Integrating Specialist Palliative Care into ICU workflows in India: a six-year theory-informed evaluation of the BLUE MAPLE program

Abstract Background In intensive care units (ICUs) in low- and middle-income countries (LMICs), high treatment intensity and out-of-pocket expenditures can lead to a misalignment between delivered care and patients’ values. In 2019, a tertiary hospital in India implemented the BLUE MAPLE program to integrate specialist palliative care (SPC) into routine ICU workflows. We evaluated temporal patterns in program uptake, referral timing, and documentation of decision-making processes following implementation. Methods We conducted a retrospective, theory-informed evaluation of consecutive ICU patients referred to SPC between Jan 1, 2019, and Dec 31, 2024, using routinely collected clinical and administrative data. We examined trends in referral volume, ICU-to-SPC interval, and documentation of goals of care (GoC), limitation of life-sustaining treatment (LST), and futility. Post-referral outcomes, including mortality and discharge against medical advice (DAMA), were also described. Findings Among 1,871 patients referred to SPC (mean age 61 years [SD 16·6]; 33% women), treatment intensity at referral was high (71% receiving mechanical ventilation; 58% inotropes). Annual referrals increased from 35 in 2019 to a peak of 611 in 2023, then to 487 in 2024. Median ICU-to-SPC intervals remained short (3–6 days) across years. Documentation of GoC discussions increased steadily over time, while documentation of LST limitation and futility showed a non-linear pattern, with a decline followed by recovery after 2022. Overall mortality was 57·3%, and DAMA occurred in 13·0% of patients without a consistent temporal trend. Interpretation Integration of SPC into ICU workflows was feasible and sustained over 6 years in a resource-limited setting, and was associated with increased referral volume, timely involvement for most patients, and improved documentation of decision-making processes. In LMIC ICUs, where financial considerations often influence end-of-life care, indicators of decision quality and value concordance may be more informative than utilization metrics alone.