Association of Palliative Care Consultation with Outcomes after Out-of-Hospital Cardiac Arrest

Abstract

Background

Out-of-hospital cardiac arrest (OHCA) is associated with high morbidity and mortality, often requiring complex decision-making in the intensive care unit (ICU). Palliative care may facilitate goal-aligned care but remains underutilized in this population.

Objective

To evaluate the impact of palliative care consultation on end-of-life decision-making and clinical outcomes in ICU patients following OHCA.

Methods

We conducted a mixed retrospective–prospective cohort study of 61 retrospective and 40 prospective adult patients admitted to the ICU after OHCA at a tertiary academic center. Patients were grouped by palliative care consultation. Primary outcomes were in-hospital mortality and ICU and hospital length of stay. Secondary outcomes included the proportion of patients with code status change, the timing of code status changes and withdrawal of life-sustaining treatment from ICU admission in both groups, and withdrawal of life-sustaining treatment. Illness severity was assessed using the Sequential Organ Failure Assessment (SOFA) score at ICU admission and at 72 hours.

Results

Among 101 patients admitted after OHCA, 34 (33.7%) received a palliative care consultation. In-hospital mortality was higher among patients who received palliative care consultation than among those who did not (79.4% vs 41.8%; P = 0.0003). SOFA scores at ICU admission and at 72 hours were similar between patients seen by palliative care and those not seen by palliative care (P = 0.72 and P = 0.27, respectively). All patients who received a palliative care consultation (100%) had a change in code status during hospitalization, compared to 32.8% of those who did not (P < 0.0001). The time from ICU admission to withdrawal of life-sustaining treatment was significantly longer in the palliative care group (6.0 vs 3.0 days, P = 0.016), while the time to code status change was similar between groups (P = 0.415). There were no significant differences in ICU or hospital length of stay, or use of vasopressors, mechanical ventilation, or continuous renal replacement therapy. Among patients who received palliative care consultation, the most common interventions included goals-of-care clarification (85.3%), symptom management, and spiritual or emotional support.

Conclusion

In ICU patients following OHCA, palliative care consultation was associated with higher in-hospital mortality despite similar baseline characteristics, illness severity by SOFA score, and treatment intensity, likely reflecting preferential consultation in patients with greater clinical complexity rather than a causal relationship. Palliative care consultation was strongly associated with goals-of-care redirection and a more deliberate process of end-of-life decision-making.

Keywords

palliative care cardiac arrest ICU goals of care end-of-life decision-making mortality

Introduction

Out-of-hospital cardiac arrest (OHCA) is a significant public health issue marked by high rates of morbidity and mortality, creating complex decision-making scenarios within the intensive care unit (ICU).¹ Despite advancements in medical care, survival rates are often low, and patients who do survive may face substantial long-term consequences. This situation frequently necessitates difficult conversations about the continuation or withdrawal of life-sustaining treatments.²

Palliative care is a specialized medical approach that focuses on improving the quality of life for patients and their families facing serious illnesses by providing relief from symptoms and stress.³ In the ICU setting, palliative care can facilitate goal-aligned care; however, it remains underutilized for the OHCA population.⁴ While existing knowledge suggests benefits in other critically ill patient groups, there is limited data on how palliative care consultation specifically affects decision-making and outcomes among patients admitted after an OHCA.5

To address this knowledge gap, we conducted a mixed retrospective-prospective cohort study to evaluate the impact of palliative care consultation on end-of-life decision-making and clinical outcomes in ICU patients following OHCA. We examined primary outcomes, such as in-hospital mortality and length of stay, and secondary outcomes, including the timing of code status changes and the withdrawal of life-sustaining treatments. We hypothesized that palliative care consultation in patients with out-of-hospital cardiac arrest would be associated with differences in end-of-life care patterns, reflecting a shift in the focus of care, without significant changes in length of stay or treatment intensity.

Methods

Study Design

This was a mixed retrospective and prospective observational study conducted at Memorial Hermann–Texas Medical Center, a tertiary academic hospital affiliated with the University of Texas Health Science Center at Houston (UTHealth). The study was carried out over a two-year period, beginning in October, 2023 and ending in March, 2025. The institutional review board approved the study, and a waiver of informed consent was granted, given the minimal risk, observational design, and the use of de-identified data.

