Embedded Palliative Care in the MICU

Impact of an Embedded Palliative Care and Hospice Practitioner in the Medical ICU

The goal of this study is to investigate whether embedding a hospice and palliative care practitioner within a medical intensive care unit will improve patient outcomes and healthcare usage. The practitioner will work solely within the medical intensive care units and offer timely as well as proactive consultations based on clinical criteria and estimated mortality risk. The study team will compare patients seen by the practitioner to patients in an adjacent ICU and historical patients to determine whether patient care is improved by this intervention.

Study Overview

• Status: Recruiting
• Conditions: Quality of Life; Critical Illness; End of Life
• Intervention / Treatment: Other: Embedded Hospice and Palliative Care Practitioner; Other: Embedded Hospice and Palliative Care Practitioner (Group Effect); Other: None (Historical)

Detailed Description

The study goal is to determine whether an embedded palliative care practitioner in the medical ICU improves patient outcomes, palliative care/hospice utilization, and healthcare quality metrics. The medical ICUs included in this study are comprised of two geographically co-located units that provide care for medically complex patients from a large tertiary referral area. Palliative care services are currently available as a consultative service at the ICU clinicians' discretion for patients with palliative needs such as complex goals of care, advanced symptom management, or chronic critical illness. Under the current consultation model, palliative care consultation is requested in a minority of critically ill patients and consults occur on average 5-14 days after a patient's admission. Hospice services are similarly available on a consultative basis for patients that the primary team has determined are suitable for hospice, however, logistical limitations of hospice consultation may lead to delays in inpatient hospice transfers and home hospice discharges.

This study's intervention is to embed a palliative care/hospice practitioner within the medical ICUs as a dedicated palliative care and hospice consultant who will offer proactively triggered palliative care consultations early in a patient's ICU stay as well as immediate availability for standard-of-care palliative care and hospice consultations.

• Study Type: Interventional
• Enrollment (Estimated): 2600
• Phase: Not Applicable

Contacts and Locations

• Study Contact: Name: Stephen Chi, MD; Phone Number: 314-273-6176; Email: chis@wustl.edu

Study Locations

• United States
  • Missouri
    • Saint Louis, Missouri, United States, 63110
      • Recruiting
      • Barnes Jewish Hospital
      • Contact: Stephen Chi, MD; Phone Number: 314-273-6176; Email: chis@wustl.edu
      • Principal Investigator: Stephen Chi, MD

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: Adult; Older Adult
• Accepts Healthy Volunteers: No

Description

Inclusion Criteria:

• Patients admitted to the medical intensive care units at a tertiary referral center
• Patients must be at least 18 years of age

Exclusion Criteria:

• None

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Supportive Care
• Allocation: Randomized
• Interventional Model: Sequential Assignment
• Masking: None (Open Label)

Number of Arms

3

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Experimental: Prospective Hospice and Palliative Care Intervention; This arm comprises patients admitted to the specific medical intensive care unit in which the hospice and palliative care practitioner is currently active. This will include all patients admitted to a single medical intensive care unit during the anticipated first half of the intervention timeframe, followed by all patients admitted to both medical intensive care units during the second half of the intervention timeframe.	Other: Embedded Hospice and Palliative Care Practitioner; The hospice and palliative care practitioner will be embedded in one medical intensive care unit for the first half of the study timeframe, after which the practitioner will expand to both medical intensive care units. While active in a medical intensive care unit, the practitioner will proactively trigger palliative care consultations based on clinical criteria and estimated mortality risk, in addition to providing immediate availability for standard-of-care hospice or palliative care consultations.
Active Comparator: Prospective Standard of Care; This arm comprises patients admitted to the medical intensive care unit in which the hospice and palliative care practitioner is not currently active, but which may experience a group effect due to the study's ongoing enrollment and the practitioner's presence. This will include all patients admitted to a single medical intensive care unit during the anticipated first half of the intervention timeframe, prior to the practitioner becoming active in both intensive care units.	Other: Embedded Hospice and Palliative Care Practitioner (Group Effect); While the hospice and palliative care practitioner is active in one medical intensive care unit with respect to triggering consultations, the other medical intensive care unit can still utilize the practitioner's services for standard-of-care hospice or palliative care consultations.
Placebo Comparator: Historical Controls; This arm comprises historical patients admitted to the medical intensive care units in the year prior to study enrollment.	Other: None (Historical); This control arm includes historical patients admitted to the medical intensive care units prior to the study's enrollment timeframe.

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
ICU Length of Stay	Length of stay in any intensive care unit during the hospitalization	From date of enrollment until hospital discharge, assessed up to 1 year
Code Status De-escalation	Frequency of changes in code status to limited code or comfort measures only	From date of enrollment until hospital discharge, assessed up to 1 year

