We conducted a systematic review to answer three questions: 1) Do advance care planning
and palliative care
interventions lead to a reduction in ICU admissions for adult patients with life-limiting illnesses? 2) Do these interventions reduce ICU length of stay
? and 3) Is it possible to provide estimates of the magnitude of these effects?
We searched MEDLINE, EMBASE, Cochrane Controlled Clinical Trials, and Cumulative Index to Nursing and Allied Health Literature databases from 1995 through March 2014.
We included studies that reported controlled trials (randomized and nonrandomized) assessing the impact of advance care planning
and both primary and specialty palliative care
interventions on ICU admissions and ICU length of stay
for critically ill adult patients.
Nine randomized controlled trials and 13 nonrandomized controlled trials were selected from 216 references.
Nineteen of these studies were used to provide estimates of the magnitude of effect of palliative care
interventions and advance care planning
on ICU admission and length of stay
. Three studies reporting on ICU admissions suggest that advance care planning
interventions reduce the relative risk of ICU admission for patients at high risk of death by 37% (SD, 23%). For trials evaluating palliative care
interventions in the ICU setting, we found a 26% (SD, 23%) relative risk reduction in length of stay
with these interventions.
Despite wide variation in study type and quality, patients who received advance care planning
or palliative care
interventions consistently showed a pattern toward decreased ICU admissions and reduced ICU length of stay
. Although SDs are wide and study quality varied, the magnitude of the effect is possible to estimate and provides a basis for modeling impact on healthcare costs.