A new screening tool can be used to identify patients who could benefit from palliative care advice

A new screening tool can be used to identify patients who could benefit from palliative care advice

To support decision-making and increase awareness of palliative care in the surgical intensive care unit (SICU), a research team at the University of North Carolina at Chapel Hill (UNC-Chapel Hill) has developed a screening tool to identify: within seconds - patients who could benefit from palliative care consultations or conversations about goals of care. Their research, presented at the Scientific Forum during the 2022 American College of Surgeons (ACS) Clinical Congress, shows that the screening tool successfully identified SICU patients who were later identified by their medical team as candidates for palliative care.

As a general and trauma surgeon, Trista Day Snyder Reid, MD, MPH, FACS, assistant professor of surgery at UNC Health and medical advisor to the study, explained that she often witnesses medical teams and families make agonizing decisions for patients in the intensive care unit. When aggressive medical interventions fail to improve outcomes or prolong life, palliative care that focuses on symptom management and supportive communication can improve a patient's quality of life. Unfortunately, a medical team may be reluctant to collaboratively identify appropriate patients or refer patients for palliative care late in their ICU stay, increasing burden and stress on the patient and their families.

One of the things we found in our facility was that sometimes we used palliative care, but that only happened later, when the patient had been in the ICU for a long time. We want discussions about palliative care to happen earlier. And even if we don’t deal with palliative care, we want conversations about goals of care to happen early so that the family has a good connection with the medical team and understands that their family member is truly sick.”

Dr. Trista Day Snyder Reid, MD, MPH, FACS, assistant professor of surgery at UNC Health

Screening criteria and access to palliative care vary across hospital systems. Research has shown that providing palliative care consultations early in an ICU stay can improve quality of life and even shorten the length of ICU stay. However, integrating palliative care into hospital systems remains a challenge due to, among other things, a lack of resources and inadequate training.

Study details

The UNC researchers first developed a screening tool with 12 “yes/no” questions with input from critical care and palliative care physicians, nurses and advanced practice providers. Fourth-year medical students at UNC-Chapel Hill completed the questionnaire after receiving feedback from the SICU medical team. Any question to which the team responded “yes” was considered a positive indicator that the patient would benefit from palliative care consultation with a specialist or discussion of treatment goals with the surgical team.

Three iterations of the screening tool were developed using the Plan-Do-Study-Act (PDSA) method before selecting three questions that the researchers believed best correlated with a positive indicator:

1. Each team member (nurse, doctor, pharmacist, etc.) expresses concern that the patient may need palliative care.

2. The answer to the question in the intensive care unit or surgical team is “no”: “Would you be surprised if this patient died?”

3. Comorbidities: irreversible, progressive or untreatable, severely impairing function.

If any of the three questions on the checklist were answered "yes," the researchers considered that the patient would likely benefit from palliative care counseling or a discussion about the goals of care.

Key findings

• Screening instruments were collected from 282 patients in the intensive care unit.

• Of these 282 patients, the screening tool successfully identified 22 patients, all of whom ultimately received a referral for palliative care.

• Each patient could be examined in about three seconds; All patients in the intensive care unit could be examined in about 30 seconds.

• The tool did not increase the burden on the palliative care team at UNC Health.

"The hope is that by using this screening tool, decisions that are traditionally made very late in the patient's ICU stay can be made much earlier," said lead author Dr. Victoria Herdman. Dr. Herdman was a fourth-year medical student at UNC-Chapel Hill at the time of the study and is currently completing her residency in cardiothoracic surgery at the University of Kentucky College of Medicine. "Doctors, physician assistants, nurse practitioners and nurse practitioners know early on who needs palliative care, but sometimes it's difficult to get started early in the stay. This screening tool is a way to make it easier for everyone to get treatment."

The research was conducted at a single site, but the team hopes to evaluate the tool through a quality improvement process in other critical care populations at UNC Health, perhaps using an electronic medical record system or by implementing it in daily single-question discussion boards. The study team also plans future research to analyze patient demographics to determine which marginalized populations are often excluded from discussions about palliative care. They said simply talking about palliative care more often and educating team members and families could make a difference.

"I think as surgeons we tend to take a lot of responsibility for our patients because they trust us with their bodies. But I think that also makes us a little biased when it comes to palliative care. We hear the words 'palliative care'." ' and might say, 'Oh, no, no, no! We don't want that. It's like giving up on our patient,'" Dr. Reid said. "But the truth is that I think many surgeons don't really understand the definition of palliative care - that the goal is to balance the patient's wishes with your treatments. Our long-term hope is to stimulate discussions about palliative care." “To make it commonplace and change the culture so that people feel comfortable seeking palliative care or at least having a discussion about the goals of care so that patients and their families understand all possible treatment options.”

The study was supported by the UNC Institute for Healthcare Quality Improvement.

Study co-authors are Casey Olm-Shipman, MD, MS; Winnie Lau, MD; Kyle Lavin, MD; Marshall W. Fritz, BS; and Geoffrey Orme-Evans, JD, MPH.

Source:

American College of Surgeons

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