Proactive palliative care in the medical intensive care unit: Effects on length of stay for selected high-risk patients Sally A. Norton, PhD, RN; Laura A. Hogan, MS, RN, ACHPN; Robert G. Holloway, MD, MPH; Helena Temkin-Greener, PhD, MPH; Marcia J. Buckley, MS, RN, BC-PCM; Timothy E. Quill, MD I npatient palliative care (PC) ser- vices are growing rapidly across academic healthcare centers in the United States (1). This growth has been triggered in part by an extensive body of research that documents difficul- ties in providing adequate pain and symp- tom management as well as inconsistent communication and decision making for hospitalized persons with serious and/or life-threatening illness (2–12). Historically, PC was initially most strongly associated with end-of-life care. PC providers have tended to see patients very late in their illness trajectories, often only after all possible life-prolonging in- terventions have been tried to no avail and there is “nothing else left to do.” However, there is a national movement to consult on patients earlier, while they continue to pursue life-prolonging inter- ventions. The argument is that PC is po- tentially relevant to all seriously ill pa- tients who might be experiencing symptoms that could be better treated, who may have support needs, or who may need assistance with goal clarification and complex medical decision making. The argument is especially compelling in intensive care units (ICUs), where the sickest patients are treated and where ap- proximately 20% of U.S. deaths occur each year (13). These deaths occur most often after shifts in patients’ care goals and decisions to withdraw life-sustaining treatment (14). There is a growing body of literature describing innovative ap- proaches to and endorsements of the in- tegration of palliative and intensive care (15–21). However, PC providers have been urged to identify measurable out- comes of such changes in care delivery, and more research is needed (22–26). Although most PC research has focused on improved symptom management and more informed decision making, a few re- searchers have examined the financial out- comes, defined by such factors as length of stay, of PC delivered within a hospital set- ting (27–29). Examining a select group of patients in an adult medical intensive care unit (MICU), Campbell and Guzman (27) found that PC nurse practitioner case- finding and early PC intervention in pa- tients with multiple-organ system failure and global cerebral ischemia were associ- ated with substantial institutional cost sav- ings generated through decreased length of stay in ICU and avoidance of often costly, nonbeneficial treatments. In another study, these same authors found that proactive PC case-finding and early PC approach for MICU patients with terminal dementia were associated with shorter hospital and ICU lengths of stay (29). From the School of Nursing (SN), Center for Ethics, Humanities, and Palliative Care (LH, RH, MB, TQ), and the Departments of Community and Preventive Medi- cine (RH, HTG) and Neurology (RH), University of Roch- ester Medical Center, Rochester, NY. Supported, in part, by the Fraser-Parker Founda- tion, Atlanta, GA. The authors have not disclosed any potential con- flicts of interest. For information regarding this article, E-mail: Sally_Norton@urmc.rochester.edu Copyright © 2007 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins DOI: 10.1097/01.CCM.0000266533.06543.0C Objective: The purpose of this study was to examine the effect of proactive palliative care consultation on length of stay for high-risk patients in the medical intensive care unit (MICU). Design: A prospective pre/post nonequivalent control group design was used for this performance improvement study. Setting: Seventeen-bed adult MICU. Patients: Of admissions to the MICU, 191 patients were iden- tified as having a serious illness and at high risk of dying: 65 patients in the usual care phase and 126 patients in the proactive palliative care phase. To be included in the sample, a patient had to meet one of the following criteria: a) intensive care admission following a current hospital stay of >10 days; b) age >80 yrs in the presence of two or more life-threatening comorbidities (e.g., end-stage renal disease, severe congestive heart failure); c) di- agnosis of an active stage IV malignancy; d) status post cardiac arrest; or e) diagnosis of an intracerebral hemorrhage requiring mechanical ventilation. Interventions: Palliative care consultations. Measurements and Main Results: Primary measures were pa- tient lengths of stay a) for the entire hospitalization; b) in the MICU; and c) from MICU admission to hospital discharge. Sec- ondary measures included mortality rates and discharge dispo- sition. There were no significant differences between the usual care and proactive palliative care intervention groups in respect to age, gender, race, screening criteria, discharge disposition, or mortality. Patients in the proactive palliative care group had significantly shorter lengths of stay in the MICU (8.96 vs. 16.28 days, p  .0001). There were no differences between the two groups on total length of stay in the hospital or length of stay from MICU admission to hospital discharge. Conclusions: Proactive palliative care consultation was associ- ated with a significantly shorter MICU length of stay in this high-risk group without any significant differences in mortality rates or dis- charge disposition. (Crit Care Med 2007; 35:1530–1535) KEY WORDS: palliative care; critical care; intensive care unit; length of stay; terminal care; patient care 1530 Crit Care Med 2007 Vol. 35, No. 6