Palliative care · Triggering palliative care
Default Palliative Care Consultation for Seriously Ill Hospitalized Patients
| Design | Pragmatic stepped-wedge cluster-randomised trial |
|---|---|
| Treatment | Default palliative care consultation order, which clinicians could opt out of |
| Control | Usual care, with consultation ordered at clinician discretion |
| Population | 24,065 patients aged 65 or over with advanced COPD, dementia or kidney failure staying at least 72 hours, across 11 US hospitals; 55.4% women, mean age 77.9 years |
| Follow-up | Hospital admission and 6 months |
| Primary endpoint | Hospital length of stay |
| Result | The primary endpoint was neutral: hospital length of stay did not differ between default-order and usual-care groups (-0.53%, 95% CI -3.51 to 2.53). The intervention did what it was designed to do on the secondary endpoint — palliative care consultation occurred in 43.9% versus 16.6%. Of 34,239 patients enrolled, 24,065 stayed at least 72 hours and formed the primary analytic sample (10,313 default order, 13,752 usual care; 55.4% women, mean age 77.9 years). |
| Secondary endpoints | Palliative care consultation rate, discharge to hospice, readmission, in-hospital death |
Default palliative care consult orders did not reduce length of stay for older, hospitalized patients with advanced chronic illnesses, but did improve the rate and timing of consultation and some end-of-life care processes.
The trial authors, in the published abstract
A behavioural intervention rather than a clinical one — changing the default rather than persuading clinicians — and among the most effective ways found to increase specialist palliative care involvement. Whether more consultations translate into better care is the harder question, and this trial's answer on its primary endpoint was no: length of stay was unchanged.
Courtright KR, Madden V, Bayes B, et al. Default Palliative Care Consultation for Seriously Ill Hospitalized Patients: A Pragmatic Cluster Randomized Trial. JAMA 2024 Jan 16;331(3):224-232.