Patients

Adult patients (aged ≥18 years) admitted to the intensive care unit (ICU) with a diagnosis of out-of-hospital cardiac arrest were eligible for inclusion. For the retrospective cohort, patients were identified through ICU and hospital admission databases. The prospective cohort enrolled patients in real-time during the ICU stay. Inclusion criteria required that patients had the return of spontaneous circulation (ROSC) and were admitted to the ICU for post-cardiac arrest care. Patients were excluded if they were admitted for in-hospital cardiac arrest, died in the emergency department before ICU admission, or lacked sufficient documentation for outcome assessment. Patients were then categorized into two groups based on whether they received a palliative care consultation at any point during hospitalization. All patients with complete clinical and outcome data were included in the final analysis.

Palliative Care Consultation

A multidisciplinary team of palliative care physicians, physician assistants, nurse practitioners, social workers, chaplains, and case managers provide palliative care consultation at Memorial Hermann- Texas Medical Center. Consultations are initiated at the discretion of the primary ICU team and are available seven days a week. The focus of the palliative care team includes clarification of goals of care, assistance with complex decision-making, management of symptoms (including pain and non-pain-related distress), support for surrogate decision-makers, and provision of spiritual and psychosocial support. For this study, a palliative care consultation was defined as any formal evaluation documented by the palliative care service during the ICU or hospital stay. The timing, frequency, modality (in-person, telephone, or teleconference), and type of interventions provided during each consultation were recorded for patients in the palliative care group.

Data collection

Data was collected using the hospital’s electronic medical record system (Epic Systems, Verona, WI), a combination of retrospective chart review and prospective data entry. For patients in the retrospective cohort, trained study team members abstracted relevant clinical and demographic information using a standardized data collection tool. For prospective cases, data were recorded in real-time during the patient’s ICU stay.

Collected variables included demographics (age, sex), past medical history (hypertension, diabetes, coronary artery disease, heart failure, chronic kidney disease, malignancy), and cardiac arrest-related information (cause of arrest and initial code status). Clinical course data included ICU length of stay, total hospital length of stay, use of vasopressors or inotropes, mechanical ventilation, continuous renal replacement therapy (CRRT), and mechanical circulatory support.

For patients who received palliative care consultation, additional information was collected regarding the number of encounters, provider type, mode of communication (in-person, telephone, teleconference), and nature of the interventions provided (eg, goals of care clarification, pain management, spiritual support). For all patients, the time from ICU admission to code status change and the time from withdrawal of life-sustaining treatment were recorded. The timing of palliative consultation relative to ICU admission was also documented.

Outcomes Measures

The primary measures included in-hospital mortality, ICU length of stay, and hospital length of stay.ICU and hospital length of stay were calculated for all patients regardless of discharge status, including those who died during hospitalization. Secondary outcomes included the time from ICU admission to code status change and to withdrawal of life-sustaining treatment in both groups, as well as the proportion of patients in each group who experienced a change in code status during hospitalization. Illness severity was assessed using the Sequential Organ Failure Assessment (SOFA) score, collected at ICU admission and at 72 hours, and compared between groupsFor patients who received a palliative care consultation, additional secondary measures included the timing of the consultation relative to ICU admission, the number and type of palliative care encounters, and the nature of palliative interventions provided. These interventions were categorized into domains such as goals-of-care clarification, pain and symptom management, psychosocial support, spiritual support, and assistance with surrogate decision-making. All outcome measures were compared between patients who received palliative care consultation and those who did not.

Statistical Method

Descriptive statistics were used to summarize patient baseline characteristics and clinical outcomes. Continuous variables were reported as means with standard deviations (SD) and medians with interquartile ranges (IQR). Categorical variables were summarized using frequencies and percentages. As the continuous variables in this study were not normally distributed, they were analyzed using the Wilcoxon rank-sum test. Categorical variables were compared using chi-square tests or Fisher’s exact tests, as appropriately based on cell counts. A two-sided P-value of less than 0.05 was considered statistically significant. All statistical analyses were performed using SAS 9.4 software (SAS Institute Inc., Cary, NC, USA).

