NEW YORK (Reuters Health) – Using clinical triggers to prompt palliative-care consultations in intensive-care units (ICUs) appears inefficient at identifying unmet care needs in critically ill patients, according to a new study.
“A palliative-care trigger seems to be as good as a coin flip in determining if a certain patient in an ICU setting has a high level of unmet needs,” said Dr. Christopher Cox of Duke University, in Durham, North Carolina.
“Given that there’s so few palliative care services for people in the country and you want to use it wisely, we’re probably going to have to ask people what they need,” he told Reuters Health by email.
In a paper in JAMA Network Open, Dr. Cox and his colleagues note that palliative-care consultations in ICUs are increasingly prompted by clinical characteristics linked with mortality or resource utilization. But it is unknown whether these triggers reflect actual palliative-care needs.
To examine whether palliative-care-trigger status accurately identified individuals with the most serious unmet needs, as reported by family members, the team assessed survey data from 257 family members of patients across six medical and surgical ICUs at North Carolina academic and community hospitals.
Participants in the prospective cohort study included consecutive patients who received mechanical ventilation plus their family members. Median ages of family members and patients were 54 and 58 years, respectively.
The exposure variable was the presence of any of nine common clinical palliative-care triggers: advanced cancer; cardiac arrest; critical acute neurologic condition; dementia; residence in a long-term acute care or skilled nursing facility or inpatient rehabilitation; three or more limitations in baseline activities of daily living; two or more hospital admissions or one or more ICU admissions within three months; and worsening organ dysfunction.
There was no difference in median scores on the Needs at the End-of-Life Screening Tool (NEST) between the 45% of patients with a trigger present and the 55% without (21.0 vs. 22.5, respectively; p=0.52).
A serious need was defined as “a total NEST score of 30 or higher, reflecting 3 possible scenarios of clinical significance that could prompt clinician concern: an average item score above the threshold of 5 or greater in a majority of domains, extremely high needs (NEST score, 8-10) in a few of the 8 palliative care quality domains sampled, or moderate needs (NEST score, 3-5) for nearly all domains.”
Presence of a trigger had a sensitivity of 45%, a specificity of 55%, a positive likelihood ratio of 1.0 and a negative likelihood ratio of 1.0 for identifying a serious need.
“The C statistic (0.50; 95% CI, 0.44-0.57) showed that trigger status was no better than chance at distinguishing dyads with and without serious needs,” the researchers report. “Sensitivity analyses revealed little difference in a wide range of NEST scores.”
They suggest that “Focusing care delivery on directly measured needs may represent a more person-centered alternative.”
Dr. Rebecca Aslakson of Stanford University, in California, who has studied how to best deliver palliative care to severely ill patients, said that because many critically ill patients are too sick to meaningfully communicate their palliative-care needs or complete a survey, direct measurement of needs “means there must be a knowledgeable family member able to communicate these needs, or there needs to be some other, non-survey-based means” to determine high palliative-care needs in select patients.
“Unfortunately, a not insignificant number of critically ill patients also lack a family member who is both available and able to communicate the patient’s needs,” Dr. Aslakson, who wasn’t involved in the new research, told Reuters Health by email. “The critical care community still needs to figure out other ways – such as a clinical or administrative trigger – that can indicate when a patient has high palliative care needs and would likely benefit from a proactive intervention.”
Dr. Aslakson added that the study supports that a “one-stop-shop” mentality focused on clinical or administrative triggers alone has significant inaccuracies and drawbacks.
“As critical-care patients and their family members are increasingly complex and diverse in their medical needs and backgrounds and as we as a critical-care community increasingly strive to provide culturally sensitive and compassionate patient- and family-centered care,” she added, “we will need increasingly nuanced and sensitive means by which to identify which patients and families are most in need and most likely to benefit from proactive palliative care.”
SOURCE: https://bit.ly/3o6RYqV JAMA Network Open, online January 4, 2022.
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