirium, fatigue, etc. and/or symptom-related treatment) are mentioned.
PC Assessment - Pain Management / The term "Pain management" or related terms (e.g. evaluation of pain-related medication/treatment) are mentioned.
PC Assessment - Goals of Care / The term "Goals of care" is used, or if a discussion on patient or family desires in terms of outcomes, disposition, acceptable quality of life/ability, acceptable level or intervention of care, etc. is described.
PC Assessment - Patient/Family Support / The term "Patient/family support" or synonymous phrases (e.g., "provided supportive counseling to patient/family", “provided emotional support”) are used. This also includes conduct of a “family conference” or “family meeting” as it refers to a multidisciplinary meeting with patient, family, primary team, palliative care team, chaplaincy, as well as bereavement counseling (identified by use of the term "Bereavement Counseling" or the recommendation/provision of bereavement resources/services).
PC Assessment - Prognosis / The term "Prognosis" or temporal mentions of life expectancy are mentioned.
PC Assessment - Withholding/Withdrawing of Life Sustaining Treatments / The term "Withholding/Withdrawing of Life Support" is used and/or specific terminal procedures (e.g. removal from mechanical ventilation) are discussed or performed.
PC Assessment - Discharge Planning / The term "Discharge Planning" is used, or concrete discussions on discharge planning to home, rehabilitation facilities, skilled nursing facilities, hospice etc. are made and arranged.
PC Assessment - Advanced Directive / The term "Advanced Directive" or references to forms directing orders for life-sustaining therapy (e.g. MOLST) are mentioned. This also includes identification of a health care agent (the term "Health Care Agent" or “Health Care Proxy” is discussed and appointed), and discussion of code status (a new code status has been confirmed, assigned or changed).
PC Assessment - Hospice Referral / The term "Hospice Referral", discussions of formal arrangements with hospice services, or a general discussion on hospice inpatient/outpatient services are mentioned (may include palliative care team-written discharge notes).

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Table 2. Characteristics of Intensive Care Unit Admissions who received a Palliative Care Consultation

All ICUs
(n=689) / MICU
(n=224) / SICU
(n=100) / CTICU
(n=70) / CCU
(n=246) / NICU
(n=49)
Rate of consultation, %a / 5.2 / 9.8 / 5.5 / 2.0 / 7.8 / 1.9
Age, mean (SD) / 66.0 (15.9) / 64.2 (16.4) / 67.4 (16.5) / 64.4 (13.0) / 67.3 (15.3) / 66.8 (18.1)
Male, % / 63.3 / 56.7 / 51.0 / 80.0 / 70.7 / 57.1
Race, %
Caucasian / 56.9 / 44.3 / 63.8 / 71.4 / 63.3 / 48.3
African Amer. / 16.1 / 13.9 / 20.0 / 4.8 / 20.7 / 6.9
Asian / 6.3 / 7.6 / 1.3 / 16.7 / 4.7 / 6.9
Other/Unknown / 20.7 / 34.2 / 15.0 / 7.1 / 11.2 / 37.9
Hospital LOS, median (IQR) / 20.0
(10.8-36.3) / 16.5
(9.4-28.4) / 23.0
(12.9-39.0) / 40.9
(19.8-73.0) / 20.1 (11.7-34.8) / 17.7
(7.2-33.9)
Order for limitation in life-sustaining therapy placed during hospitalizationb, % / 69.1 / 76.8 / 73.0 / 50.0 / 65.5 / 71.4
Discharge Destination, %
Died in Hospital / 53.1 / 58.6 / 64.0 / 53.7 / 44.6 / 46.9
Home / 24.1 / 18.9 / 18.0 / 20.9 / 34.7 / 12.2
SNF / 11.9 / 14.9 / 6.0 / 7.5 / 9.1 / 30.6
Rehabilitation
Facility / 1.3 / 0.5 / 0.0 / 4.5 / 1.7 / 2.0
Other Care Facility / 6.5 / 5.4 / 8.0 / 13.4 / 4.6 / 8.2
Hospice / 3.1 / 1.8 / 4.0 / 0.0 / 5.4 / 0.0

ICU, intensive care unit; MICU, medical intensive care unit; SICU, surgical intensive care unit; CTICU, cardiothoracic intensive care unit; CCU, cardiac care unit; NICU, neurological intensive care unit; SD, standard deviation; LOS, length of stay; IQR, interquartile range; SNF, skilled nursing facility

a Rate of consultation calculated as number of palliative care consultations / all admissions.

b Orders for limiting life-sustaining therapy include do-not-resuscitate orders, as well as orders for withholding and withdrawal of life-sustaining therapy.

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Fig. 1 Additional Palliative Care Needs Addressed Throughout the Course of Consultation

By performing a chart review of 125 randomly selected patients (25 from each ICU), additional palliative care needs that were addressed during consultation were determined. For the initial consultation, palliative care needs that were not documented as a “reason for consultation,” but were addressed in the initial assessment were counted. For the follow-up visit, palliative care needs that were not addressed at any point during initial consultation, but were addressed during any follow-up visit were counted. Percentages represent the number of patients who had the need addressed / overall number of patients.

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