Results

Out of 101 patients admitted with out-of-hospital cardiac arrest, 61 (60.4%) were identified through retrospective chart review, and 40 (39.6%) were enrolled prospectively. Of the total cohort, 34 (33.7%) received a palliative care consultation, and 67 (66.3%) did not. The average age of the total cohort was 58.5 ± 15.0 years, and 62.4% were male. There were no statistically significant differences between the groups regarding age (60.4 ± 13.2 vs 57.5 ± 15.9 years, P = 0.452) or gender (55.9% vs 65.7% male, P = 0.337). Comorbidities such as hypertension, diabetes, coronary artery disease, heart failure, chronic kidney disease, and malignancy were similarly distributed (all P > 0.05). The leading causes of cardiac arrest were primary arrhythmia (40.6%), hypoxemia (19.8%), and acute myocardial infarction (13.9%) (Table 1). A legally assigned medical power of attorney (MPOA) was identified in 8.96% of the non-palliative group and none of the patients in the palliative care group (P = 0.0602). At admission, all patients were documented as full code status, with no cases of Do Not Resuscitate (DNR), Do Not Intubate (DNI), or comfort care status. Other surrogate decision-makers included spouses, children, parents, and adult siblings, with spouses being the most frequently identified surrogate across both groups.

Table 1.

Demographic and Clinical Characteristics

	Overall (n = 101)	Palliative (n = 34)	No palliative (n = 67)	P value
Demographics
Age, years *mean (SD), median^ (IQR)	58.45 ± 15.04 61 (16)	60.41 ± 13.20 61.50 (17)	57.45 ± 15.89 61 (20)	0.452
Gender, n (%)				0.3372
Male	63 (62.38)	19 (55.88)	44(65.67)
Female	38 (37.62)	15 (44.12)	23 (34.33)
PMH, n (%)
Hypertension	48 (47.52)	18 (52.94)	30 (44.78)	0.4375
Diabetes mellitus	28 (27.72)	9 (26.47)	19 (28.23)	0.8413
CAD	18 (17.82)	8 (23.53)	10 (14.93)	0.2856
Heart failure	16 (15.84)	7 (20.59)	9 (13.43)	0.3520
CKD	15 (14.85)	4 (11.76)	11 (16.42)	0.7681
COPD/Asthma	3 (2.97)	0 (0.00)	3 (4.48)	0.5489
Hyperlipidemia	21 (20.79)	7 (20.59)	14 (20.90)	0.9713
Malignancy	10 (9.90)	4 (11.76)	6 (8.96)	0.7291
Cause of cardiac arrest, n (%)
AMI	14 (13.86)	6 (17.65)	8 (11.94)	0.4328
Primary arrhythmia	41 (40.59)	16 (47.06)	25 (37.31)	0.3460
Hypoxemia	20 (19.80)	4 (11.76)	16 (23.88)	0.1911
Neurologic	13 (12.87)	4 (11.76)	9 (13.43)	1.000
Other	21 (20.79)	7 (20.59)	14 (20.90)	0.9713
Decision maker, n (%)
Legally assigned MPOA	6 (5.94)	0 (0.00)	6 (8.96)	0.0602^**
Spouse	51 (50.50)	18 (52.94)	33 (49.25)
Children	21 (20.79)	6 (17.65)	15 (22.39)
Parent	10 (9.90)	2 (5.88)	8 (11.94)
Adult siblings	12 (11.88)	8 (23.53)	4 (5.97)
Distant relatives	1 (0.99)	0 (0.00)	1 (1.49)
Legal guardian	0 (0.00)	0 (0.00)	0 (0.00)
Two physicians	0 (0.00)	0 (0.00)	0 (0.00)
Code status upon arrival to the hospital, n (%)
Full code	101 (100)	34 (100)	67 (100)	NA***
DNI	0 (0.00)	0 (0.00)	0 (0.00)
DNR	0 (0.00)	0 (0.00)	0 (0.00)
DNI/DNR	0 (0.00)	0 (0.00)	0 (0.00)
Comfort care	0 (0.00)	0 (0.00)	0 (0.00)

PMH; past medical history, CAD; coronary artery disease, CKD; chronic kidney disease, COPD, chronic obstructive pulmonary disease, AMI; acute myocardial ischemia, MPOA; medical power of attorney, DNI; do not in tubate, DNR, do not resuscitate.

