The Impact of Early Palliative Care Consultation on Length of Stay for Critically Ill Adults in the Intensive Care Unit

Abstract

Palliative Care Consultation (PCC) is an established intervention that prioritizes goals of care conversations and assists patients with complex medical decision-making. Evidence suggests that PCC can reduce the amount of non-goal concordant care patients receive such as fewer invasive procedures, less mechanical ventilation, and quicker transition to hospice and referral to appropriate resources, if that aligns with patient wishes. This results in decreased resource utilization, reduced anxiety for patients and their family members, and decreased moral distress for the health care team. Studies generally agree that benefits of PCC are greater the quicker the time to intervention, but results are mixed regarding hospital and intensive care unit (ICU) length of stay (LOS). LOS is a surrogate marker for goal-concordant care, and shorter LOS has been associated with decreased health care costs. This systematic literature review seeks to clarify the effects of early PCC versus standard PCC on length of stay. From an extensive search of CINAHL, EMBASE, Scopus, and PubMed, 17 articles met criteria to be reviewed. These articles include 2 randomized controlled trials (RCTs), 6 prospective cohort studies, and 9 retrospective cohort studies. Nine studies found statistically significant results linking early PCC with shorter length of stay. These results indicate that a change in practice could be considered given the multiple positive outcomes associated with early PCC. Further research is recommended with larger sample sizes across multiple institutions to improve generalizability of these initial findings, and to examine the different modalities of implementing early PCC into existing ICU workflows.

Keywords

intensive care unit early timing palliative care consult embedded length of stay

Introduction

In the United States, an estimated 1 in 5 Americans will die while utilizing ICU services that they may not have wanted.¹ Palliative care consultations (PCC) are a known tool that help clinicians provide goal concordant care, alleviating anxiety and moral distress for patients, their families, and the care team.² Palliative care (PC) is an interdisciplinary specialty that emphasizes prevention and relief of suffering by focusing on symptom management, psychosocial well-being, shared-decision making, and patient-directed goals of care.^1,3,4 The current body of literature shows PCC is associated with numerous positive outcomes, such as improved quality of life; increased patient and caregiver satisfaction; fewer emergency room visits; reductions in unplanned hospitalizations; and lower rates of caregiver burden.^1,2

Research indicates involvement of PC is beneficial early in the disease course, but many factors affect whether a patient will receive PC interventions. In 2017, a multidisciplinary, multicenter set of surveys indicated that ICU clinicians, including nurses, physicians, and advanced providers, agree PC is underused.⁵ The same survey highlighted difficulties with ordering PCC, citing confusion or disagreement over what factors necessitate one.⁵ There is no standard screening or assessment tool to determine which patients would benefit from PC involvement – PCC typically come from a subjective assessment by the primary care team responsible for the patient or from meeting a list of institution-specific triggers.⁶ Many of these institution-specific screening tools are based on data and recommendations from the Improving Palliative Care in the ICU (IPAL-ICU) Project in 2013.⁷

In some cases, patients and/or clinicians are not aware that palliative care can be offered concurrently with curative treatments, and so clinicians may not offer palliative consults especially in critical care units for fear it is seen as undermining life-saving efforts.⁸Patients in the ICU have high rates of unmet symptom needs and complex medical decision-making^8-10 and may be missing valuable services that could guide goal-concordant care.

Purpose

There is no specific timeline for PC involvement for critically ill patients, although the Center to Advance Palliative Care urges proactive PCC.⁷ The American College of Surgeons’ Palliative Care Best Practices Guidelines¹¹ recommend evaluation for PCC within 24 hours of admission and a structured family meeting for critically ill patients within 72 hours. As a result, 72 hours is widely accepted as the target time-to-intervention for PCC.

Amidst many positive outcomes associated with PCC, the data regarding the effects of early PCC on ICU patients has been mixed and studies have not consistently shown statistically significant results.¹² Articles included in this review consider the embedded PC model as well as referral-based PC, both with the intent to decrease time from admission to PC intervention. The embedded model consists of a PC provider or team that is based within the unit where they work and are part of the established care team. A referral-based model aligns with the typical consult service model seen in hospitals, where the primary team refers patients to receive PC from a separate palliative service that may work with patients across the entire hospital.

Length of stay was the primary outcome chosen because it is related to several secondary outcomes of interest to the healthcare system at large, such as decreased costs for patients and hospitals.^1,3,10,12,13 This review also considers the rate of invasive procedures, code de-escalation, and transition to hospice care. Evidence suggests that shorter LOS in the ICU and fewer invasive interventions are surrogate markers of goal-concordant care and decreased patient suffering, which should also reduce clinician moral distress related to providing care that is medically futile or not aligned with patient wishes.^3,6,9,12 While previous research supports the use of LOS as a marker of goal-concordant care, it is understood that there may be individual patient scenarios where prolonged care in the ICU and invasive procedures align with patient wishes. Therefore, this literature review aims to determine the effect of early PCC on length of stay in the hospital and/or ICU compared with usual PCC for critically ill adults.

Methods

Search Strategy

This systematic literature review consists of sources from citation searching, and the following databases: CINAHL, EMBASE, PubMed and Scopus. All articles assessed were published prior to September 23rd, 2025 when the last search occurred. Specific search terms can be found in Table 1. In each database search, filters were added to screen articles for English language, adult population (>18 years old), and a publishing date of 2015 to present. A prior review³ examined articles from 2000-2016 to assess effects of PCC on ICU LOS and healthcare costs, but did not consider time to intervention. To address this gap, the present review focuses on studies from 2015-2025. Reviews of any kind and conference abstracts were excluded.

Table 1.

Literature Search Strategy for Palliative Care Timing in Critical Care, all Searches Completed Between May 20^th and September 23rd, 2025

Database	Search terms/Query	Limits or filters applied	Results
PubMed	(((((“Early Medical Intervention”[Mesh]) OR “Time Factors”[Mesh] OR early OR late OR embed* OR proactiv* OR integrat) AND ((“Critical Care”[Mesh] OR “Critical Care Nursing”[Mesh] OR “Critical Care Outcomes”[Mesh]) OR “Intensive Care Units”[Mesh:NoExp] OR intensive OR critical)) AND (((“Referral and Consultation”[Mesh]) OR “Time-to-Treatment”[Mesh]) OR “Consultants”[Mesh]OR consult)) AND (“Length of Stay”[Mesh] OR “length of stay”)) AND (“Palliative Care”[Mesh] OR “Hospice and Palliative Care Nursing”[Mesh] OR “Palliative Medicine”[Mesh] OR palliative)	English, 2015-2025, Adult	44
CINAHL	((“palliative care” or “palliative medicine” or “palliative”) AND (“intensive care unit” or “icu” or “critical care” or “critical care unit”) AND (“length of stay” or “los” or “inpatient stay”)) AND (“time to treatment” or “early intervention” or “early” or “late” or “integrat” or “embed”or “proactiv*” OR “referral and consultation”)	English, 2015-2025, all adult	99
Embase	((‘palliative care’/exp OR ‘palliative care’ OR ‘palliative medicine’/exp OR ‘palliative medicine’ OR ‘palliative therapy’/exp OR ‘palliative therapy’) AND (‘length of stay’/exp OR ‘length of stay’) AND (‘patient referral’/exp OR ‘patient referral’ OR ‘time to treatment’/exp OR ‘time to treatment’ OR ‘consultants’/exp OR ‘consultants’ OR ‘consultation’/exp OR ‘consultation’) AND (‘intensive care’/exp OR ‘intensive care’ OR ‘intensive care unit’/exp OR ‘intensive care unit’ OR ‘critical care outcomes’/exp OR ‘critical care outcomes’ OR intensive OR ‘critically ill patient’/exp OR ‘critically ill patient’) AND (‘early intervention’/exp OR ‘early intervention’ OR ‘time factor’/exp OR ‘time factor’ OR ‘time'/exp OR ‘time’ OR ‘time to treatment’/exp OR ‘time to treatment’ OR early OR late OR embed* OR proactive* OR integrat*))	English, 2015-2025, Adult	89
Scopus	((“Critical care” or “intensive care unit” or “ICU”) AND (“palliative care” or “palliative medicine” or “palliative”) AND (“length of stay” or “los” or “inpatient stay”) AND (“time to treatment” or “early intervention” or “early” or “late” or “integrat” or “embed” or “proactiv*”) AND (“referral and consultation”))	English, 2015-2025	43

