By GSN Staff

SAN DIEGO—To assist decision-making processes and increase awareness of palliative care in the surgical ICU (SICU), researchers developed a screening tool to identify—within seconds—patients who may benefit from palliative care consultations or discussions of goals of care. 

As a general and trauma surgeon, Trista Day Snyder Reid, MD, also an assistant professor of surgery at the University of North Carolina (UNC) at Chapel Hill, and the study’s medical advisor, explained that she often witnesses medical teams and families make agonizing decisions for patients in the SICU. 

“One of the things that we found at our institution was sometimes we would involve palliative care, but it would happen way down the line when the patient had been in the SICU for a long time already,” Dr. Reid said. “We want palliative care discussions to be happening sooner. And even if we’re not involving palliative care, we want goals of care discussions to happen early so the family has a rapport with the medical team and understands that their family member is really sick.”

Across hospital systems, screening criteria and access to palliative care vary. Research has shown that offering palliative care consultations early in an ICU stay can improve the patient’s quality of life and even reduce the length of stay there (J Am Coll Surg 2022;235[2]:278-284). However, integrating palliative care into hospital systems remains challenging due to a lack of resources and insufficient training, among other factors (Crit Care Med 2014;42[11]:2418).

Study Details

The researchers initially developed a screening tool with 12 questions with responses of yes or no, with input from SICU and palliative care physicians, nurses, and advanced practice providers. Fourth-year medical students at UNC at Chapel Hill completed the questionnaire after receiving feedback from the SICU medical team. Any question with a response of yes was deemed a positive indicator that the patient would benefit from a palliative care consultation with a specialist or a discussion of goals of care with the surgical team.

Three iterations of the screening tool were developed using the Plan-Do-Study-Act method before selecting three questions that the researchers found correlated best with a positive indicator:
     • any team member expresses concern that the patient may need palliative care; 
     • the ICU or surgical team answers ”no” to the question: Would you be surprised if this patient died? and 
     • comorbidities: irreversible, progressive or untreatable, severely impairing function.
If yes was the response to any of the three checklist questions, the researchers concluded the patient would likely benefit from a palliative care consultation or discussion of goals of care.

Key Findings

The findings were presented at the American College of Surgeons 2022 Clinical Congress. 
     • Screening tool use with 282 patients in the SICU was recorded.
     • Of those patients, the screening tool successfully identified 22 patients, all of whom eventually received referrals for palliative care.
     • Each patient could be screened in about three seconds, and all patients in the SICU could be screened in about 30 seconds.
     • The screening tool did not increase the workload of the palliative care team at UNC Health.

“The hope is that by using this screening tool, decisions traditionally made very late in the patient’s SICU stay could be made much earlier,” said lead author Victoria Herdman, MD. Dr. Herdman was a fourth-year UNC at Chapel Hill medical student at the time of the study and now is completing her residency in cardiothoracic surgery at the University of Kentucky College of Medicine, in Lexington. “Physicians, physician assistants, nurse practitioners and nurses know early on who needs palliative care, but sometimes that’s hard to jump into early in the stay. This screening tool is a way to guide everyone into it easier.”

Although the research was conducted at a single site, the team hopes to evaluate the tool in other ICU populations at UNC Health using a quality improvement process, possibly using an electronic health record system or implementing it during daily rounds discussions with only one question. 

“I think as surgeons we tend to have a lot of ownership of our patients because they’re trusting us with their bodies, but I think that may also bias us a little bit in terms of palliative care. We hear the words ‘palliative care’ and may say, ‘Oh, no, no, no! We don’t want that. That’s like giving up on our patient,’” Dr. Reid said. “But the truth is, I think a lot of surgeons don’t truly understand the definition of palliative care—that the goal is to align what the patient wants with your treatments.”

The study was supported by the UNC Institute for Healthcare Quality Improvement. Study co-authors are Casey Olm-Shipman, MD, MS, Winnie Lau, MD, Kyle Lavin, MD, Marshall W. Fritz, BS, and Geoffrey Orme-Evans, JD, MPH.

The story is based on a press release.