Note. Continuous variables are presented as *mean ± SD (first line) and ^median (IQR) (second line), as indicated. Categorical variables are presented as n (%). P-values were calculated using Student’s t-test or Wilcoxon rank-sum test for continuous variable, as appropriate. Categorical variable were compared using the chi-square test or Fisher’s exact test when expected cell counts were <5. **P-value from chi-square test comparing the overall distribution of decision-maker categories between groups. ***NA indicates no statistical test was performed due to lack of variability.

ICU Course, Mortality, and Life-Sustaining Treatment

The median ICU length of stay was longer in patients seen by palliative care (6.0 days, IQR 5.5) compared to those not seen (4.0 days, IQR 5.0), though this difference was not statistically significant (P = 0.0999). Median hospital length of stay was 6.0 days (IQR 5.5) in the palliative group and 5.0 days (IQR 7.0) in the non-palliative group (P = 0.28). In-hospital mortality was significantly higher in the palliative care group (79.4%) compared to the non-palliative group (41.8%) (P = 0.0003). SOFA scores at ICU admission and at 72 hours were similar between patients seen by palliative care and those not seen by palliative care [8.0 (IQR 7.0-11.0) vs 9.0 (IQR 5.0-11.0), P = 0.72; and 9.0 (IQR 6.0-11.8) vs 7.5 (IQR 3.0-11.0), P = 0.27, respectively].

There were no statistically significant differences between groups in the use of life-sustaining treatments. The use of vasopressors (52.9% vs 55.2%, P = 0.8277), continuous renal replacement therapy (20.6% vs 17.9%, P = 0.7449), and mechanical ventilation (100% vs 98.5%, P = 1.000) were similar between patients who received palliative care and those who did not (Table 2). All 34 patients (100%) seen by palliative care had a change in code status during hospitalization, compared to 22 patients (32.8%) who were not seen by palliative care (P < 0.0001). The median time from ICU admission to code status change was similar between groups [4.00 days (IQR 4.25) vs 2.50 days (IQR 4.50), P = 0.415]. However, the median time from ICU admission to withdrawal of life-sustaining treatment was significantly longer in patients seen by palliative care compared to those not seen [6.00 days (IQR 6.00) vs 3.00 days (IQR 4.00), P = 0.016] (Table 3).

Table 2.

Comparison of Critical Care Measures and Life-Sustaining Treatments Between Patients With and W/Out Palliative Care Consultation

	Total n (%)	Palliative consult n (%)	No palliative consult n (%)	P value
On vasopressors	55 (54.46)	18 (52.94)	37 (55.22)	0.8277
On continue renal replacement therapy	19 (18.81)	7 (20.59)	12 (17.91)	0.7449
On mechanical ventilation	100 (99.01)	34 (100)	66 (98.51)	1.0000
On mechanical cardiovascular support	4 (3.96)	2 (2.99)	2 (2.99)	0.6011

Table 3.

Code Status Changes and Timing by Group

Outcome	Palliative patients (n = 34)	Non-palliative patients (n = 67)	P value
Patient with code status change, n (%)	34 (100%)	22 (32.8%)	<0.0001
Duration from admission to change code status	4.47 ± 3.03 (4.00/4.25)	4.55 ± 4.97 (2.50/4.50)	0.415
Duration from admission to withdrawal of care	7.22 ± 6.69 (6.00/6.00)	4.64 ± 5.13 (3.00/4.00)	0.016

Characteristics of Palliative Care Encounters

Among the 34 patients seen by the palliative care team,the median time from ICU admission to palliative care consultation was 2.0 days (IQR 1.0-4.0), with a mean of 2.6 ± 1.8 days (range 1-9 days).The most common interventions included clarification of goals of care (85.3%), management of non-pain symptoms (50.0%), pain management (47.1%), spiritual support (50.0%), and assistance in determining treatment preferences (32.4%). Education about the clinical condition and help in identifying a surrogate decision-maker were provided in 26.5% of cases. Psychosocial support was documented in one patient (2.9%). The average number of physician visits per patient was 1.76 ± 0.52. On average, physician assistants participated in 0.27 ± 0.57 visits, while social workers/case managers were involved in 0.32 ± 1.25 visits. Chaplains were involved in most cases (mean 2.00 ± 2.00 visits). Nearly all palliative care consultations were conducted in person (97.1%), with minimal use of telephone or teleconferencing (Table 4).