Review Process

Two hundred and eighty-seven articles met criteria for review between the 4 databases and additional searches. Once the articles were consolidated, duplicates were removed, leaving 181 sources for review. The titles and abstracts of these articles were screened by a single reviewer. Based on the original filters from the database searches, 108 studies were excluded. Primary reasons for article exclusion beyond the established parameters included studying patients outside of ICUs or failing to consider length of stay as an outcome. This resulted in 73 full text articles that were then assessed for eligibility. Seventeen studies were included in the final review, consisting of: 2 Randomized Control Trials (RCTs), 6 prospective cohort studies, and 9 retrospective cohort studies. For a detailed view of the process of article selection during each phase of the review, see the PRISMA diagram, Figure 1.

Figure 1.

PRISMA Diagram¹⁴

Data Extraction

After articles were assessed for eligibility, they were reviewed in their entirety. Data was methodically consolidated into a Table of Evidence (TOE). The TOE allowed for side-by-side comparison of the 17 articles. The TOE includes authors and date, country where the study was conducted, study aim and design, sample size and demographics, research setting, and findings. All 17 articles focus on the effect of early PCC on patients in ICUs and study multiple outcomes, including but not limited to LOS. More details of the analysis can be found in the TOE, Table 2.

Table 2.

Table of Evidence

Study ID	Title	Setting	Methods: Design	Methods: Study Aim	Population: Inclusion criteria	Population: Total sample size	Intervention	Intervention Characteristics: Number of participants allocated	Intervention Characteristics: Timing of Intervention	Intervention Characteristics: Who was involved in PCC	Result data: Hospital and/or ICU LOS Findings	Result data: Hospital and/or ICU LOS Quote	Result data: Rate of Invasive Procedures (trach, peg) Findings	Result data: Rate of Invasive Procedures (trach, peg) Quote	Result data: Change in Code Status Findings	Result data: Change in Code Status Quote	Johns Hopkins Level of Evidence
Babar et al. (2021)	Incorporating Early Palliative Medicine Consultation Into Daily Morning Huddle in the ICU	26-bed medical ICU at the Fairview Hospital, a Cleveland Clinic regional hospital	Prospective cohort study	To determine the impact of including a recommendation for palliative medicine consult in the ICU morning huddle.	- >18 years old admitted with cardiac arrest, stage IV cancer, and circulatory shock on mechanical ventilation to the medical ICU - Expected to be admitted for over 24 hours	83 patients met the trigger criteria for early PCC -> 23 pts had an early PCC, 21 had a late PCC, 39 pts who met criteria for a PCC did not have one ordered	Early PCC	23	early - within 48 hrs	Not specified - there was no standardized process of delivering PCC in this study	Median LOS 5 days (1-27 days)		0 patients received trach, 0 patients received PEG	“There was no observed differences in rates of tracheostomy or PEG tube placement between the two groups [early vs late PCC].” P>0.05”	63.6% downgraded from full code to DNR/DNI, P < 0.0001		Level IIIB – this is a prospective, observational, study with no randomized assignment to a control or intervention group. Single-center QI design. Data collection methods were well-described and results were presented clearly.
							Usual or Late PCC	21	PCC order placed over 48 hours after ICU admission		Median LOS 11 days (1-45)		19% of patients received trach, 19% of patients received PEG		7.7% transitioned from full code to DNR/DNI
							No PCC	39	No PCC		Median LOS 3 days (1-25)		7.7% of patients received trach, 7.7% of patients received PEG
Barasa et al. (2021)	Assessment of Palliative Care Needs in a Kenyan Intensive Care Unit Using a Trigger-Based Model	ICU within the Aga Khan University Hospital, Nairobi	Prospective cohort study	To determine the prevalence of ICU admissions in those who met at least one palliative care trigger and whether a palliative care consult influenced the length of ICU stay and time to change of goals order.	Patients who met the criteria for ICU admission and one of the following triggers: ICU admission after hospital stay >10 days, age >80 years with two or more life-threatening comorbidities, diagnosis of active stage 4 malignancy, status after cardiac arrest, and diagnosis of intracerebral hemorrhage requiring mechanical ventilation	159 patients -> 72 met the palliative care trigger -> 21 received PCC while 51 did not	Usual or Late PCC	21	Any PCC at all	Palliative consult team comprises two board-certified palliative care physicians, one palliative nurse, and a social worker	Time to discharge from ICU admission - median 15 days (for 5 patients who received PCC); time from ICU admission to death - median of 4.5 days (for 16 patients who received PCC)	“There was no statistically significant difference between the consult and nonconsult groups in terms of time to change of goal orders, time to death or discharge, and length of ICU stay.”			53% of patients who received PCC had a formal change of goals (P=0.009); intervention group had earlier and significant more frequent transition to DNR/DNI than control group (50.5% vs 23.4%, P <0.0001)	“Change of goal order forms include directives on different interventions such as resuscitation, endotracheal intubation and mechanical ventilation, hemodialysis, vasopressor support, use of parenteral feeds, laboratory investigations, and imaging. The change of goals form allows the family and physician to agree upon and formally document which interventions they would like to proceed with or withhold from the patient.”	Level IIIB – this is a prospective, observational, study with no randomized assignment to a control or intervention group. Data collection methods were well-described and results were presented clearly.
Barasa et al. (2021)		ICU within the Aga Khan University Hospital, Nairobi	Prospective cohort study				No PCC	51	No PCC		Time to discharge from ICU admission - median 17 days for 26 patients; time from ICU admission to death - median 2 days for 25 patients				19.6% of patients who did not have PCC had a documented formal change of goals
Bharadwaj et al. (2016)	Making the Case for Palliative Care at the System Level: Outcomes Data	Seven hospitals across Virginia within the Sentra Healthcare system	Retrospective cohort study	To quantify the impact of PC throughout a multihospital health care delivery system.			Early PCC		PCC within 48 hours	Palliative Care clinician		“PC patients in the ICU with sepsis seen within the first 48 hours had a shorter LOS of 1.12 days ( P = 0.021)”					Level IIIB - this is a retrospective review of outcomes across 7 hospitals.
Bharadwaj et al. (2016)			Retrospective cohort study				Usual or Late PCC		No PCC or PCC after 48 hrs	Palliative Care clinician
Braus et al. (2015)	Prospective study of a proactive palliative care rounding intervention in a medical ICU	24-bed ICU in a 566-bed academic medial center	Prospective, before-and-after interventional study	To evaluate the effects of a novel proactive palliative care intervention aimed at improving the ICU physician team's attention to palliative care needs, rather than at increasing the utilization of palliative care consultants.	Patients with one or more of the following pre-specified clinical triggers: Metastatic or otherwise incurable malignancy Hospital LOS of 10 days prior to transfer to the ICU Duration of ongoing invasive mechanical ventilation of 7 days or more ICU LOS of 14 days or more Age 80 years old or older with 2 or more significant chronic diseases, (e.g. chronic obstructive pulmonary disease requiring home oxygen therapy, chronic kidney disease requiring renal replacement therapy); Out of hospital or in-hospital cardiac arrest. Cerebral hemorrhage requiring mechanical ventilation Admission to the ICU from a long-term acute care hospital	203 patients total (100 vs 103)	Early PCC	103	the adjusted time between ICU admission and the occurrence of a family meeting in the ICU was 41% shorter in the intervention period (95% CI 52% shorter to 28% shorter, p<0.001); days between ICU admission and family meeting - median of 3 days; 59% of the intervention group had a family meeting within the first 72 hours in ICU	A member of the palliative care consult team (either a palliative care clinical nurse specialist or a palliative medicine fellow or faculty member) was embedded in the ICU and would join bedside rounds for patients meeting triggers. The PC clinician would make suggestions for interdisciplinary family meetings being held in a timely fashion and how to better address palliative care needs of the patient	hospital LOS - 11 days; hospital LOS for pts who died before discharge - 5 days	“After adjusting for potential confounders, hospital LOS was significantly shorter in the intervention group, with an estimated 26% shorter hospital LOS (95% CI 31% to 20% shorter, P < 0.001). In exploratory analyses including only those individuals who died in the hospital, the intervention was associated with a 30% reduction in hospital LOS (95% CI 40% to 18% shorter, P<0.001).”		“Interestingly, in exploratory analyses we observed significant reductions in both hospital and ICU LOS for those individuals in the intervention group who died in the hospital. A possible explanation for this observation is that more timely family meetings in the ICU led to earlier decisions about withholding or withdrawing life sustaining treatment in patients who were unlikely to benefit from ongoing critical care therapies.”			Level IIB - this is a prospective, quasi-experimental study with a moderate sample size. Data collection methods were well-described and results were presented clearly.
