1. It is needed to know how EOL care (advanced care planning and palliative acre consultation ) decreased cost
   1. increasing cost with critical care
      1. aging population
      2. advances in management of acute and chronic illness
   2. Increasing ICU use in last 30 days of life
      1. unwanted intensive care at end of life
      2. costly intervention causing discomfort and ineffective
      3. unnecessary in emotional, financial, physical burden in dying patient and families
   3. intervention at end of life effective
      1. advanced care planning early reduce ICU admissions
      2. time-limited trials and proactive early palliative care consultation in the ICU reduce the length of stay (LOS) and intensity of treatment for patients who die in the ICU
2. Discussing costs of care for critically ill and dying patients is a sensitive and controversial topic
3. STUDIES EVALUATING ICU ADMISSIONS-palliative care consultation (PC consultation )
   1. Reduction in ICU admission with compared with those without PC consultation : higher risk of death higher risk reduction
      1. Gade et al. RCT(2008), hospitalized patient with (+) surprising question , Risk reduction: 50%
      2. Penrod et al. (2006): (retrospective observational study), only descends , Risk reduction 51%
      3. Penrod et al(2010). : observational study, any veteran in veterans hospital with 1 advanced disease , risk reduction : 11%
4. STUDIES REPORTING ON ICU LENGTH OF STAY(LOS)
   1. 5 no change on LOS
      1. Bakitas
         1. advanced cancer , outpatient
         2. randomized patients, weekly educational sessions
         3. ICU LOS not differ
      2. Andereck
         1. prolonged ICU LOS(>5 days): a mixed medical/surgical ICU
         2. proactive clinical ethicist
         3. same ICU days
      3. Curtis
         1. targeted at hospitals and clinicians to integrate palliative care in the ICU
         2. quality improvement intervention
         3. not result in a significant decrease in LOS
      4. Shelton
         1. a full-time, family support coordinator to a surgical ICU team
         2. a pre-post study design
         3. no differences in LOS
      5. Daly.
         1. proactive multidiscipllinary family conference
         2. 5 ICUs , pre-post design
         3. no significant differences
   2. 11: reduction of LOS
      1. Schneiderman.
         1. Schneiderman.
         2. routine ethics consultation,
         3. patients with treatment conflicts . (one single-center study and one multicenter study)
         4. reductions in ICU LOS for decedents (intervention vs. usual care) , negative in survival group
      2. Eight-palliative care intervention
         1. Ahrens et al.
            1. communication team physician and clinical nurse specialist
            2. the intervention group had shorter LOS compared
         2. Campbell and Guzman’s
            1. routine palliative care consults
            2. global cerebral ischemia after cardiopulmonary resuscitation vs. historical control
            3. patients with MOF, no longer time in the ICU
         3. Campbell and Guzman
            1. advanced dementia using historical controls proactive case finding facilitated
         4. Dowdy
            1. ethics service intervened proactively
            2. MV>96hrs
         5. Curtis
            1. In a single-center study
            2. quality improvement target ICＵworrkers
            3. pre-, postimplementation
         6. Mosenthal
            1. interdisciplinary family meeting,family bereavement support,
            2. decedents in trauma ICU.
            3. Pre-post implementation
         7. Lilly et al
            1. multidisciplinary family meeting held within 72 h of
            2. Baseline vs. postimplementation
         8. Norton
            1. proactive palliative care consultation
            2. medical ICU, high risk of death.
            3. pre-post design,
5. Studies reporting ICU utilization
   1. reduction in ICU admissions- palliative care consultation
      1. trend in the LOS reduction
      2. advanced care planning or palliative care intervention
      3. Additionally, interventions that were targeted
      4. Targets at providers , patients at the highest risk of death
6. FInancial burdern at EOL
   1. little is known about the costs of dying
   2. Marshall
      1. spending in the last year of life for decedents represents a substantial portion of liquid wealth.
      2. out-of-pocket expenditures are growing over time
   3. Asch et al.
      1. conflicts between physicians’ practices and patients’wishes
      2. Phisican assessment of prognosis, fmailies perceptions of ethic , good communication and family engagement
      3. good communication and family engagement
   4. important issue of justice
      1. financial burden in decision making about intensity of care at the end of life
      2. quality of care in seriously ill
      3. What families perceived