Original Investigation
December 16, 2024
Mobile App-Facilitated Collaborative Palliative Care Intervention for Critically Ill Older Adults: A Randomized Clinical Trial
Christopher E. Cox, Deepshikha C. Ashana, Katelyn Dempsey, et al
JAMA Intern Med. Published online December 16, 2024. doi:10.1001/jamainternmed.2024.6838
Question Can an automated, mobile application–based, personalized, electronic health record–integrated palliative care intervention delivered by intensive care unit (ICU) physicians and palliative care specialists reduce family members’ unmet palliative care needs?
Findings In a randomized clinical trial, intervention and control participants experienced similar reductions in the severity of unmet needs during ICU care. However, intervention participants more frequently had ICU family meetings and palliative care consultations.
Meaning Although the automated intervention was delivered successfully, future ICU-based palliative care trials should consider focusing on a population with longer ICU stays.
Abstract
Importance Few person-centered, scalable models of collaborative intensive care unit (ICU) clinician–palliative care specialist care exist.
Objective To evaluate the effect of a collaborative palliative care intervention compared to usual care among family members of patients in the ICU.
Design, Setting, and Participants This parallel-group randomized clinical trial with patient-level randomization was conducted between April 2021 and September 2023. The study was set at 6 medical and surgical ICUs in 1 academic hospital and 1 community hospital. The study participants included critically ill older adult patients with 1 of 11 poor outcome phenotypes, their family members with elevated palliative care needs, and their attending ICU physicians.
Intervention An automated electronic health record–integrated, mobile application–based communication platform that displayed family-reported needs over 7 days, coached ICU attending physicians on addressing needs, and prompted palliative care consultation if needs were not reduced within 3 study days.
Main Outcomes and Measures The primary outcome was change in the family-reported Needs at the End-of-Life Screening Tool (NEST) score between study days 1 and 3. The 13-item NEST score is a number between 0 and 130, with higher scores indicating a greater need. Secondary outcomes included quality of communication and goal of care concordance, as well as 3-month psychological distress.
Results Of 151 family members, the mean (SD) age was 57.4 (12.9) years, and 110 (72.9%) were female. Of 151 patients, the mean (SD) age was 69.8 (9.7) years, and 86 (57.0%) were male. Thirty-five ICU physicians were male (68.6%). Seventy-six patients were randomized to the intervention group and 75 to the control group. Treatment group differences in estimated mean NEST scores were similar at 3 days between the intervention and control groups (−3.1 vs −2.0, respectively; estimated mean difference in differences, −1.3 points [95% CI, −6.0 to 3.5]) and 7 days (−2.3 vs −2.2, respectively; estimated mean difference in differences, 0 points [95% CI, −6.2 to 6.2]). Median (IQR) need scores were lower among individuals who remained in the ICU at day 3 for intervention participants vs controls (24.5 [16.5-34.5] vs 27.5 [13.0-40.0], respectively); median (IQR) need scores were also lower among those who remained in the ICU at day 7 for intervention vs controls (22.0 [11.0-35.0] vs 28.0 [14.0-35.0], respectively). Goal concordance, quality of communication, and psychological distress symptoms did not differ. Twenty-nine intervention participants (38.2%) had palliative care consultations, compared to only 3 (4.0%) among controls, (P < .001); 66 intervention participants (87.0%) had a family meeting, compared to 48 (64.0%) among controls (P = .001).
Conclusions and Relevance In this randomized clinical trial, a collaborative, person-centered, ICU-based palliative care intervention had no effect on palliative care needs or psychological distress compared to usual care despite a higher frequency of palliative care consultations and family meetings among intervention participants.
Trial Registration ClinicalTrials.gov Identifier: NCT04414787