Braus et al. (2015)		24-bed ICU in a 566-bed academic medial center	Prospective, before-and-after interventional study			203 patients total (100 vs 103)	Usual or Late PCC	100	days between ICU admission and family meeting - median of 5 days; 35% of these patients had a documented family meeting while in the ICU, and 35% of those documented meetings took place within the first 72 hours in ICU		hospital LOS - 13 days; hospital LOS for pts who died before discharge - 9 days
Cox et al. (2018)	Palliative care planner: A pilot study to evaluate acceptability and usability of an electronic health records system-integrated, needs-targeted app platform	Adult medical, surgical, cardiac, and neurologic ICUs at Duke University Medical Center	Prospective before-and-after interventional pilot study	To develop and pilot an app platform for clinicians and ICU patients and their family members that enhances the delivery of needs-targeted palliative care.	age 18 years or older, admission to an ICU for at least 48 hours, and presence of at least one of five e-triggers: dementia (Alzheimer's, multi-infarct, other dementia etiology), declining health status (>2 hospital admissions in 3 months or >1 ICU admission in 3 months), poor functional status (admit from SNF or LTAC or >3 ADL limitations at admission), severe acute illness (cardiac arrest or multisystem organ failure that has worsened over 48hrs), or severe acute stroke (acute intracranial hemorrhage, ischemic stroke, or traumatic brain injury)	423 patients were screened -> 385 excluded, 24 refusals (14 by physicians, 10 by legal decision maker) -> 42 (14 patients, 18 family members, 10 clinicians) enrolled	Early PCC - pts screened by PCPlanner	14	3.6 mean days in ICU before PCC	content of meeting was unscripted - practitioners were encouraged to explore the family-reported needs (NEST scale items)entered in PCplanner. At least 2 palliative care specialists conducted each family meeting, ICU team was invited to attend	Intervention group had a shorter mean hospital LOS (20.5 [SD, 9.1] vs. 22.3 [SD, 16.0] patient number)	Intervention patients had shorter postconsultation mean hospital length of stay compared with Control A patients (7.9 [6.2] vs. 9.7 [7.9] days), although this was not statistically significant (P = 0.48).	29% in intervention group had a trach; Intervention group had increased frequency of goal-concordant care after PCC (79% -> 100%)		Intervention group downgraded code status from 93 -> 29%		Level IIB - this is a non-randomized prospective intervention with before and after comparison. The sample size was small and obtained at a single institution, but demonstrated positive statistically significant results.
Cox et al. (2018)			Prospective before-and-after interventional pilot study				Usual or Late PCC - standard intervention	A - 25; B - 39	6.9 mean days in ICU before PCC				patients with trach - 16% in Control A and 11% in Control B		Control A decreased from 100 -> 40%
Helgeson et al. (2023)	Early Versus Usual Palliative Care Consultation in the Intensive Care Unit	28-bed MICU in an academic medical center	Randomized controlled trial	To evaluate the benefit of early PCC (within 24 hours) in the MICU on clinical and patient satisfaction outcomes	- expected stay in the MICU >24 hours - had to meet at least one of the following: age >80, APACHE II >14, SOFA >9, late-stage dementia, pre-existing functional dependency stage 4 metastatic disease, recurrent ICU admission in the past year, post-cardiac arrest, end-stage organ disease	91 patients	Early PCC	50	<24 hours from admission to ICU	PCC team was led by a physician board-certified in palliative care medicine	Median ICU LOS - 3 days (IQR 2 - 5), P = 0.018	Statistically significant if <0.05	38% of patients were intubated, 12% received a tracheostomy		Change in code status - 56% (P = 0.037)		Level IA – this is a randomized control study where pts were placed into a control or intervention group. Instrument reliability and validity were discussed, and all results were discussed clearly. Study limitations were discussed.
Helgeson et al. (2023)		28-bed MICU in an academic medical center	Randomized controlled trial			91 patients	Usual or Late PCC	41	>24 hours from admission to ICU		Median ICU LOS - 8 days (IQR 2 - 21)	Statistically significant if <0.05	59% of patients were intubated, 15% received a tracheostomy		change in code status - 34%
Hochberg et al. (2025)	The Real-World Effect of Early Screening for Palliative Care Criteria in a Medical Intensive Care Unit: An Instrumental Variable Analysis	24-bed tertiary-care academic MICU	Retrospective cohort study	To evaluate the real-world effects of early screening for palliative care criteria in a medical ICU - hypothesized that receipt of early screening would increase early use of specialty palliative care consultation and, via this mechanism, decrease time to DNR and/or MICU discharge.	age >18, remained in MICU >12 hours, and meets one or more triggers for early screening: resides in SNF or dependent for ADLs, neurodegenerative disorder, end-stage liver/kidney/heart disease, COPD requiring home oxygen, advanced metastatic cancer, post-cardiac arrest with neurologic sequelae, multi-system organ failure, shock requiring vasopressors for >6 hours, acute respiratory failure, prior hospitalization >5 days in the past year or ICU admission within the last 30 days	1382 encounters (1254 patients) as some patients were admitted multiple times to the ICU over the course of the study -> 591 patients received early screening, 714 did not “Those receiving early screening were more likely to have early specialty palliative care consultation (within 2 d of MICU admission) versus those who did not (17% vs. 1%; P, 0.001)”	Early PCC	591	591 patients were screened within 2 days of MICU admission >> 17% received PCC within two days, 39% received PCC at all	palliative care team: physicians, advanced practice providers, and a dedicated social worker all specialized in palliative care	Median hospital LOS - 9.8 days	Median days to DNR or ICU discharge for the early screening and no early screening groups were 2.5 (IQR, 1.6 to 4.6) and 2.8 (IQR, 1.5 to 4.6) days (Figure 2). The instrumental variables analysis showed no significant difference in this primary outcome (relative percentage difference = 15% greater; 95% confidence interval [CI],211 to 148; P = 0.28)”; ”Although our screening program did significantly increase early specialty palliative care consultation, uptake was still low, and only 17% of patients who received early screening went on to receive early consultation. This may have limited any potential effect that screening, via increasing specialty palliative care use, could have had on patient outcomes”			Change to DNR code status - 19.3% (p = 0.95); mean days to DNR or ICU discharge - 2.5		Level IIIB - this is a retrospective cohort study comparing pre- and post-implementation cohort with strong methodology and a large sample. Study limitations were discussed.
Hochberg et al. (2025)		24-bed tertiary-care academic MICU	Retrospective cohort study				Usual or Late PCC	714	714 patients screened after >2 days in the MICU >> 1% received PCC within two days, 22% received PCC at all		median hospital LOS - 10.8 days				Change to DNR code status - 21.6%; mean days to DNR or IICU discharge - 2.8
