Cardiac arrest on the wards may be preceded by unmet palliative care needs, including advance care planning and specialty palliative consultation that can seek to align patients’ prognoses and goals for care. Identification of hospitalized patients with limited life expectancy allows for the delivery of appropriate palliative interventions. However, the prognosis on admission of patients experiencing ward cardiac arrest and its relationship to palliative care has not been well characterized.
We retrospectively reviewed the charts of all ward cardiac arrests patients over two years at an academic medical center. We abstracted components of the CARING (Cancer, Admissions ≥ 2, Residence in a nursing home, Intensive care unit admission with multi-organ failure, ≥2 non-cancer hospice Guidelines) prognostic score. The CARING score is a previously validated predictor of one-year mortality from hospital admission. We also reviewed charts for patient demographics, documented code status discussions and palliative care consultations prior to the cardiac arrest, and hospital mortality. We examined the patient characteristics and outcomes across previously reported CARING score cut points of low risk (≤ 4 points, probability of death < 17.5%), moderate risk (5-12 points, probability of death 17.5%-48%), and high risk (≥ 13 points, probability of death ≥ 49%) using non-parametric tests for trend.
One-hundred forty unique patients had a ward cardiac arrest during the study period. Patients had a median age of 57 years (IQR, 49-64) and 47% were female. The most common comorbidities were congestive heart failure (56, 40.0%), malignancy (48, 34.3%), and COPD (27, 19.3%). One-half (n = 70) had low risk CARING scores, one-third (n = 46) had high risk scores, and the remaining (n = 24) had moderate risk scores. Mortality during hospitalization was 78.5% for the low risk group, 79.2% for the moderate risk group, and 89.1% for the high risk group (Figure 1). Yet the high risk group had a code status documented in only 10 patients (21.7%) and only one of these patients (2.2%) had a palliative care consultation. There was no significant association between increasing risk group and code status documentation or palliative care consultation (p = 0.07 and 0.7, respectively).
One-third of patients with cardiac arrest on the wards had a poor prognosis on admission however less than one-quarter of these patients had a documented code status discussion and only one of these patients was seen by the palliative care service prior to arrest. Further work should examine ways to improve the incidence of palliative care among hospitalized patients with poor prognoses, including the use of validated prognostic tools.