Can palliative care consults in hospitals improve end of life care

Having clinicians automatically order palliative care increased consultation rates and expedited consultations for seriously ill hospitalized people but did not decrease length of stay, according to an NIA-funded study. The findings, published in JAMA, suggest that while ordering by default rather than by choice improves certain end-of-life care processes, the impact on hospital stay length is limited.

Previous research suggested benefits of palliative care such as reduced hospital stays and costs. However, many people either do not get referred to palliative care or receive it late in their illness. This delay often happens because clinicians must identify who might benefit from palliative care, which can be challenging. Additionally, there is a lack of evidence on the impact of requesting a palliative care consult in routine practice. To address these gaps, researchers from the University of Pennsylvania led a study to determine whether ordering palliative care by default for hospitalized older adults with common serious illnesses would increase consultation rates and improve outcomes.

The study was conducted in 11 community hospitals across eight U.S. states, all of which used the same electronic health record system and had established palliative care programs. The trial included 34,239 people age 65 and older with serious illnesses, such as advanced chronic obstructive pulmonary disease, dementia, or kidney failure. Participants were enrolled upon admission to the hospital and divided into two groups. For the first group, palliative care consult orders were generated by default, which could be canceled by clinicians if deemed unnecessary. The second group received usual care, in which clinicians had to identify who could benefit from palliative care and then choose whether to order a consult. The researchers collected data on various outcomes, including palliative care consultation rates, length of stay in the hospital, discharge to hospice, do-not-resuscitate (DNR) orders, and in-hospital mortality rates.

Next, the researchers analyzed data from 24,065 participants who had hospital stays of at least 72 hours. They compared outcomes between 10,313 participants who received palliative care consults by default and 13,752 participants who received usual care. They found that 43.9% of people who had default orders received palliative care consults compared with 16.6% of those who received usual care. Additionally, default consultation orders sped up the time to consultation by more than one day. Compared to people in the usual care group, those who received palliative care by default had higher rates of DNR orders at discharge and were more likely to be transferred to hospice care. There was no difference in hospital stay length, deaths while hospitalized, or other clinical outcomes between the default order and usual care groups. Clinicians opted out of 9.6% of default orders for reasons including no current need for palliative care and the primary medical team already addressing the patient's needs.

Overall, while default orders for palliative care consultations did not reduce hospital stays, they did improve the frequency and timing of consultations as well as some end-of-life care processes, aligning with clinical guidelines for high quality palliative care. Earlier delivery of palliative care is also associated with reduced hospitalization costs for people with serious illnesses. Furthermore, considering that less than 10% of default orders were canceled, clinicians are likely to find the opt-out process acceptable.

This study suggests that default palliative care could be a valuable tool for health systems to enhance the delivery of guideline-recommended clinical consultations, even though it may not directly influence hospital stay length. Future research may explore if coupling default consultation orders with increased palliative care team staffing further improves care.

This research was supported in part by NIA grant UH3AG050311.

Reference: Courtright KR, et al. Default palliative care consultation for seriously ill hospitalized patients: A pragmatic cluster randomized trial. JAMA. 2024;331(3):224-232. doi: 10.1001/jama.2023.25092.