Kim et al. (2025)	Integration of Palliative Care in Neurosurgical Critical Care: Insights from a Single-Center Perspective	12-bed neurosurgical ICU in a tertiary hospital	Retrospective cohort study	To identify the characteristics, palliative care needs, and outcomes of patients referred to palliative care services during admission to the neurosurgical intensive care unit (NS-ICU).	Adults admitted to the NS-ICU with one of the following diagnoses: non-traumatic brain hemorrhage, traumatic brain injury, or brain neoplasm.	38 patients	Early PCC	38	Median time from admission to PCC - 3.5 days; median time from referral to PCC - 1 day	Inpatient PC team - one palliative care physician, one clinical fellow in internal or family medicine, one palliative care nurse, and one medical social worker.	median hospital stay after PCC is 12.5 days in ICU vs overall median length of hospital stay of 14 days	“The absence of a control group hinders the ability to compare and assess the unique impact of palliative care” and “Palliative care consultation was formally integrated into the Korean healthcare system following the implementation of the LST Decision Act in 2018, which limited our data collection to that year onward.”			Change in code status from before to after PCC: full code 32 -> 11%, partial code 66 -> 42%, comfort care 2 -> 47% (P <0.001)		Level IIIC - this is a descriptive, non-experimental, single-center observational study.
Kumar et al. (2024)	Optimizing outcomes: Impact of palliative care consultation timing in the cardiovascular intensive care unit	CICU in a 912-bed urban academic medical center	Retrospective cohort study	To explore the impact of early palliative care consultation (PCC) on patient outcomes in the CICU, including mortality, LOS, and family meeting frequency.	Patients >18 admitted to the CICU who received PCC for any indication while in the CICU	209 patients	Early PCC	165	within 72 hours	Physician or advance practice provider who is a palliative care specialist, palliative social work, pharmacy, and spiritual care specialists.	LOS after PCC - 3 days (IQR 1 to 6) (statistically significant at P = 0.005)		Rates of invasive procedures were generally lower in the early group compared to the late group. In particular, rates of tracheostomy and PEG tube placement were significantly lower (p = 0.007) - 2.4% received tracheostomy and PEG tube		63% of patients who were admitted with full code status downgraded their status		Level IIIB - this is a retrospective comparative cohort looking at early versus late consult with statistical testing.
Kumar et al. (2024)		CICU in a 912-bed urban academic medical center	Retrospective cohort study			209 patients	Usual or Late PCC	41	after 72 hours		LOS after PCC - 5.5 days (IQR 3 to 11.3)		13.6% received tracheostomy and PEG tube		59% of patients admitted with full code status downgraded their code status
Ma et al. (2019)	Early Palliative Care Consultation in the Medical ICU: A Cluster Randomized Crossover Trial	Two medical ICUs at Barnes Jewish Hospital	Randomized controlled trial	To assess the impact of early triggered palliative care consultation on the outcomes of high risk ICU patients.	>18 years old and at least one of the following: late-stage dementia, metastatic cancer, cardiac or respiratory arrest, multiple organ system failure, known end-stage organ disease, acute shock, hospital stay greater than 5 days or ICU readmission for the same diagnosis within 30 days	199 patients -> 102 in the control group, 97 in the intervention group	Early PCC	97	within 48 hours of MICU admission (30.9% of pts seen within 24 hours)	Interprofessional team including board-certified palliative care providers.	on average, 10 days (IQR 6 to 15 (P >0.05, not significant)		While not statistically significant, rates of mechanical ventilation, vasopressors, hemodialysis, tracheostomy, CPR were all lower in the intervention group than the usual care group		transition to DNR/DNI - 50.5% (P <0.0001)	“The interprofessional palliative care team interacted with the patient, family, and primary team on multiple occasions throughout the admission to facilitate symptom relief, set appropriate expectations, and address goals of care. Code status changes were significantly increased in the intervention group, even after controlling for potential confounders, and as expected there were improvements in multiple other clinically important metrics likely driven by effective goals of care discussions.”	Level IA – this is a randomized control study where pts were placed into a control or intervention group. Instrument reliability and validity were discussed, and all results were discussed clearly. Study limitations were discussed.
Ma et al. (2019)		Two medical ICUs at Barnes Jewish Hospital	Randomized controlled trial				Usual or Late PCC	102	>48 hours of MICU admission (on average 7 days after admission)		on average 11 days (IQR 6 to 19)				transition to DNR/DNI - 23.4%
Martz et al. (2020)	Outcomes Associated With a Nurse-Driven Palliative Care Screening Tool in the Intensive Care Unit	14-bed MICU in a community hospital	Retrospective cohort study	To identify outcomes associated with specialty palliative care referral among patients with critical illness.	Hospital stay >24 hours, >18 years old, and 4 or more of the following: metastatic cancer, advanced/end-stage disease, advanced cardiac disease, advanced dementia, other life-limiting illness	112 patients	Usual PCC	47	Mean time from receiving positive screening tool to PCC was 1.1 days (SD 1.7 days, range <1 - 7 days)	Specialty palliative care consultation team - physician, nurse practitioner, and social worker.	Mean ICU LOS - 6 days; mean hospital LOS - 11.6	“We found no significant differences between groups in the length of hospital or ICU stay”	23% of patients received mechanical ventilation (p = 0.02)			“Of the 47 patients who received a palliative care consult, 13 had full resuscitation code status and 34 had a DNR order in place before the consult. After the palliative care consult, 1 patient remained at full resuscitation code status and 43 patients had a DNR order; data pertaining to code status after the consult were missing for 3 patients.”	Level IIIB - this is a retrospective cohort study.
Martz et al. (2020)		14-bed MICU in a community hospital	Retrospective cohort study			112 patients	No PCC	65			mean ICU LOS - 6.5 days; mean hospital LOS - 10 days		40% of patients received mechanical ventilation				Level IIIB - this is a retrospective cohort study.
Mehta et al. (2023)	Lessons Learned from an Embedded Palliative Care Model in the Medical Intensive Care Unit	MICU in an urban, quaternary academic medical center	Retrospective cohort study	To describe a physician and registered nurse led palliative care consultation team embedded in the MICU and compare patterns of palliative care consultation, and rates of goals of care documentation before and after the implementation of an embedded team compared to a referral-based consult.	Any patient admitted to the MICU	221 patients	Early PCC - Embedded team-based PCC	169	Mean number of days from admission to consult - 7.6 days (median 3 days) (p = 0.005)	Palliative care RN met with patients and their family to document a medical decision maker and provide bedside education on palliative care, while a palliative care MD worked alongside the MICU team to evaluate and manage symptoms, in addition to leading goals of care conversations.	Mean hospital LOS - 23.2 days; mean ICU LOS - 8.7 days	Mixed results - “As compared to the patients who received a referral-based consult, there was a statisically significant […] increase in the median number of days from consult to discharge (3 days [pre] to 8 days [embedded], P<0.001) among those who received the embedded consult.”				“By seeing patients earlier in their illness trajectory, there is greater opportunity to improve quality of care, and lead to reduced hospital costs and improved resource allocation”. “There was a statistically significant increase in rate of documentation of medical decision-maker (40% [pre] vs. 66% [embedded], P<0.001) and goals of care (37% [pre] vs. 71% [embedded], P=0.002) in the embedded group as compared to the referral group.”	Level IIB - this is a retrospective cohort before-and-after analysis comparing referral-based versus embedded model. There was a moderate sample size with statistically significant clinical outcomes.
Mehta et al. (2023)		MICU in an urban, quaternary academic medical center	Retrospective cohort study		Any patient admitted to the MICU	221 patients	Usual or Late PCC - Referral-based PCC, standard	52	mean number of days from admission to consult - 14.3 days (median 10 days)		Mean hospital LOS - 21.7 days; mean ICU LOS - 10.6
