Integrated palliative care (PC) is recommended for all cancer patients. It improves patient experience and communication, reduces symptom burden and futile medical interventions, and shortens length of hospital stay. Despite the mortality of 27-43% for cancer patients admitted to intensive care (ICU), early PC involvement has not been widely adopted. Previous studies have shown the potential for using specific “trigger” criteria to identify ICU patients for early PC referral. We show the benefits of using a novel trigger tool in practice at the time of admission to ICU in a specialist cancer hospital.
We developed a novel electronic tool, combining criteria outlined by Hua et al. (2016) with a locally-developed triggers checklist already used in the outpatient setting. This tool was integrated into the ICU clerking proforma. Patients meeting any of the tool’s criteria were referred to the PC team who provided early advice for symptom control and advanced care planning. Quality improvement methodology was used between February 2020 and January 2021 as we embedded this tool into clinical practice.
In a timeline disrupted by two waves of COVID-19, there were 151 admissions of which 74 (49%) had a triggers form completed. Sixty-six cases (89%) were positive (≥1 criterion), leading to 16 (24%) referrals to palliative care. This represented 46% of all PC referrals made from ICU during this period. We show that many patients admitted to ICU have a poor functional baseline (47% had metastatic cancer progressing despite 1st line chemotherapy, 49% had an ECOG score ≥2). Many patients also had severe or uncontrolled symptoms (52%). Early palliative care provided vital input for those patients.
Our tool proactively identifies patients for early PC referral, streamlines the referral process, and empowers staff to consider treatment goals in a timely manner for the benefit of patients. Technical, practical, and cultural barriers to implementation were identified and changes made to address these, for example, having PC present at the weekly ICU meeting. We demonstrate a model for collaborative working which can be adapted for use in other ICUs and facilitate early PC for a broader cohort of cancer patients.
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Legal entity responsible for the study
The authors (all staff at The Royal Marsden NHS Foundation Trust).
Has not received any funding.
All authors have declared no conflicts of interest.