title: Changing end-of-life care practice for liver transplant service patients: structured palliative care intervention in the surgical intensive care unit.
abstract: BACKGROUND
  Patients, families, and surgeons often have high expectations of life-saving surgery following liver transplantation (LT), despite the presence of a severe life-limiting underlying illness. Hence, transition from curative to palliative care is difficult and may create conflicts around goals of care.
  
  
  OBJECTIVE
  We hypothesized that early communication with physicians/families would improve end-of-life care practice in the LT service patients.
  
  
  METHODS
  Prospective, observational, pre/poststudy of consecutive LT service, surgical intensive care unit (SICU) patients, before and after a palliative care intervention was integrated. This included Part I (at admission), family support, prognosis, and patient preferences delineation; and Part II (within 72 hours), interdisciplinary family meeting. Data on goals-of-care discussions, do-not-resuscitate (DNR) orders, withdrawal of life support, and family perceptions were collected.
  
  
  RESULTS
  Seventy-nine LT patients with 21 deaths comprised the baseline group and 104 patients with 31 deaths the intervention group. Eighty-five percent of patients received Part I and 58% Part II of the intervention. Goals-of-care discussions on physician rounds increased from 2% to 38% of patient-days. During the intervention, although mortality rates were unchanged, DNR status increased (52-81%); withdrawal of life support increased (35-68%); DNR was instituted earlier; admission to DNR decreased (mean of 38-19 days); DNR to death time increased (two to four days); and SICU mean length of stay decreased (by three days). Family responses suggested more "time with family"/"time to say goodbye."
  
  
  CONCLUSIONS
  Interdisciplinary communication interventions with physicians and families resulted in earlier consensus around goals of care for dying LT patients. Early integration of palliative care alongside disease-directed curative care can be accomplished in the SICU without change in mortality and has the ability to improve end-of-life care practice in LT patients.
authors: New Jersey Medical School, University of Medicine and Dentistry of New Jersey, University Hospital, Newark, NJ 07103, USA.
authors: Sangeeta
authors: S
authors: Lamba
authors: Patricia
authors: P
authors: Murphy
authors: Susan
authors: S
authors: McVicker
authors: Janet
authors: J
authors: Harris Smith
authors: Anne C
authors: AC
authors: Mosenthal
mesh_terms: D003657:Decision Making; D006801:Humans; D007362:Intensive Care Units; D016031:Liver Transplantation; D008875:Middle Aged; D010166:Palliative Care; D010348:Patient Care Team; D010817:Physician-Patient Relations; D011379:Prognosis; D011446:Prospective Studies; D013727:Terminal Care; D028761:Withholding Treatment