Table 4.

Characteristics of the Group Evaluated by Palliative

Characteristics
Average number of palliative care encounters	Means ± SD*
Physician N = 34	1.76 ± 0.521
Physician assistant N = 34	0.265 ± 0.567
Nurse practitioner N = 34	0
Social workers/case managers N = 34	0.324 ± 1.249
Chaplain N = 34	2.00 ± 2.00
Communication method	n (%)
In person N = 34	33 (97.08)
Telephone N = 34	1 (2.94)
Teleconference N = 34	1 (2.94)
Interpreter service N = 34	0 (0.00)
Palliative care intervention
Pain management N = 34	16 (47.06)
No pain-related symptoms N = 34	17 (50.00)
Clarify goals of care N = 34	29 (85.29)
Determine surrogate decision-maker N = 34	9 (26.47)
Education about the condition N = 34	9 (26.47)
Psychosocial support N = 34	1 (2.94)
Spiritual support N = 34	17 (50.00)
Help determine treatment preference N = 34	11 (32.35)

Note. SD = Standard Deviation.

Discussion

This mixed retrospective-prospective cohort study evaluated the impact of palliative care consultation on end-of-life decision-making and clinical outcomes among 101 patients admitted to the ICU after out-of-hospital cardiac arrest (OHCA) at a large tertiary academic center. Several important findings emerged.

First, patients who received a palliative care consultation (33.7% of the cohort) experienced substantially higher in-hospital mortality (79.4% vs 41.8%) despite having similar baseline demographic characteristics, comorbidities, and use of life-sustaining therapies. This association likely reflects differences in clinical context, prognostic uncertainty, and evolving goals of care at the time of consultation. Second, all patients who received a palliative care consultation (100%) had a change in code status during hospitalization, compared to only 32.8% of those who did not (P < 0.0001), suggesting that palliative care consultation was strongly associated with goals-of-care discussions that led to a redirection of care. Furthermore, the time from ICU admission to withdrawal of life-sustaining treatment was significantly longer in the palliative care group (6.0 vs 3.0 days, P = 0.016), while the time to code status change was similar between groups (P = 0.415). Third, the utilization of life-sustaining therapies (including vasopressors, mechanical ventilation, and continuous renal replacement therapy) was similar between groups, indicating that palliative care engagement did not lead to early withdrawal of aggressive interventions. Palliative care teams primarily focused on clarifying goals of care (85.3%), symptom management, and spiritual support. Finally, palliative care consultation occurred in approximately one-third of patients in this cohort, highlighting variability in referral patterns within this high-risk population. Palliative care involvement was not associated with differences in ICU or hospital length of stay.

The high in-hospital mortality among patients receiving palliative care consultation in our cohort (79.4% vs 41.8%) aligns with prior critical care observational studies, including those by Curtis et al⁶ and the SUPPORT trial.⁷ This association has been described in prior observational studies and, in some contexts, has been attributed to confounding by indication, whereby palliative care consultation is initiated in the setting of perceived poor prognosis, particularly after catastrophic events like OHCA, as discussed by Lilly et al⁸ and Elmer et al⁹ Notably, SOFA scores at ICU admission and at 72 hours were similar between patients seen by palliative care and those not seen by palliative care (P = 0.72 and P = 0.27, respectively), suggesting that the decision to consult palliative care was likely driven by clinical factors beyond objective severity scores, such as perceived neurological prognosis, illness trajectory, or the treating team’s overall assessment of prognosis. In the OHCA population specifically, neurological prognosis following anoxic brain injury is a critical determinant of outcomes that is not captured by the SOFA score, and may have influenced the decision to consult palliative care independent of measured illness severity. The higher mortality in the palliative care group should therefore be interpreted as a reflection of the clinical context in which consultation was requested, rather than as evidence that palliative care adversely influenced outcomes.

