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Palliative Care in the Cardiac Intensive Care Unit

Published:December 17, 2014DOI:https://doi.org/10.1016/j.amjcard.2014.12.023
      Patients admitted to today's cardiac intensive care units (CICUs) have increasingly complex medical conditions; consequently, palliative care is becoming an integral component of their care. Although there is a robust body of literature emanating from other intensive care unit settings, there has been less discussion about the role of palliative care in the CICU. This study examined all admissions to the Mount Sinai Hospital CICU from January 1 through December 31, 2012. Of the 1,368 patients admitted, there were 117 CICU patient deaths. End-of-life discussions were carried out in 85 patients (72.6%) who died during that hospital admission; the primary CICU team led these discussions and helped with decision making in >1/2 of them. For the 85 patients who had goals of care (GOC) discussions, there was a higher rate of redirected GOC toward comfort care or no escalation of care (38.8% vs 3.1%, p <0.001) and withdrawal of life-sustaining treatments, such as mechanical ventilation and vasopressors (23.5% vs 6.3%, p = 0.02) compared with patients for whom no GOC discussions were held. Among patients who had GOC discussions, there was no statistically significant difference for patients who had their mechanical circulatory support, defibrillator, or pacing therapies turned off compared with patients who were not involved in GOC discussions. With the exception of discontinuation of mechanical circulatory support which took place for 6 of the 7 patients in the CICU, end-of-life interventions were split evenly between the palliative care unit and the CICU. There was no difference in CICU length of stay or days to mortality from the time of CICU admission between the 2 groups. In conclusion, our study demonstrates the effect of palliative care and end-of-life decision making in the CICU. As such, we advocate for increased palliative care education and training among clinicians who are involved in cardiac critical care.
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      References

        • Hollenberg S.M.
        Intensive coronary care.
        Crit Care Med. 2010; 38: 685-686
        • Katz J.N.
        • Shah B.R.
        • Volz E.M.
        • Horton J.R.
        • Shaw L.K.
        • Newby L.K.
        • Granger C.B.
        • Mark D.B.
        • Califf R.M.
        • Becker R.C.
        Evolution of the coronary care unit: clinical characteristics and temporal trends in healthcare delivery and outcomes.
        Crit Care Med. 2010; 38: 375-381
        • Curtis J.R.
        • Rubenfeld G.D.
        Improving palliative care for patients in the intensive care unit.
        J Palliat Med. 2005; 8: 840-854
        • Morrow D.A.
        • Fang J.C.
        • Fintel D.J.
        • Granger C.B.
        • Katz J.N.
        • Kushner F.G.
        • Kuvin J.T.
        • Lopez-Sendon J.
        • McAreavey D.
        • Nallamothu B.
        • Page 2nd, R.L.
        • Parrillo J.E.
        • Peterson P.N.
        • Winkelman C.
        • American Heart Association Council on Cardiopulmonary, Critical Care, Perioperative and Resuscitation, Council on Clinical Cardiology, Council on Cardiovascular Nursing, and Council on Quality of Care and Outcomes Research
        Evolution of critical care cardiology: transformation of the cardiovascular intensive care unit and the emerging need for new medical staffing and training models: a scientific statement from the American Heart Association.
        Circulation. 2012; 126: 1408-1428
        • Kaldjian L.C.
        • Curtis A.E.
        • Shinkunas L.A.
        • Cannon K.T.
        Review article: goals of care toward the end of life: a structured literature review.
        Am J Hosp Palliat Med. 2009; 25: 501-511
      1. The IPAL-ICU Project. Available at: http://www.capc.org/ipal-icu. Accessed on December 2, 2014.

        • Nelson J.E.
        • Curtis J.R.
        • Mulkerin C.
        • Campbell M.
        • Lustbader D.R.
        • Mosenthal A.C.
        • Puntillo K.
        • Ray D.E.
        • Bassett R.
        • Boss R.D.
        • Brasel K.J.
        • Frontera J.A.
        • Hays R.M.
        • Weissman D.E.
        Choosing and using screening criteria for palliative care consultation in the ICU: a report from the Improving Palliative Care in the ICU (IPAL-ICU) Advisory Board.
        Crit Care Med. 2013; 41: 2318-2327
        • Nelson J.E.
        • Bassett R.
        • Boss R.D.
        • Brasel K.J.
        • Campbell M.L.
        • Cortez T.B.
        • Curtis J.R.
        • Lustbander D.R.
        • Mulkerin C.
        • Puntillo K.A.
        • Ray D.E.
        • Weissman D.E.
        Models for structuring a clinical initiative to enhance palliative care in the intensive care unit: a report from the IPAL-ICU Project (Improving Palliative Care in the ICU).
        Crit Care Med. 2010; 38: 1765-1772
        • Nelson J.E.
        • Campbell M.L.
        • Cortez T.B.
        • Curtis J.R.
        • Lustbader D.R.
        • Mosenthal A.C.
        • Mulkerin C.
        • Puntillo K.A.
        • Ray D.E.
        • Bassett R.
        • Boss R.D.
        • Brasel K.J.
        • Weissman D.E.
        Organizing an ICU Palliative Care Initiative: A Technical Assistance Monograph from the IPAL-ICU Project.
        Center to Advance Palliative Care, New York2010 (Available at:) (Accessed on December 2, 2014)
        • Swetz K.M.
        • Mansel J.K.
        Ethical issues and palliative care in the cardiovascular intensive care unit.
        Cardiol Clin. 2013; 31: 657-668
        • Campbell M.L.
        • Guzman J.A.
        A proactive approach to improve end-of-life care in a medical intensive care unit for patients with terminal dementia.
        Crit Care Med. 2004; 32: 1839-1843