King's College Hospital, London, SE5 9RS, UK.
School of Medicine, Human Health Sciences, Kyoto University, Kyoto, Japan.
Intensive Care Med. 2021 Dec;47(12):1415-1425. doi: 10.1007/s00134-021-06544-6. Epub 2021 Oct 15.
The integration of palliative care into intensive care units (ICUs) is advocated to mitigate physical and psychological burdens for patients and their families, and to improve end-of-life care. The most efficacious palliative care interventions, the optimal model of their delivery and the most appropriate outcome measures in ICU are not clear.
We conducted a systematic review of randomised clinical trials and observational studies to evaluate the number and types of palliative care interventions implemented within the ICU setting, to assess their impact on ICU practice and to evaluate differences in palliative care approaches across different countries.
Fifty-eight full articles were identified, including 9 randomised trials and 49 cohort studies; all but 4 were conducted within North America. Interventions were categorised into five themes: communication (14, 24.6%), ethics consultations (5, 8.8%), educational (18, 31.6%), involvement of a palliative care team (28, 49.1%) and advance care planning or goals-of-care discussions (7, 12.3%). Thirty studies (51.7%) proposed an integrative model, whilst 28 (48.3%) reported a consultative one. The most frequently reported outcomes were ICU or hospital length of stay (33/55, 60%), limitation of life-sustaining treatment decisions (22/55, 40%) and mortality (15/55, 27.2%). Quantitative assessment of pooled data was not performed due to heterogeneity in interventions and outcomes between studies.
Beneficial effects on the most common outcomes were associated with strategies to enhance palliative care involvement, either with an integrative or a consultative approach. Few studies reported functional outcomes for ICU patients. Almost all studies were from North America, limiting the generalisability to other healthcare systems.
提倡将姑息治疗纳入重症监护病房（ICU），以减轻患者及其家属的身心负担，并改善临终关怀。目前尚不清楚最有效的姑息治疗干预措施、其实施的最佳模式以及 ICU 中最合适的结果测量方法。
我们对随机临床试验和观察性研究进行了系统回顾，以评估在 ICU 环境中实施的姑息治疗干预措施的数量和类型，评估其对 ICU 实践的影响，并评估不同国家姑息治疗方法的差异。
共确定了 58 篇全文，包括 9 项随机试验和 49 项队列研究；除 4 项外，其余均在美国进行。干预措施分为五个主题：沟通（14 项，24.6%）、伦理咨询（5 项，8.8%）、教育（18 项，31.6%）、姑息治疗团队的参与（28 项，49.1%）和预先护理计划或目标关怀讨论（7 项，12.3%）。30 项研究（51.7%）提出了综合模式，28 项研究（48.3%）报告了咨询模式。报告最多的结果是 ICU 或住院时间的长短（33/55，60%）、限制生命支持治疗决策（22/55，40%）和死亡率（15/55，27.2%）。由于研究之间干预措施和结果存在异质性，因此未对汇总数据进行定量评估。
与增强姑息治疗参与度相关的策略（无论是综合模式还是咨询模式）都对最常见的结果产生了有益的影响。很少有研究报告 ICU 患者的功能结果。几乎所有研究都来自北美，限制了其在其他医疗保健系统中的推广。