Although baseline demographic characteristics and treatment intensity were similar between groups, palliative care consultation may have been influenced by the broader clinical context and evolving goals of care rather than measurable differences in baseline illness severity. Prior work has demonstrated that proactive palliative care consultation can shorten the time to establish comfort-focused goals, particularly when consultation occurs early and systematically. Structured communication models (Campbell & Guzman¹⁰) and family engagement interventions (Azoulay et al¹¹) further highlight the role of palliative care teams in supporting timely, value-concordant decision-making. However, in our cohort, the timing of end-of-life decision-making remained variable and did not demonstrate a consistent temporal pattern following palliative care consultation. Our findings are consistent with prior systematic reviews describing the role of proactive palliative care consultation in supporting goals-of-care discussions in critically ill patients.¹² Comparable use of life-sustaining therapies between groups challenges the misconception that palliative care automatically leads to treatment withdrawal. However, the significantly longer time from ICU admission to withdrawal of life-sustaining treatment in the palliative care group (6.0 vs 3.0 days, P = 0.016) suggests that palliative care facilitated a more deliberate and structured process of goals-of-care decision-making rather than an abrupt withdrawal of care. Of note, interventions such as mechanical ventilation and vasopressors are typically initiated following ROSC before palliative care is consulted, and the absence of duration data for these treatments is a limitation that precludes definitive conclusions about their trajectory in each group. Aslakson et al¹³ emphasize that palliative care in the ICU supports patient- and family-centered, goal-directed decision-making, which may include the continuation of intensive interventions. This echoes findings from ethics consultations (Schneiderman et al¹⁴), demonstrating that palliative care promotes goal-directed care rather than premature therapy limitation. Our finding of no significant difference in length of stay is consistent with some literature (Norton et al¹⁵) but not all (Kyeremanteng et al,¹⁶ Morrison et al¹⁷), likely due to variations in study design, patient populations, and “early” consultation definitions (Turnbull et al¹⁸). The absence of differences in several outcomes may also reflect limited statistical power to detect modest effects in this relatively small cohort.

Underutilization of palliative care consultation in our OHCA cohort (33.7%) reflects a persistent gap (Nelson et al,¹⁹ Wunsch et al²⁰). Barriers include prognostic uncertainty, lack of clear triggers,²¹ time constraints, limited primary palliative skills, and misconceptions.²² Nevertheless, the core functions provided by palliative are teams in our study (goals-of-care clarification, symptom management, and spiritual support) align with established quality indicators²³ and professional guidelines.²⁴

The higher mortality observed among patients receiving palliative care consultation should be interpreted within the context of evolving goals of care following OHCA. In this setting, palliative care consultation may be best understood as part of a broader decision-making framework that emphasizes communication, clarification of goals of care, and support for patients and families. Although the timing of end-of-life decision-making varied in our cohort, prior studies highlight the role of palliative care in supporting structured communication and aligning care with patient goals.¹⁰ Larger studies may be needed to further clarify whether the timing of consultation influences decision-making patterns in this population.

Palliative care consultation was not associated with differences in life-sustaining therapies or ICU and hospital length of stay. These findings suggest that consultation was integrated alongside ongoing critical care rather than serving solely as a marker of treatment withdrawal. Further study is needed to better characterize referral patterns and to define the optimal integration of palliative care principles in this high-risk population.

Future research should address several key areas. Standardized screening tools or trigger criteria for palliative care consultation may help mitigate selection bias and ensure timely involvement. Incorporating patient- and family-reported outcome measures will be important to better characterize the impact of palliative care interventions. Further work is warranted to define the optimal timing and model of palliative care delivery after OHCA.

Conclusion

In this study of ICU patients following out-of-hospital cardiac arrest, palliative care consultation was associated with higher in-hospital mortality, while baseline characteristics, illness severity treatment intensity, and length of stay were similar between groups. Palliative care consultation was strongly associated with goals-of-care redirection and a more deliberate end-of-life decision-making process. Palliative care services primarily focused on goals-of-care clarification and supportive interventions and were utilized in only a minority of this high-risk population. These findings provide insight into current referral patterns and reinforce the importance of integrating palliative care as a complementary tool to support patient and family-centered decision-making after OHCA, rather than interpreting its consultation as a marker of poor prognosis.

Footnotes

ORCID iDs

Gabriel Patarroyo-Aponte

Brandon Sarver

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.

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Luce

, et al. Quality indicators for end-of-life care in the intensive care unit. Crit Care Med. 2003;31(9):2255-2262. doi:10.1097/01.CCM.0000084849.96385.85