Palliative Care Involvement in Relation to Rapid Response Events: A Focus on Care Intensity at the End of Life

OBJECTIVES: To examine current practice patterns of palliative care involvement in relation to rapid response (RR) events and to evaluate its association with ICU utilization and intensity of care received before death. DESIGN: Retrospective cohort study of patients who underwent a RR event. SETTING: General medical, cardiology, oncology, and observation patients admitted to a tertiary care academic medical center in the United States. PATIENTS: Adults (≥ 18 yr) with an RR event. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: A total of 903 RR events occurred in 616 unique patients. The palliative care team was involved in 110 of 616 (17.9%) patients. Palliative care (PC) involvement was not associated with differences in repeat RR events or ICU transfer rates following an event. In-hospital mortality or hospice discharge occurred in 32.0% (197/616). Palliative care was involved in 36.5% (72/197) of these patients. PC involvement was associated with lower intensity of care within 24 hours before death after adjustment for age, sex, Charlson Comorbidity Index, pre-RR code status, and RR trigger (adjusted odds ratio [aOR], 0.26; 95% CI, 0.14–0.47; p < 0.001; Brant test, p = 0.44). This finding remained across sensitivity analyses for oncology status, primary service line, ICU transfer, and advanced directive documentation. PC consultation occurred only before RR in 16 of 110 (14.5%), only after RR in 63 of 110 (57.3%), and both before and after in 31 of 110 (28.2%). In timing-stratified ordinal regression, PC consultation only after RR (aOR, 0.19; 95% CI, 0.10–0.38; p < 0.001) or both before and after RR (aOR, 0.22; 95% CI, 0.09–0.56; p = 0.002) was associated with less-intense care, while pre-RR PC alone was not (aOR, 1.06; 95% CI, 0.33–3.35; p = 0.93). CONCLUSIONS: Palliative services may be underutilized in the RR patient population, a group with a high in-hospital mortality rate; when palliative care is consulted, it may be associated with a reduction in the intensity of interventions at the end of life.