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Multidisciplinary Palliative Care Team at Johns Hopkins Achieves Reduction in ICU Utilization, Cost

January 2013, Vol 4, No 1

San Diego, CA—A multidisciplinary team approach for discussing end-of-life issues with patients reduces the use of the intensive care unit (ICU) without shortening survival time, researchers from the Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins University said at ASCO’s inaugural 2012 Quality Care Symposium.

Multidisciplinary Support in End-of-Life Decisions

“Advanced life support and intensive care resources are essential for the optimal care of patients undergoing aggressive treatment with curative intent, but they are much less likely to help terminally ill patients. In fact, they may actually interfere with other important unfinished business for these individuals,” said lead investigator Allen Ray Sing Chen, MD, PhD, MHS, Director of Pediatric Bone Marrow Transplantation at Johns Hopkins. “We wondered if we could help patients and their families make difficult decisions about the level of care they would receive.”

The Pain and Palliative Care Pro­gram at Johns Hopkins was established in 2007 as a consultative service for patients with cancer who are receiving active treatment. The multidisciplinary team, which was initially comprised of 2 nurses, a social worker, a palliative care physician, a pharmacist, a nutritionist, and a chaplain, now provides comprehensive services, including symptom control and emotional support for patients before, during, and after hospitalization.

“The team regularly reviews pa­tient cases and discusses strategies for helping patients navigate these difficult decisions,” Dr Chen said.

“One of our goals in establishing the team was to help our physicians improve at discussing end-of-life issues with patients. We hypothesized that if this effort was effective, we might see less utilization of ICU management among patients who die in the center,” he explained.

Dr Chen and his colleagues ob­served 4-year trends in care for 525 patients who died while hospitalized at the cancer center between 2008 and 2011. All deaths were tabulated, and the patients’ code statuses were displayed at the morbidity and mortality review twice per quarter. ICU utilization (ie, ventilator or dialysis support) was identified from the billing data and confirmed by chart review. The survival of ICU patients to discharge from the hospital was tracked on the safety dashboard—a spreadsheet that allows for monitoring of the most important measures of healthcare quality and issues alerts of major hazards in real time.

More Patients Accepting Palliative Care

“We found that of the patients who died while hospitalized, the proportion who elected a change in code status, comfort care, or withdrawal of ICU support gradually and steadily climbed over the 4-year interval. The evolution was highly statistically significant (P  <.001),” Dr Chen said.

The percentage of patients choosing “do not resuscitate” status rose from approximately 70% to nearly 100% (P <.001) by the end of the study period.

The proportion who received ICU care during their final hospitalization did not change; however, their stays were shorter, and the percentage of patients who had received prolonged ventilation (>14 days) dropped from 11% to 4% (P <.05), Dr Chen said.

The authors concluded that a comprehensive approach to palliative care, with regular feedback for providers, reduced ICU utilization during the cancer patients’ terminal hospitalizations. More patients chose to avoid resuscitation, and fewer died after prolonged ventilation—all without a decrement in survival.

The investigators plan to calculate the cost-savings of their approach. “There is no doubt that ICU management is among the most expensive care that we can provide, and the figures run several thousands of dollars a day,” Dr Chen noted.

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