Mun et al. (2016)	Trend of Decreased Length Of Stay in the Intensive Care Unit (ICU) and in the Hospital with Palliative Care Integration into the ICU	15-bed adult mixed ICU at a 318-bed tertiary care hospital in Honolulu, HI	Pre-post intervention observational study	To incorporate palliative care into the routine ICU workflow to increase the numbers of palliative care consultations, improve end-of-life care in the ICU, and demonstrate an impact on ICU and/or hospital LOS.	Any adult patient admitted to or transferred to the ICU who met daily screening/trigger criteria for potential PCC. Triggers included: advanced cancer, chronic and severe cognitive dysfunction, consistency with or lack of goals of care, conflict with goals of care, multiorgan system failure, LOS in ICU longer than seven days.	392 patients -> pre-intervention consists of 194 patients receiving usual PCC compared with post-intervention of 198 patients receiving early PCC based on meeting trigger criteria	Early PCC - “post-intervention” group	198	Within 72 hours	Palliative care team consists of: board-certified physician, registered nurse, chaplain, and social worker. Within the first 3 days of admission/transfer to ICU, patient families watched a video on goals of care, and meetings were held between families and an MD/RN and social worker. A proactive family meeting was scheduled for day 3, with a multidisciplinary family meeting on day 5.	hospital LOS - mean of 12.88 days (p = 0.05)				By day 3 of ICU stay, 37% of patients had a clarified code status and 33% had goals of care identified (p 0.05 and 0.01 respectively).		Level IIB - this is a retrospective observational trend over time comparing pre- and post-intervention cohorts. It was an analysis of QI data, so there is no experimental design or randomization.
Mun et al. (2016)			Pre-post intervention observational study				Usual or Late PCC - “pre-intervention” group	194	after 72 hours		hospital LOS - mean of 17.42 days				By day 3 of ICU stay, 16% of patients had a clarified code status and 10% had goals of care identified.
Nakagawa et al. (2019)	Palliative Care Consultation in Cardiogenic Shock Requiring Short-Term Mechanical Circulatory Support: A Retrospective Cohort Study	ICU at the Columbia University Medical Center	Retrospective cohort study	To describe the utilization of PCC in this patient population and to examine the relationship between the timing of PCC and patient outcomes.	age >18, cardiogenic shock requiring STMCS (ECMO or STVAD)	248 eligible patients -> 53 met exclusionary criteria -> 159 patients were included -> 49 had early PCC, 45 had late PCC, 65 had no PCC	Early PCC	49	within 7 days of initiating STMCS	palliative care team: board-certified palliative care physicians and NPs, social workers, and chaplains	median days in hospital after STMCS - 19; median days from PCC to discharge - 18	“STMCS duration, ICU stay after STMCS, and hospital stay after STMCS were significantly shorter in the no PCC group than the early PCC group (4 vs. 12 days, P < 0.001; 11 vs. 19 days, P = 0.004; and 16 vs. 19 days, P = 0.031; respectively). ICU stay after STMCS and hospital stay after STMCS were significantly shorter in the early PCC group than the late PCC group (19 vs. 38 days, P < 0.001; 19 vs. 49 days, P < 0.001; respectively). However, time from initial PCC to discharge was not significantly different between early and late PCC groups (18 vs. 31 days, P = 0.13)”	Median days on STMCS for all patients - 12; Days on STMCS for deceased patients - 9	“[C]ompared with the late PCC patients, the early PCC patients have higher mortality, shorter STMCS days, and higher rate of withdrawal of STMCS.”			Level IIIB - this is a retrospective cohort study cohort with strong methodology and a moderate sample size. Study limitations were discussed.
							Usual or Late PCC	45	8 or more days after implementing STMCS		median days in hospital after STMCS - 49; median days from PCC to discharge - 31		Median days on STMCS for all patients - 18; Days on STMCS for deceased patients - 17
							No PCC	65			median days in hospital after STMCS - 16; median days from PCC to discharge - NA		Median days on STMCS for all patients - 4; Days on STMCS for deceased patients - 1.5
Rotundo et al. (2022)	Retrospective Review of Trauma ICU Patients With and Without Palliative Care Intervention	ICU in a level 1 trauma center	Retrospective cohort study	To assess the impact of specialist PC involvement on the management and outcomes of ICU trauma patients at a level 1 trauma center.	Age 18-99, alive 48 hours after admission to trauma ICU	166 patients	Usual PCC	83	PCC was requested on average 16 days into hospitalization	Specialty palliative care team	mean hospital length of stay - 18.33; mean ICU length of stay - 9.83	Trauma ICU patients who received PC consultation were more likely to have a shorter hospital LOS (P <0.001) and ICU LOS (P = 0.001)	Mean days with mechanical ventilation - 10.12; PEG placement in 26.5% of patients; tracheostomy placed in 20.6% of patients	Patients who received PCC had fewer days on a ventilator (P = 0.039), fewer PEG tubes placed (p = 0.008), and fewer tracheostomies (P < 0.001) compared to patients who did not have PCC.			Level IIIB - this is a retrospective cohort study with thorough description of limitations.
Rotundo et al. (2022)		ICU in a level 1 trauma center	Retrospective cohort study		Age 18-99, alive 48 hours after admission to trauma ICU	166 patients	No PCC	83	No PCC	Specialty palliative care team	mean hospital length of stay - 30.10; mean ICU length of stay - 23.38		Mean days with mechanical ventilation - 14.35; PEG placement in 46.9% of patients; tracheostomy in 52.0% of patients
Spencer et al. (2023)	Timing is everything: Early versus late palliative care consults in trauma	Level I academic trauma center	Retrospective cohort study	To compare hospitalization metrics of early versus late PCC in trauma patients.	Trauma admissions (trauma service and trauma ICU) over 18 years old who received PCC	154 patients met inclusion criteria	Early PCC	60	Within 72 hours; mean time to PCC was 1.27 days	Specialty palliative care team	mean hospital LOS 7.0 days (IQR 2.7 - 8.2) (p <0.01)	“Patients in the LATE group had significantly longer hospital LOS (20.5 vs. 7.0 days, P < 0.01), more days in the ICU (11.1 vs. 4.9, P < 0.01), and higher median total hospital costs ($53,165 vs. $17,654, P < 0.01)”	1.7% in the early group received tracheostomy and a feeding tube (p = 0.03). Mechanical ventilation - a mean of 4.9 days (P <0.01).				Level IIIB - this is a retrospective comparative observational cohort study with solid methodology.
Spencer et al. (2023)		Level I academic trauma center	Retrospective cohort study			154 patients met inclusion criteria	Usual or Late PCC	94	>72 hours; mean time to PCC was 10.38 days	Specialty palliative care team	mean hospital LOS 20.5 (IQR 9.3 - 26.0)		11.7% of the late group received tracheostomy and a feeding tube. Mechanical ventilation - a mean of 7 days.
Zalenski et al. (2017)	Impact of Palliative Care Screening and Consultation in the ICU: A Multihospital Quality Improvement Project	Three major metropolitan areas - two university-affiliated urban tertiary care centers, five community hospitals	Prospective cohort study	To determine the outcomes of receiving palliative care consultation (PCC) for patients who screened positive on palliative care referral criteria.	Patients in the ICU must have a positive screen (at least one of the following criteria): admitted from SNF or LTAC, end-stage dementia, ALS, MS, large intracranial hemorrhage with anoxic encephalopathy, advanced or metastatic cancer, post-cardiac or respiratory arrest with neurological compromise	1134 patients were screened for palliative care needs -> 431 screened positive for PC triggers -> 29 excluded for missing data -> 405 patients included	Early PCC	161 -> 84 on days 1-4, 27 on days 5-7, 50 on day >7	Data is split into subgroups: “early” -PCC on or before day 4; between days 5 and 7; and PCC after day 7	Varied by hospital, but all included at least a dedicated palliative care physician. Some hospitals had nurse practitioners, palliative care nurses, chaplains, and dedicated social worker.	The no PCC group LOS fell between the early and late PCC. Median LOS for patients who received PCC on or before day 4 was 1.7 days shorter than those who did not receive PCC.	“in further subgroup analysis stratified by time of PCC, the median hospital LOS among patients who received PCC on or before hospital Day 4 (N ¼ 84) was 1.7 days (95% CI 33.1, 11.2) shorter compared to screen-positive patients who did not receive a PCC (Fig. 1). The median LOS among patients who received PCC between Days 5 and 7 (N ¼ 27) was 1.8 days (95% CI 33.4, 0.1) shorter than patients who did not receive a consultation; however, this difference did not meet the threshold for statistical significance, possibly due to a smaller N. In contrast, patients who received a PCC after Day 7 (N ¼ 50) had a median LOS that was 6.2 days (95% CI 4.1e8.7) longer than those who did not receive a PCC”			Without differentiating time of intervention, 74.1% of patients who received PCC changed from full code to DNR (P < 0.0001)		Level IIIB - this is a multi-hospital QI project without randomization, which had statistically significant findings.
Zalenski et al. (2017)			Prospective cohort study				No PCC	244	No PCC						19.6% of patients changed from full code to DNR

