Background for Fast Fact #253     The intensive care unit (ICU) is principally designed to address life-threatening illnesses and extend life if possible.  However, risks of mortality and severe morbidity remain high in the ICU and virtually all ICU patients have palliative care (PC) needs.  Integration of PC services into ICU care can improve clinical care (1,10).  This Fast Fact reviews the role of PC consultations in the ICU along with options for more generalist PC services provided by ICU clinicians.

What occurs in an ICU palliative care (PC) consultation 

• Assess/treat distressing physical, psychological, and spiritual symptoms/problems. 
• Assess decision-making capacity and identify appropriate surrogate decision makers.
• Communicate information about prognosis and treatment options to patient/family in concert with ICU, primary care and subspecialty colleagues.
• Establish/clarify care goals of care (e.g., life prolongation, comfort, rehabilitation) that are realistic and appropriate in relation to the patient’s condition, values, preferences.
• Help to match treatments to these established goals.
• Formulate a transition care plan that accounts for prognosis, goals of care, and patient/family needs.
• Provide support for the patient and families as they cope with serious illness.
• Support the ICU medical team in making clinically, ethically, and emotionally challenging decisions.

Research data on benefits of PC consultation in the ICU 

• Early identification of a dying trajectory leading to decreased time to institution of patient- and family-centered, comfort-focused treatment goals (2-3).
• Appropriate patients are moved to lower intensity care sites (e.g., ward, home hospice, PC unit) (5-6).
• Reduction in ICU length of stay (2-4, 7).
• Reduction in the cost of care, without an increase in mortality, due to early establishment of realistic treatment goals leading to reduction in use of high-cost ICU resources/interventions (2-4, 7-9).
• Support for ICU staff in emotionally challenging/morally distressing care situations.
• Reduction in future ICU admissions through establishment of more realistic treatment goals (7-8).
• Continuity of care when the patient transitions from the ICU to medical ward.

ICU/PC collaboration   A range of options exist for integrating palliative care services into the ICU.  At one extreme, ICU staff consult a palliative care specialist team for consultative advice on an ad hoc basis.  At the other extreme, the ICU embeds systems in place to provide ICU-led generalist palliative care services to all ICU patients, utilizing palliative care specialists for complex problems.  Embedding systems that ensure the needs of all patients are met includes screening all patients on admission and daily for unmet palliative care needs, early identification of a surrogate, timely symptom management, and a scheduled family meeting within 72 hours of ICU admission and routinely afterword to discuss goals of care (1,10-12). Quality outcomes related to patient and family experience and to health care utilization should be tracked within the framework of available resources (1,13).

When to use specialist PC services    Consultations can be initiated on a case-by-case basis by ICU (or other primary) clinicians or triggered proactively using a system to identify patients at risk for unmet PC needs (2-4). Early PC involvement, meaning a PC consultation performed within 24-48 hours of ICU admission, has been associated with improved care satisfaction, reduced ICU length of stay, and greater use of do-not-resuscitate orders and hospice care transitions (14,15). Indications for consultation include: 

• Difficult-to-control physical symptoms despite usual treatment approaches.
• Patients/surrogates wish to explore non-ICU supportive care options such as hospice services.
• Staff is questioning the appropriateness of life-sustaining therapies in the setting of serious illness.
• Complex family dynamics impacting decisions about use of life-sustaining treatments.
• Disagreements among staff or between staff and patients/surrogates about prognosis and/or use of life-sustaining treatments.
• Frequent ICU admissions.

Summary     Specialist PC consultations, together with integration of PC principles into the care of all ICU patients, can improve the patient/family experience, reduce length of stay and improve ICU throughput without increasing mortality.

References 

1. Nelson JE, Mulkerin CM, Adams LL, Pronovost PJ. Improving comfort and communication in the ICU: a practical new tool for palliative care performance measurement and feedback. Qual Saf Health Care. 2006; 15(4):264-271. 
2. Campbell ML, Guzman JA. Impact of a proactive approach to improve end-of-life care in a medical ICU. Chest. 2003; 123(1):266-271. 
3. Campbell ML, Guzman JA. A proactive approach to improve end-of-life care in a medical intensive care unit for patients with terminal dementia. Crit Care Med. 2004; 32(9):1839-1843.
4. Norton SA, Hogan LA, Holloway RG, Temkin-Greener H, Buckley MJ, Quill TE. Proactive palliative care in the medical intensive care unit: effects on length of stay for selected high-risk patients. Crit Care Med. 2007; 35(6):1530-1535.
5. Carlson RW, Devich L, Frank RR. Development of a comprehensive supportive care team for the hopelessly ill on a university medical service. JAMA. 1988; 259(3):378-383.
6. Smith TJ, Coyne P, Cassel B, Penberthy L, Hopson A, Hager MA. A high-volume specialist palliative care unit and team may reduce in-hospital end-of-life care costs. J Palliat Med. 2003; 6(5):699-705.
7. Morrison RS, Dietrich J, Ladwig S, et al. Palliative care consultation teams cut hospital costs for Medicaid beneficiaries. Health Aff (Millwood). 2011; 30(3):454-463.
8. Penrod JD, Deb P, Luhrs C, et al. Cost and utilization outcomes of patients receiving hospital-based palliative care consultation. J Palliat Med. 2006; 9(4):855-860.
9. Kyeremanteng  K, Gagnon L-P, Thavorn K, et al.  The impact of palliative care consultation in the ICU on length of stay: a systematic review and cost evaluation. Journal of Intensive Care Medicine 2016; 33(6):346-353.
10. Weissman DE, Meier DE. Identifying patients in need of palliative care assessment in the hospital setting: consensus recommendations. J Palliat Med. 2011; 14(1):1-7.
11. Nelson JE, Bassett R, Boss RD, et al. Models for structuring a clinical initiative to enhance palliative care in the intensive care unit: a report from the IPAL-ICU Project (Improving Palliative Care in the ICU). Crit Care Med. 2010; 38(9):1765-1772.
12. Davidson J, Aslakson RA, Long AC, et al.  Guidelines for family-centered care in the neonatal, pediatric, and adult ICU. Critical Care Medicine 2017; 45(1):103-128.
13. Nelson JE, Brasel KJ, Campbell ML, et al. Evaluation of ICU Palliative Care Quality: A technical assistance monograph from the IPAL-ICU Project.
14. Helgeson SA, Burnside RC, Moss JE. Early versus usual palliative care consultation in the intensive care unit.  American Journal of Hospice and Palliative Medicine 2022; 40(5):544-51.
15. Ma J, Shi S, Buettner B, et al.  Early palliative care in the medical ICU: a cluster randomized crossover trial. Critical Care Medicine 2019; 47(12):1707-15. 

Authors’ Affiliations: College of Nursing, Wayne State University, Detroit, MI (MLC); Medical College of Wisconsin, Milwaukee, WI (DEW); Mount Sinai School of Medicine, New York, NY (JEN). 
Version History: Originally published April 2012; reviewed and updated in August 2015; reviewed and updated again in April 2024 by Sean Marks MD.