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J Pain Symptom Manage. 2012 Oct;44(4):508-19. doi: 10.1016/j.jpainsymman.2011.10.018. Epub 2012 Jul 4.

Changing end-of-life care practice for liver transplant service patients: structured palliative care intervention in the surgical intensive care unit.

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1
New Jersey Medical School, University of Medicine and Dentistry of New Jersey, University Hospital, Newark, NJ 07103, USA.

Abstract

CONTEXT:

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.

OBJECTIVES:

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."

CONCLUSION:

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.

[Indexed for MEDLINE]

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