Editor's Note
Less Is More
March 17, 2025
Nudging Toward Effective and Scalable Palliative Care Interventions in Intensive Care
Nathan M. Stall, Tracy Y. Wang, Sharon K. Inouye
JAMA Intern Med. 2025;185(5):521. doi:10.1001/jamainternmed.2025.0100
More than 5 million patients are admitted to intensive care units (ICUs) across the US every year, and mortality rates average between 10% and 29% for ICU stays.1 Intensive care is characterized by the use of advanced life support and invasive interventions aimed at prolonging life. Considering the high ICU mortality rate and to ensure delivery of goal-concordant care that avoids unwanted and burdensome interventions, guidelines recommend that clinicians discuss prognosis and offer a comfort-focused treatment alternative for critically ill patients at high risk of death or severe functional impairment during an ICU stay.2,3
In this issue of JAMA Internal Medicine, Courtright et al4 conducted a pragmatic cluster randomized clinical trial to determine if nudging ICU clinicians with electronic health record (EHR) reminders to document short-term prognosis and offer a comfort-focused treatment alternative improved ICU outcomes among critically ill patients. The trial enrolled 3250 patients at high risk of death or severe functional impairment on admission to 17 ICUs in North Carolina and found that EHR nudge interventions resulted in guideline-recommended communication for approximately three-fourths of patients overall.
Notably, the study by Courtright et al4 found no significant effects for both the primary and most secondary outcomes. Compared with patients receiving usual care, those cared for by clinicians receiving EHR nudge interventions had no difference in the primary outcome, hospital length of stay, an important person-centered outcome. Although most patients and their caregivers prefer more time at home or outside the hospital setting, this goal is often counter-balanced by clinician-level, hospital-level, and system-level factors in the setting of severe illness that tend to prolong aggressive treatment and delay the transition to comfort-focused care. Thus, the lack of effect on length of stay in this study is not surprising. Moreover, 22 secondary outcomes yielded only a few positive results and did not account for multiple comparisons; thus, these findings can only be considered exploratory and will need to be confirmed in future studies.
Despite the trial results not yielding significant effects, we wanted to highlight the trial by Courtright et al4 due to the importance of the topic and the need to encourage more research on palliative care interventions in the ICU. Even though this trial did not demonstrate the clinical effectiveness of the EHR nudge intervention, the development of an intervention that increases physician documentation of prognosis and promotes discussion with families about treatment alternatives is a vitally important first step, especially given the limited palliative care resources in many ICU settings. Moreover, such EHR interventions are potentially scalable and appear feasible to implement. The 75% fidelity rate, though not ideal, is acceptable in the busy, high-risk ICU setting.
To date, clinical trials in the ICU to promote goal-concordant care for critically ill patients and their families have yielded limited actionable changes.5 Nudge interventions in EHRs show promise for increasing clinician engagement in serious illness conversations, but additional research is greatly needed to determine if these palliative care interventions can translate to improved outcomes for patients in the ICU at the end of their lives.
