Transitioning the Treatment Paradigm: How Early Palliative Care Service Involvement Affects the End-of-Life Course for Critically Ill Patients in the Neuro-Intensive Care Unit

Abstract

<b><i>Background:</i></b> Involvement of the palliative care service has potential for patient and family benefit in critically ill patients, regardless of etiology. Anecdotally, there is a lack of involvement of the palliative care (PC) service in the neuro-intensive care unit (neuro-ICU), and its impact has not been rigorously investigated in this setting. <b><i>Objective:</i></b> This study aims at assessing the effect of early involvement of the PC service on end-of-life care in the neuro-ICU. <b><i>Design:</i></b> Demographic variables and elements pertaining to the end-of-life care were obtained retrospectively via the electronic medical record from patients receiving their care at the University of Alabama at Birmingham Hospital neuro-ICU. The patient population was divided into two cohorts: patients who received PC services and patients who did not. Contingency analysis was performed to assess for associations with PC service involvement. <b><i>Results:</i></b> A total of 149 patients were included in the study. PC services were included in 56.4% of the cases. Involvement of the PC service led to more code status changes to comfort care-do-not-resuscitate <i>p</i> = 0.0021. This was more often a decremental change to less invasive measures rather than a direct change from full code to comfort care measures (<i>p</i> = 0.026). When PC specialists were involved, medications to treat anxiety/agitation, dyspnea/pain, and respiratory secretions were utilized more frequently (<i>p</i> < 0.001) and fewer procedures were performed on these critically ill patients within 48 hours of death (<i>p</i> < 0.001). <b><i>Conclusion:</i></b> Early involvement of the PC service has an impact on adjusting the treatment paradigm for patients suffering from devastating neurologic injuries. We recommend the creation of a standardized protocol to ensure early PC consultation in the neuro-ICU based on initial patient presentation parameters, imaging characteristics, and prognosis.