Changing the culture around end-of-life care in the trauma intensive care unit.
BACKGROUND
Ten percent to 20% of trauma patients admitted to the intensive care unit (ICU) will die from their injuries. Providing appropriate end-of-life care in this setting is difficult and often late in the patients' course. Patients are young, prognosis uncertain, and conflict common around goals of care. We hypothesized that early, structured communication in the trauma ICU would improve end-of-life care practice.


METHODS
Prospective, observational, prepost study on consecutive trauma patients admitted to the ICU before and after a structured palliative care intervention was integrated into standard ICU care. The program included part I, early (at admission) family bereavement support, assessment of prognosis, and patient preferences, and part II (within 72 hours) interdisciplinary family meeting. Data on goals of care discussions, do-not-resuscitate (DNR) orders and withdrawal of life support (W/D) were collected from physician rounds, family meetings, and medical records.


RESULTS
Eighty-three percent of patients received part I and 69% part II intervention. Discussion of goals of care by physicians on rounds increased from 4% to 36% of patient-days. During intervention, rates of mortality (14%), DNR (43%), and W/D (24%) were unchanged, but DNR orders and W/D were instituted earlier in hospital course. ICU length of stay was decreased in patients who died.


CONCLUSIONS
Structured communication between physician and families resulted in earlier consensus around goals of care for dying trauma patients. Integration of early palliative care alongside aggressive trauma care can be accomplished without change in mortality and has the ability to change the culture of care in the trauma ICU.
Mosenthal
Anne C
AC
Division of Trauma/Critical Care, Department of Surgery, New Jersey Medical School, University of Medicine and Dentistry of New Jersey, Newark, New Jersey, USA. mosentac@umdnj.edu
Murphy
Patricia A
PA
Barker
Lyn K
LK
Lavery
Robert
R
Retano
Angela
A
Livingston
David H
DH
D000293:Adolescent; D000328:Adult; D000368:Aged; D000704:Analysis of Variance; D001291:Attitude of Health Personnel; D003422:Critical Care / Q000592:standards* / Q000639:trends; D016638:Critical Illness / Q000401:mortality / Q000628:therapy; D003657:Decision Making; D005260:Female; D005544:Forecasting; D017052:Hospital Mortality / Q000639:trends; D006801:Humans; D007362:Intensive Care Units / Q000592:standards* / Q000639:trends; D008020:Life Support Care / Q000592:standards* / Q000639:trends; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D010166:Palliative Care / Q000592:standards* / Q000639:trends; D010817:Physician-Patient Relations; D011368:Professional-Family Relations; D011446:Prospective Studies; D016414:Resuscitation Orders; D018570:Risk Assessment; D018709:Statistics, Nonparametric; D016019:Survival Analysis; D014193:Trauma Centers; D014947:Wounds and Injuries / Q000175:diagnosis / Q000401:mortality / Q000628:therapy*