Specialist palliative care in different intensive care unit populations: a retrospective longitudinal study

BACKGROUND: Integration of specialist palliative care (PC) in intensive care units (ICUs) is recommended but remains underutilized. Understanding differences among ICU populations (i.e., medical vs. surgical) is crucial to overcome barriers and guide optimized care. METHODS: Retrospective longitudinal analysis of surgical, medical-neurological and COVID-19 ICU patients receiving specialist PC consultations at a tertiary care center between 2018 and 2022. Measures and outcomes included patient characteristics, timing of PC involvement, PC triggers according to ICU and PC teams, multi-dimensional symptom assessments and care trajectories. RESULTS: 518 cases were included, 268 (51.7%) from surgical, 174 (33.6%) from medical-neurological and 76 (14.7%) from COVID-19 ICUs. 39.0% of patients (mean age 67 years, 38.6% female) had cancer, pronounced in the surgical population, while medical ICU patients were older and more often female. The first PC encounter was in median 5 (interquartile range [IQR] 1-14) days after ICU admission with an ICU length of stay of 11 (IQR 5-26) days. ICU mortality was 77.2%, hospital mortality 87.6% with 11.6% of all patients were admitted to PC unit. While ICU teams predominantly saw malignancy, lack of curative treatment options and the need to care for next-of-kin as PC triggers, the PC teams mainly the need to care for next-of-kin and symptom burden. In the surgical ICU, malignancy was more often present as a trigger (maximum standardized mean difference [mSMD]: 0.676), for the medical ICU no curative options (mSMD: 0.256) and cardiopulmonary resuscitation (mSMD: 0.375). Symptom assessment regarding pain (mSMD: 0.676), depressive mood (mSMD: 0.552) and dyspnea (mSMD: 0.468) differed between ICU populations. 28.6% of patients had advance directives (p = 0.16 between ICUs), 48.1% a power of attorney (p = 0.22 between ICUs). CONCLUSIONS: In this pandemic-era cohort, ICU patients receiving specialist PC showed high mortality and symptom burden but differed regarding PC triggers and symptom assessments between ICUs. Further, perceptions of PC triggers and symptoms vary between ICU and PC teams. Future studies in non-pandemic settings are needed to determine the broader applicability of these observations.