A proactive approach to improve end-of-life care in a medical intensive care unit for patients with terminal dementia

Objectives: To compare usual care with a proactive case-finding approach for critically ill patients with terminal dementia using an inpatient palliative care service. Design: Prospective comparison to historical control. Setting. Urban, university-affiliated hospital. Patients: Total of 52 men and women with end-stage dementia, 26 subjects in each control and intervention group. Interventions. Proactive case-finding by the palliative care service was done to offer early assistance to the intensive care unit staff about the treatment of patients with terminal dementia. Results were compared with data obtained retrospectively. Measurements and Main Results. Measurements included age, gender, Acute Physiology and Chronic Health Evaluation Score, Therapeutic Intervention Scoring System, mortality, intensive care unit and hospital lengths of stay, frequency, timing, and goals of do-not-resuscitate orders. The proactive, case-finding approach decreased hospital and medical intensive care unit length of stay. More important, a proactive palliative intervention decreased the time between identification of the poor prognosis and the establishment of do-not-resuscitate goals, decreased the time terminal demented patients remained in the intensive care unit, and reduced the use of nonbeneficial resources, thus reducing patient burden and the cost of care while having the potential to afford the patient and family increased comfort and psychoemotional support. Conclusions. Proactive interventions from a palliative care consultant within this subset of patients improved end-of-life care and decreased use of superfluous resources.