One in 5 US citizens will die having spent some time in the intensive care unit (ICU), many of whom will be older adults. These individuals who do not survive hospitalization, particularly those receiving mechanical ventilation (MV) are at risk for poor outcomes related to end-of-life (EOL) care;these include unrelieved pain, ICU-acquired pressure ulcers, heavy sedation and physical restraint use. These outcomes are inconsistent with established goals of EOL care and reflect the quality of dying experienced by this population. Improving EOL care remains a challenge and has been identified by the IOM, NINR and others as an area for concentrated research efforts to bring about improvements in patient outcomes. Little research to date has been focused on the patient experience at EOL and on outcomes related to care that is implemented and regulated by nurses. Research has shown that palliative care consultation can improve EOL care, but implementation in the ICU is inconsistent and proxy measures are commonly employed. The purpose of this expanded secondary analysis is to provide insight into the quality of dying in the ICU among patients at EOL who experience sustained periods of wakefulness prior to death in order to inform future studies designed to improve EOL care.
The specific aims are to: 1) describe patient outcomes (unrelieved pain, ICU-acquired pressure ulcers, heavy sedation and days in restraint) among sample patients who were at EOL (decedents and/or those at high risk of dying);2) identify patient-level predictors of these patient outcomes;and 3.) explore the relationship between presence, timing and duration of palliative care (PC) service consultations and these patient outcomes among sample patients at EOL (decedents and/or those at high risk of dying). This proposed project is an expanded secondary analysis, using a retrospective observational cohort design, of clinically-detailed data drawn from the electronic medical record of 1440 patients who underwent MV in the ICU and had at least one shift of sustained wakefulness. The sample was drawn from 6 ICUs in 2 hospitals between August 2009 and July 2011. Additional data will be collected on palliative care consultations among decedents and those at high risk of dying. This project will result in an increased understanding of the EOL experience of MV older adults in relation to a framework for quality of dying in ICU. These findings will guide the development of assessment tools and interventions designed to test and ultimately improve EOL care. This work will form the foundation for building a program of research centered on the improvement of EOL care for this population.
Improving patient outcomes at end-of-life (EOL) remains a clinical and ethical challenge, particularly among older adults receiving mechanical ventilation. The purpose of this study is to better understand, using a patient centered approach, quality of dying in the ICU;to identify predictors of poor patient outcomes at EOL and to explore the impact of palliative care consultation on outcomes. Knowledge gained from this study will assist in the development of targeted interventions to improve EOL care for ICU patients, particularly older adults.