Inpatient Goals-of-Care Conversations Reduce Intensive Care Unit Transfers in High-Risk Patients

Despite an aging population and an increase in the prevalence of chronic severe illness, many patients will not have end-of-life care discussions with their outpatient physicians. This very likely contributes to considerable hospital utilization toward the end of life, without any clear benefit. At our medical center, we noticed a very high rate of floor-to-intensive care unit (ICU) transfers for patients with life-limiting illness and poor prognosis. We initiated a quality assessment and improvement project aimed at increasing goals-of-care conversations for high-risk patients early in their hospital stays. Patients were identified using a risk assessment score combined with presence of life-limiting illness and alerting the inpatient attending physician to the patient's severity of illness. Inpatient attending physicians were encouraged to expeditiously initiate and document goals-of-care discussions with their patients and families or to consult palliative care. Patient data were extracted retrospectively from high-risk patients prior to and during the intervention period. Analysis showed a significant increase in overall goals-of-care discussions and a significant reduction in floor-to-ICU transfers during initial admission. There was no change in mortality at 1 year, but there was a trend toward more in-home deaths for those patients who died within the year. Early inpatient goals-of-care conversations may reduce ICU utilization at index hospitalization and may reduce overall health-care utilization near the end of life.