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Presence of Advance Care Planning Documentation during Current Admission	Documentation of advance directives, limitations in life-sustaining treatments, or code status that is newly created during the active hospital admission	From date of enrollment until hospital discharge, assessed up to 1 year
Hospice Consultation	Frequency of Hospice consultations	From date of enrollment until hospital discharge, assessed up to 1 year
Hospice Enrollment	Frequency of discharge or transition to hospice during or immediately following the hospital stay	From date of enrollment until hospital discharge, assessed up to 1 year
Palliative Care Consultation	Frequency of Palliative Care consultations	From date of enrollment until hospital discharge, assessed up to 1 year
Time to change in code status, advance care planning documentation, palliative care consultation, and hospice consultation	Time in days to the first occurrence of the above outcomes	From date of enrollment until hospital discharge, assessed up to 1 year
Inpatient Hospice Duration	Days while patients are enrolled in inpatient hospice (GIP)	From date of enrollment until hospital or hospice discharge, assessed up to 1 year
Location of discharge disposition	Discharge disposition to home, skilled nursing facility, long term acute care facility, inpatient rehabilitation, etc.	From date of enrollment until hospital discharge, assessed up to 1 year
Hospital Length of Stay	Length of hospital stay in days	From date of enrollment until hospital discharge, assessed up to 1 year
Mortality Index (Vizient)	Mortality index as calculated by Vizient	From date of enrollment until hospital discharge, assessed up to 1 year
Length of Stay Index (Vizient)	Length of stay index as calculated by Vizient	From date of enrollment until hospital discharge, assessed up to 1 year
Operating cost in dollars, including departmental breakdown	Hospital operating cost for each patient, including departmental breakdown such as ICU, pharmacy, procedural, operating room, etc.	Assessed six months following discharge
Mechanical Ventilation Duration	Days on mechanical ventilation	From date of enrollment until hospital discharge, assessed up to 1 year
Vasopressor Utilization	Days on vasopressors	From date of enrollment until hospital discharge, assessed up to 1 year
Hospital Mortality	Inpatient all-cause mortality	From date of enrollment until hospital discharge, assessed up to 1 year
30-Day Mortality	All-cause mortality within 30 days of hospital admission	Assessed 30 days after hospital admission
30-day Emergency Room Visit	Emergency Room encounter in the same healthcare system within 30 days of discharge	Assessed 30 days after hospital discharge
30-day Readmission	Hospital readmission in the same healthcare system within 30 days of discharge	Assessed 30 days after hospital discharge

Collaborators and Investigators

• Sponsor: Washington University School of Medicine
• Investigators: Principal Investigator: Stephen Chi, MD, Washington University School of Medicine

Publications and helpful links

General Publications

• Ma J, Chi S, Buettner B, Pollard K, Muir M, Kolekar C, Al-Hammadi N, Chen L, Kollef M, Dans M. Early Palliative Care Consultation in the Medical ICU: A Cluster Randomized Crossover Trial. Crit Care Med. 2019 Dec;47(12):1707-1715. doi: 10.1097/CCM.0000000000004016.
• Aslakson R, Cheng J, Vollenweider D, Galusca D, Smith TJ, Pronovost PJ. Evidence-based palliative care in the intensive care unit: a systematic review of interventions. J Palliat Med. 2014 Feb;17(2):219-35. doi: 10.1089/jpm.2013.0409.
• Khandelwal N, Kross EK, Engelberg RA, Coe NB, Long AC, Curtis JR. Estimating the effect of palliative care interventions and advance care planning on ICU utilization: a systematic review. Crit Care Med. 2015 May;43(5):1102-11. doi: 10.1097/CCM.0000000000000852.
• Kyeremanteng K, Gagnon LP, Thavorn K, Heyland D, D'Egidio G. The Impact of Palliative Care Consultation in the ICU on Length of Stay: A Systematic Review and Cost Evaluation. J Intensive Care Med. 2018 Jun;33(6):346-353. doi: 10.1177/0885066616664329. Epub 2016 Aug 31.
• Braus N, Campbell TC, Kwekkeboom KL, Ferguson S, Harvey C, Krupp AE, Lohmeier T, Repplinger MD, Westergaard RP, Jacobs EA, Roberts KF, Ehlenbach WJ. Prospective study of a proactive palliative care rounding intervention in a medical ICU. Intensive Care Med. 2016 Jan;42(1):54-62. doi: 10.1007/s00134-015-4098-1. Epub 2015 Nov 10.
• Helgeson SA, Burnside RC, Robinson MT, Mack RC, Ball CT, Guru PK, Moss JE. Early Versus Usual Palliative Care Consultation in the Intensive Care Unit. Am J Hosp Palliat Care. 2023 May;40(5):544-551. doi: 10.1177/10499091221115732. Epub 2022 Jul 14.
• Chi S, Kim S, Reuter M, Ponzillo K, Oliver DP, Foraker R, Heard K, Liu J, Pitzer K, White P, Moore N. Advanced Care Planning for Hospitalized Patients Following Clinician Notification of Patient Mortality by a Machine Learning Algorithm. JAMA Netw Open. 2023 Apr 3;6(4):e238795. doi: 10.1001/jamanetworkopen.2023.8795.

Study record dates

Study Major Dates

• Study Start (Actual): July 29, 2024
• Primary Completion (Estimated): June 1, 2026
• Study Completion (Estimated): June 1, 2027

Study Registration Dates

• First Submitted: August 21, 2024
• First Submitted That Met QC Criteria: August 23, 2024
• First Posted (Actual): August 28, 2024

Study Record Updates

• Last Update Posted (Actual): July 16, 2025
• Last Update Submitted That Met QC Criteria: July 14, 2025
• Last Verified: July 1, 2025

More Information

Terms related to this study

• Keywords: Palliative Care; Hospice; Medical ICU
• Additional Relevant MeSH Terms: Pathologic Processes; Disease Attributes; Critical Illness; Death
• Other Study ID Numbers: 202406143

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: NO

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No