Critical Appraisal

Each study was critically analyzed for the quality of its evidence and graded according to the Johns Hopkins Evidence-Based Practice Model and can be found in the final column of the TOE.¹⁵ Two articles were rated high quality, 14 medium quality, and 1 low quality. No articles were excluded for quality reasons.

Results

Patient Populations

Sample size ranged from 38¹⁶ to 1,035¹⁷ patients. The mean age across studies was 60-77 years old, barring 2 studies. Barasa et al¹⁸ included a younger patient population, with a mean age of 56 and 58 years old in the intervention and control groups, respectively. Nakagawa et al⁶ also had a younger population with mean ages of 55.3-60.9 years old. Race and gender varied more widely across studies but were well-matched between intervention and control groups within each study. No studies reported notable group differences. Details regarding group demographics can be found in Table 2.

Inclusion and Exclusion Criteria

Inclusion criteria varied across the 17 studies. Each study included patients over the age of 18 who were admitted to the ICU. Four studies^12,18-20 referenced the IPAL-ICU criteria⁷ and used that screening tool as a base for their individual criteria, opting to include chronic and severe cognitive dysfunction, metastatic cancer, cardiac or respiratory arrest, multiple organ system failure, known end-stage organ disease, and recurrent hospital and ICU admissions within a specific time frame among the list of PC triggers.

Seven studies^12,17,21-25 relied on triggers determined in prior RCTs taken in consideration with internal data collected from their institution and suggestions made by experienced ICU clinicians. For example, Cox et al²⁴ evaluated PC triggers that clinicians flagged as valuable, and which had evidence of association with readmission, symptoms, and mortality. Ultimately, Cox et al²⁴ included patients receiving mechanical ventilation or in shock for greater than 48 hours after ICU admission, in addition to experiencing 1 of the following: dementia, declining health status, poor functional status, severe acute illness, or severe acute stroke.

All studies excluded patients younger than 18 years old, patients or surrogates who refused a PCC, and patients who already had a PCC prior to admission to the ICU. Multiple authors excluded patients who died before PCC or who were expected to be discharged from the ICU within <24 hours because it was deemed inadequate time for a PCC to take place.^21,22,24 Other exclusion criteria included patients already having their code status as do-not-resuscitate and do-not-intubate (DNR/DNI) prior to ICU admission or within 6 hours of transfer^12,17 and insufficient data from medical records for the retrospective studies.

Study Design and Methods

All studies reviewed were published between 2015 and 2025. The only studies published from outside of the United States were conducted in a university hospital in Kenya¹⁸ and a tertiary hospital in South Korea.¹⁶

Thirteen studies occurred in a single ICU within 1 institution. Ma et al¹² included patients from 2 ICUs in the same hospital. Cox et al²⁴ included patients from adult medical, surgical, cardiac, and neurological ICUs within the same institution. Zalenski et al²⁵ collected data from ICUs in 2 university-affiliated hospitals and 5 community hospitals. Bharadwaj et al²⁶ examined multiple ICUs across 7 hospitals in 1 health system. Of note, Bharadwaj et al (2016) conducted 5 different retrospective studies reported in 1 article. Studies 2 and 4 specify that all patients involved were in the ICU,²⁶ so only results from those studies are considered in this portion of the review.

