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Association between Palliative Care and End-of-Life Resource Use for Older Adults Hospitalized with Septic Shock.

RATIONALE
The care of critically ill patients often involves complex discussions surrounding prognosis, goals, and end-of-life decision making. Yet, physician and hospital practice patterns, rather than patient goals, remain a major determinant of the intensity of end-of-life care. For critically ill patients, palliative care may help promote treatments that are concordant with patients' goals, while minimizing the use of invasive and costly intensive care unit resources that may not be consistent with those goals.


OBJECTIVES
To determine whether inpatient palliative care, delivered by specialist consultants or a primary medical team, is associated with reduced hospital length-of-stay and costs for older adults with septic shock at the end of life.


METHODS
Retrospective cohort using the National Inpatient Sample (NIS) 2013-2014, examining patients aged ≥ 65 years with septic shock who died during their hospitalization. The exposure of interest was inpatient palliative care encounter, including either generalist or specialist-delivered palliative care. Outcomes were hospital length-of-stay, total cost for the hospitalization, and daily hospital cost. Patient and hospital-level confounders were used to derive inverse probability of treatment weights and estimate the association between palliative care and outcomes in a generalized linear model.


RESULTS
We studied 45,868 patients who died with a diagnosis of septic shock; 15,370 of these patients had a palliative care encounter. After inverse probability of treatment weighting, there were no appreciable differences between the population characteristics. Palliative care was associated with a shorter adjusted mean hospital length-of-stay (12.0 vs 13.1 days, difference -1.1 days, 95% CI -1.4 to -0.9; P <0.001), lower total hospital costs (69,700 vs 76,800 USD, difference -7,100 USD, 95% CI -8.5 to -5.2 thousand USD; P <0.001) and lower daily hospital cost (5,900 vs 6,200 USD, difference -310 USD per day, 95% CI -420 to -200 USD; P<0.001) when compared to no palliative care.


CONCLUSIONS
In a nationally representative sample of adults who died during a hospitalization with septic shock, receipt of palliative care was associated with shorter length-of-stay and lower total and daily hospital costs. This finding was robust to adjustment for patient and hospital-level confounders, though unmeasured confounders still could be impacting these findings.