Lessons Learned from an Embedded Palliative Care Model in the Medical Intensive Care Unit

Objective: To describe a physician (MD) and registered nurse (RN) led palliative care consultation team embedded in the medical intensive care unit (MICU). To compare patterns of palliative care consultation, and rates of goals of care documentation and in-ICU mortality before and after the implementation of the embedded team. Context: By embedding MD/RN palliative care team in the MICU, more critically ill patients with unmet palliative care needs could receive an earlier palliative care consultation. Methods: In a retrospective cohort study of patients admitted to the MICU who received a palliative care consultation, we compared sociodemographic and clinical characteristics of patients who received a referral-based consultation (01/01/2019-06/30/2019) and those who received an embedded MD/RN consult (09/01/2019-02/28/2020). Using the electronic health record data, we compared palliative care consultation characteristics, rates of documentation of medical decision-maker and goals of care, and percentage of in-ICU mortality between the referral group and the embedded group. Results: In a six-month period, 169 MICU patients received an embedded consultation, as compared to 52 MICU patients who received a referral-based consultation. As compared to the referral-based period, those patients who received an embedded consult were seen significantly earlier in hospitalization (median number of days from hospital admission to consult: 10 days [pre] vs. 3 days [embedded], P<0.001), more likely to have documentation of medical decision-makers (40% [pre] vs. 66% [embedded], P=0.002) and goals of care (37% [pre] vs. 71% [embedded], P<0.001) and less likely to die in the hospital (75% [pre] vs. 44% [embedded], P<0.001). Conclusions: After embedding a palliative care MD/RN team into the MICU, patients received earlier palliative care consultation, were more likely to have medical decision-maker and goals of care documented, and less likely to die in the hospital. Future work will examine how to adapt this model to other ICUs to improve palliative care access for critically ill patients broadly.