Early PCC was the independent variable in all the studies conceptually. However, early PCC was defined differently across studies. Four studies^19,23,27,28 in this review considered early PCC as intervention within 72 hours of admission to the ICU; 1 study²¹ considered consultation within 24 hours of admission to the ICU; and 3 studies^12,22,26 considered consultation within 48 hours of admission to the ICU. Hochberg et al¹⁷ screened patients within 48 hours of admission to the ICU, but only 17% of those patients received PCC within 48 hours. PCC placed outside of these windows were considered late PCC, usual intervention, or standard of care. Four studies did not define early PCC by a specific time frame because they considered PCC for patients who met the triggers as the intervention and usual intervention was considered no PCC at any point during the ICU stay.^8,16,18,20

Helgeson et al²¹ and Ma et al¹² conducted RCTs by randomizing eligible patients to either a control group or an intervention group by a random number generator. In the intervention groups, patients received early PCC within 24 and 48 hours of admission to the ICU, respectively. In the control group, PCC was ordered as needed at the discretion of the ICU intensivists or as requested by patients or surrogate decision makers, if at all.

There was no standardization of who conducted the PCC and what a PCC consisted of from study to study. Thirteen of the studies had a PC team consisting of at least a board-certified PC physician, often also including advance practice providers, registered nurses, and dedicated social workers and chaplains.^{6,9,12,16-21,23-25,27} Four studies^8,22,26,28 did not define the members of the PC team or give insight as to their level of expertise or specialty certification. Priorities in PCCs included discussing advance care planning and completing an advance directive, identifying a surrogate, addressing code status, identifying what needs remain unmet, facilitating family meetings, and updating goals of care based on prognosis.

Outcomes

Nine studies^{6,8,19,21,23,24,26-28} found a statistically significant decrease in length of stay for patients who received early PCC. Helgeson et al²¹ examined the shortest time to intervention and found ICU LOS was shorter for patients who received PCC within 24 hours of ICU admission (P = 0.018) at 3 days, versus 8 days for patients in the control group who received late or no PCC. Bharadwaj et al²⁶ examined PCC within a 48 hour window found patients had significantly shorter ICU LOS. Four studies^19,23,26,28 found hospital and ICU LOS was significantly shorter for patients who received PCC within 72 hours of ICU admission. Nakagawa et al⁶ examined the longest time to intervention, considering early PCC as intervention within 7 days of initiating short term mechanical circulatory support, usual or late PCC as intervention after eight or more days on short-term mechanical circulatory support, and compared both groups to those who did not receive any PCC in the ICU. Even considering the longest time to intervention in this review, Nakagawa et al found median days from PCC to discharge significantly shorter (P < 0.001) for those who received early PCC compared to those who received usual care, at 18 and 31 days respectively.

While not statistically significant, 5 studies^12,16-18,25 showed a decrease in hospital and/or ICU length of stay for patients who received early PCC. Barasa et al found ICU LOS to be 2 days shorter for patients who received PCC,¹⁸ while Hochberg et al and Ma et al found patients who received early PCC had a shorter hospital stay by about 1 day compared to groups who received usual or late PCC.^12,17 Kim et al¹⁶ did not have a control group but found that the median hospital LOS for those who received PCC while in the neurosurgical ICU was 12.5 days, which was shorter than the overall average hospital LOS of 14 days. Zalenski et al¹⁹ compared 4 distinct sets of data: PCC on or before day 4, between days 5 and 7, and PCC after day 7, all compared to the control group who did not receive PCC at all while in the ICU. Results indicated patients who received PCC between days 1 and 7 had a shorter median length of stay than those who did not receive PCC, however the patients who received PCC after day 7 had a median length of stay many days longer than those without PCC.

The final 3 studies in this review found mixed results. Babar et al²² reported a shorter median ICU LOS of 5 days for early PCC and 11 days for late PCC, however the cohort that did not receive PCC at all had the shortest median LOS at 3 days. Mehta et al⁹ compared patients who received an embedded team-based PCC that was generally 3 days after ICU admission, against patients who received the standard referral-based PCC a median of 10 days after admission to the ICU and found that mean ICU LOS was shorter than in the usual PCC group. However, in this study, the median number of days from PCC to discharge was significantly longer in the embedded team-based cohort that received early PCC (8 days vs 3 days, P < 0.001).⁹ Martz et al²⁰ found that patients who received PCC had a shorter mean ICU LOS but longer hospital LOS than the cohort of patients who did not receive PCC. This was the only study in this review where hospital and ICU LOS did not correlate after intervention.

While length of stay is the primary outcome of interest, de-escalation of code status, the rate of invasive interventions, and transition to hospice were statistically significant in many studies. Table 3 summarizes all outcomes discussed.

Table 3.

Overview of Pertinent Findings for the Intervention Group (Patients Who Received Early/Any PCC) Compared to the Control Group (Patients Who Received Usual/Late or No PCC) Within Each Study

Study (Year)	Timing of PCC relative to ICU admission	ICU LOS	Hospital LOS	Code status de-escalation	Rates of invasive interventions	Referral or transfer to hospice	Notes
Helgeson et al (2023)	<24 hours	↓*	-	↑*	↓	↑*
Babar et al (2021)	<48 hours	↑↓	-	↑*	↓	↑*	Patients who received early PCC had shorter ICU LOS than those who received late PCC, however both PCC groups had a longer LOS than the control group who did not receive any PCC.
Bharadwaj et al (2016)	<48 hours	↓*	-	-	-	↑
Ma et al (2019)	<48 hours	↓	↓	↑*	↓*	↑*
Braus et al (2015)	<72 hours	↓	↓*		-	↑
Kumar et al (2024)	<72 hours	↓*	-	↑	↓	↑
Mun et al (2016)	<72 hours	↓	↓*	↑	-	-
Spencer et al (2023)	<72 hours	↓*	↓*	-	↓*	↑
Mehta et al (2023)	∼3 days	↑↓	↑	-	-	↓*	Mean ICU LOS overall was shorter in the intervention group, however ICU LOS post-PCC intervention was longer (P < 0.001)
Kim et al (2025)	∼3.5 days	↓	-	↑*	-	-
Cox et al (2018)	∼3.6 days	↓	↓*	↑	↑↓	↑	Mean ICU and hospital LOS were shorter in the intervention group than the control group after PCC. Overall mean ICU LOS was longer for patients in the intervention group, and overall mean hospital LOS was shorter for intervention patients (P < 0.05)
Zalenski et al (2017)	<4 days	-	↓	↑*	-	↑*
Nakagwa et al (2019)	<7 days	↑↓	↑↓	-	↓	-	ICU and hospital LOS were significantly shorter in the no PCC group than the early PCC group. ICU and hospital LOS were significantly shorter in the early PCC group than late PCC group
Barasa et al (2021)	Any PCC	↓	-	↑*	-	-
Hochberg et al (2025)	Any PCC	↓	↓	-	-	↑
Martz et al (2020)	Any PCC	↓	↑	↑	↓*	↑*
Rotundo et al (2022)	Any PCC	↓*	↓*	-	↓*	↑

Notes. Some studies do not specify the time of intervention as a strict window and instead reported their data as mean days after ICU admission or identified what percentage of patients received PCC within a certain timeframe. Details regarding PCC timing can be found in Table 2 (Table of Evidence) or within the original texts. Legend:↓ = decrease. ↑ = increase. ↑↓ = mixed results. - = not reported. * = statistically significant (P < 0.05).

