A Needs-focused Palliative Care Intervention for Older Adults in ICUs
A Needs-focused Palliative Care Intervention for Older Adults in ICUs
The quality of intensive care unit (ICU)-based palliative care is highly variable,
 particularly for the 2 million older adults admitted annually to ICUs. To address these care
 delivery barriers among older ICU patients, a mobile app platform called PCplanner
 (Palliative Care planner) was developed. PCplanner automates the identification of high-risk
 patients (e.g., dementia, declining health status, poor functioning) by directly capturing
 data from electronic health record (EHR) systems, cultivates family engagement with
 supportive information and a digital system for self-report of actual needs, and facilitates
 the delivery of care to those with a high burden of need by coordinating collaboration
 between ICU teams and palliative care specialists.

 240 patients, 240 family caregivers, and 215 physicians and nurses from academic and
 community settings will be enrolled in a RCT designed to test the efficacy of
 PCplanner-augmented collaborative palliative care vs usual care. Family caregiver and
 clinician experiences will be explored using mixed methods to understand intervention
 mechanisms as well as implementation barriers within diverse case contexts. The key
 hypothesis is that compared to usual care, PCplanner will reduce family caregivers' unmet
 needs and psychological distress, increase the frequency of goal concordant treatment among
 older adult patients, and reduce hospital length of stay.
The quality of intensive care unit (ICU)-based palliative care is highly variable,
 particularly for the 2 million older adults admitted annually to ICUs. However, improving
 care quality on a broad scale with the efficient delivery of patient-centered, need-targeted
 palliative care is challenging because of logistical and technological barriers. To address
 these care delivery barriers among older ICU patients, a mobile app platform called PCplanner
 (Palliative Care planner) was developed. PCplanner automates the identification of high-risk
 patients (e.g., dementia, declining health status, poor functioning) by directly capturing
 data from electronic health record (EHR) systems, cultivates family engagement with
 supportive information and a digital system for self-report of actual needs, and facilitates
 the delivery of care to those with a high burden of need by coordinating collaboration
 between ICU teams and palliative care specialists. In pilot comparison to a standard
 palliative care control, the intervention reduced unmet needs, psychological distress, and
 length of stay and increased goal concordant care, communication, and hospice utilization.

 While these data are compelling, an efficacy evaluation of PCplanner is needed. Therefore,
 240 patients, 240 family caregivers, and 215 physicians and nurses will be enrolled from
 academic and community settings in a project with 2 key aims: (1) Test the efficacy of
 PCplanner-augmented collaborative palliative care vs usual care in a randomized clinical
 trial (RCT) with 3-month follow up, and (2) Explore family caregiver and clinician
 experiences using mixed methods to understand intervention mechanisms as well as
 implementation barriers within diverse case contexts. The key hypothesis is that compared to
 usual care, PCplanner will reduce family caregivers' unmet needs and psychological distress,
 increase the frequency of goal concordant treatment among older adult patients, and reduce
 hospital length of stay.
PATIENTS

 Inclusion Criteria:

 -  ≥65 years of age

 -  Receive care in a study ICU for ≥24 hours

 -  Meets ≥1 of 9 high risk phenotypes a. Dementia (e.g., Alzheimer's, multi-infarct,
 other dementia etiology) b. Declining health status defined by EITHER: i. ≥2 hospital
 admissions in 3 months preceding current admission OR ii. >1 ICU admission in 3 months
 preceding current admission c. Poor functional status defined by EITHER: i. admit from
 Skilled Nursing Facility (SNF) or Long-Term Acute Care (LTAC) facility OR ii. ≥3
 activities of daily living (ADL) limitations at admission d. Severe acute illness
 defined by EITHER: i. cardiac arrest OR ii. multisystem organ failure (≥3 of: lung,
 kidney, hematological, brain, cardiac, liver) that has worsened over 48 hours (i.e.,
 Sequential Organ Failure Assessment [SOFA] score increase) e. Severe acute stroke
 (e.g., acute intracranial hemorrhage, ischemic stroke, or traumatic brain injury) f.
 Acute respiratory failure (ventilation for ≥24 hours) g. Acute renal failure (new
 hemodialysis or continuous venovenous hemodiafiltration for ≥1 hour) h. Advanced
 cancer (Advanced / metastatic cancer diagnosis) i. Shock (use of vasopressor or
 inotrope for ≥4 hours)

 Exclusion Criteria (pre-consent):

 -  Palliative care consultation performed during the hospitalization before eligibility
 determination

 -  Current admission to ICU at the index hospital ≥8 days

 -  Imprisoned

 -  No known family or surrogate decision maker

 -  Death expected within 24 hours

 Exclusion Criteria (post-consent):

 - Patient dies before T2

 FAMILY MEMBER

 Inclusion Criteria:

 -  ≥18 years of age

 -  Self-described as the individual (related or unrelated) who provides the most support
 and with whom the patient has a significant relationship (per definition of 'family'
 described in the Society of Critical Care Medicine 2016 Guidelines for Family-Centered
 Care in the Neonatal, Pediatric, and Adult ICU)

 Exclusion Criteria (pre-consent):

 -  Lack a knowledge of English such that the potential participant is not confident that
 they could complete study tasks (app viewing, surveys)

 -  Imprisoned

 -  Unable to complete surveys for any reason

 Exclusion Criteria (post-consent):

 - Low need burden (NEST score <10) at baseline

 ICU PHYSICIANS

 Inclusion Criteria:

 -  ≥18 years of age

 -  Attending or fellow physician in a study ICU

 Exclusion Criteria:

 - None