Helgeson et al²¹ found that 56% of patients who received early PCC changed their code status to DNR/DNI, compared to 34% of patients in the control group (P = 0.037). Ma et al¹² found patients who received early PCC de-escalated their code status more frequently and earlier in the hospital stay than patients in the control group (50.5% vs 23.4%, P = <0.0001). Babar et al²² determined patients who received early PCC were more likely to transition to DNR/DNI than those who did not have PCC (63.6% vs 7.7%, P < 0.0001). While more patients who received early PCC transitioned, patients who received PCC at any point during their hospital visit also transitioned to DNR/DNI significantly more often than patients who did not receive PCC (P = 0.0001).²²

Referral or transfer to hospice care occurred much more often in intervention groups than control groups. For example, Helgeson et al²¹ found 42% vs 15% of patients enrolled in hospice (P = 0.004); Ma et al¹² found 18.6% vs 4.9% patients entered hospice (P = 0.0026); and Babar et al²² found 36% compared to 2.6% patients transitioned to hospice (P = 0.0001).

Discussion

Primary findings in this literature review indicate that early PCC has an impact on length of stay in the ICU and the hospital overall. The methods of implementing early PCC ranged from an embedded model and a trigger-based referral model to an integrated electronic health-record app that triggers targeted PC. Regardless of the specific delivery model, multiple studies found that early screening for unmet PC needs led to earlier PCC in the ICU, ultimately decreasing LOS.

Of note, data for multiple variables was reported by median and mean, which makes comparison of results difficult across studies. The median was more likely reported due to significant variation or standard deviation that would skew results if reported as the mean, and so it gives a more appropriate sense of the effect of the intervention. The data was notable for other findings related directly to components of a comprehensive PCC and thus show a positive relationship between PCC and patient-centered goals of care being met.

The findings of this literature review underscore the persistent lack of standardization in both the implementation and operationalization of PCC in the critical care setting. Across these studies, there was considerable variability in the tools, criteria, and triggers used to initiate PCC. As detailed in the Results section, the most common approach to initiating PCC relied on institution-specific triggers, often shaped by individual clinician experience and informed by broader recommendations like those from the Improving Palliative Care in the ICU (IPAL-ICU) Project.⁷ While these guidelines have provided a valuable framework, they have not been universally adopted in a standardized manner.

This variability introduces significant opportunities for bias in determining which patients receive PC, particularly in observational or non-randomized study designs. Studies demonstrated that without random assignment to PCC, clinician discretion played a central role in consult initiation, leaving room for subjective factors to influence patient selection. For example, Babar et al.²² found the most common reason that eligible patients did not receive early PCC was due to clinical decisions made by their primary team. Data was not collected regarding why teams opted not order PCC in most studies. Future studies would be beneficial to determine reasoning behind the choice not to order PCC for patients who meet validated triggers. Such bias complicates the interpretation of outcomes and limits the generalizability of findings across institutions.

Furthermore, several studies lacked clarity regarding the composition of the PC team delivering the intervention and the specific objectives of PCC for each patient. Specialty trained PC clinicians should be able to thoroughly assess patients and conduct goals-of-care discussions, beyond non-specialty trained providers performing primary PC. Without consistent reporting on whether PCC focused on goals-of-care discussions, symptom management, or psychosocial support, it becomes difficult to assess the true impact and efficacy of these interventions. This gap highlights the need for greater transparency and standardization in both the initiation and documentation of PC involvement in the ICU setting.

Of note, 2 of the studies included in this literature review were conducted outside of the United States. As such, there are cultural, political, and epidemiological differences that may impact the generalizability of the findings from those studies to the critically ill patients in the United States. The Barasa et al study was conducted in Kenya, while the Kim et al study was based in South Korea. Kim et al¹⁶ noted that the Life Sustaining Treatment Decision Act, passed in 2018, widely expanded the availability of PC and hospice in services in South Korea, but patient and family knowledge and acceptance of these services was still in the early stages. Barasa et al¹⁸ enrolled a younger patient population, possibly due to the difference in life expectancies in Kenya as compared to the United States, with a life expectancy of 79.61 years in the United States vs 64.01 years in Kenya.²⁹ Age of the patient is often a factor considered along with overall health status, as people tend to accumulate comorbidities over time. The difference in age may have impacted study findings in a way that was not seen in the other studies.

Nakagawa et al⁶ also had a younger population with mean ages of 55.3 – 60.9 years. Because this study looked specifically at PCC for patients on short-term mechanical circulatory support, there were likely other factors like comorbidities and protocols, that reduce the likelihood older adults will receive short-term mechanical circulatory support, resulting in a younger population.

Strengths and Limitations

In this review, 2 studies included patients across multiple institutions^8,25 and 2 studies evaluated more than 1 unit within a single institution.^12,24 Due to the limited sample sizes and the predominance of single-unit, single-institution designs, the findings of most studies in this review are not broadly generalizable. However, this review encompasses multiple studies involving patients from a wide range of critical care subspecialties, including mixed ICUs, surgical, medical, trauma, neurosurgical, and cardiovascular ICUs. This diversity in patient populations helps mitigate subspecialty-specific bias and enhances the applicability of findings across the broader critical care setting.

The patients in all included studies, while balanced within their intervention and control groups, were not reflective of the larger population in the United States and this is a source of sample bias and minimizes generalizability of the results of this review. It is possible that lack of racial diversity and limited data collection on religious and spiritual beliefs may have also obscured bias regarding the willingness of patients and families to participate in PCC or extensive life-sustaining therapies like mechanical circulatory support or receiving blood products.

A key limitation of this review is the heterogeneity in PC intervention design and delivery. Timing varied widely, with no consistent definition of ‘early’ vs ‘late’ PCC, complicating conclusions about optimal consultation timing but underscoring its potential impact when provided within specific time frames. Many studies also lacked detail on the personnel delivering PCC; while some described team composition, none specified which members provided bedside care. Similarly, intervention goals and objectives were rarely reported. This variability in structure and intent limits comparability and interpretation of outcomes across studies.

Conclusion

The results of this literature review are promising, but not conclusive for changing practice at this time. Further research is needed to determine the best way to implement earlier PCC amid already over-extended PC providers and busy shifts in the ICU. PC can be provided by any clinician, and while the results are not as well studied as interventions provided by a PC specialist, patients still derive benefits from primary PC. Decreased hospital and ICU length of stay, reduced rates of invasive procedures and non-goal concordant care, and code status de-escalation are only a limited example of the appealing outcomes tied to early PCC. These outcomes are reasonable proxies for an expected increase in patient and caregiver satisfaction, decreased moral distress for health care providers, and reduced healthcare resource utilization and costs. The goal of providing early PC, as evidenced by the literature, is to have more time to intervene and thus benefit from having a greater opportunity to tailor care to a patient’s needs and wishes. Effective PC lends itself to improvement in many clinically important metrics⁹ because of the patient-centered nature of the specialty and emphasis on communication.

To advance the field, additional research is recommended with larger sample sizes across multiple institutions to produce statistically meaningful and generalizable results. There was also no consensus across the literature of the best way to integrate PC into the workflow in the ICU – Mehta et al.⁹ was the only study that compared an embedded team-based model and a referral-based model, which showed mixed results.

Footnotes

ORCID iDs

Sophie Caplan

Patricia C. Pawlow

Ethical Considerations

Not applicable as there is no original research in this manuscript. All references have been properly cited throughout this work.

Author Contributions

All authors meet the ICMJE criteria for authorship.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data Availability Statement

The data used in this review comes from published and peer-reviewed works. This literature review cites all the studies referenced appropriately.*

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