Acute Palliative Care Unit: A new frontier in managing patients with end-stage chronic disease

A new study shows that hospitals with specialized units combining the compassionate care of hospice and the level of care offered in medical-surgical units may provide efficient, cost effective assistance to patients with advanced chronic illness or terminal disease.

The study was published in the American Journal of Hospice & Palliative Medicine and done at Montefiore Medical Center.

“Acute Palliative Care Units, APCUs, are really a new frontier in managing patients with end-stage chronic disease,” said study co-author Marlene McHugh, DNP, FNP, Assistant Professor of Clinical Nursing at Columbia University School of Nursing and Associate Director of Palliative Care at Montefiore Medical Center. “In an APCU, patients receive acute and palliative care regardless of prognosis, the technology required to keep a patient alive, or end-of-life wishes. In addition, these units are primarily managed by palliative medicine specialists, working with medical management.” McHugh is one of the first Nurse Practitioners in New York City to move palliative care into the acute care hospital setting.

“We are creating the future by bringing palliative care units within hospital walls,” says co-author Serife Eti, MD, Director of the Fellowship Program in Palliative Medicine, Department of Pain Medicine and Palliative Care at Beth Israel Medical Center. “Consequently, going forward, nurses and medical personnel will need specialized palliative care training to assist patients with chronic, advanced and terminal illness in APCUs.”

In the US, the majority of patients with advanced illness die in acute or long-term care facilities, with around 20% of Americans dying in ICUs. In the absence of specialized units, at a certain point, patients in an ICU are sent to a general medical unit, step-down respiratory unit, or must continue care in the ICU. Establishing APCUs allows patients to leave the ICU yet still receive a high level of medical care focusing on patients’ values and treatment preferences, as well as support for their family members.

The study suggests potential cost benefits can be achieved by managing terminally ill patients in APCUs rather than in ICUs or MSUs, and that these benefits are more likely to occur when patients are directly managed by palliative care specialists, trained in chronic disease management as well as family and end-of-life counseling. The report notes that this combination of advanced disease management and personal counseling can assist patients and families in the transition from aggressive treatment to more palliative care. In fact, recent studies indicate that palliative care counseling can shorten ICU stays, reduce costs and enhance the overall quality of care.

Conducted during 2007-2010, researchers looked at the admissions and economic implications in Intensive Care Units (ICUs), Medical-Surgical Units (MSUs) and Acute Palliative Care Units (APCUs), with special focus on Montefiore Medical Center’s APCU in Bronx, NY.

The study examined several factors at Montefiore: demographics, diagnosis-related groups, length of hospital stays, discharge status, and hospital charge data. The research indicated that a high proportion of patients were admitted to the APCU from critical care units – indicating there is a pronounced need for such units to service patients when hospital-based end-of-life care is needed. It’s noteworthy that the use of ICUs during the last month of life for Medicare beneficiaries with cancer was dramatically lower (12.1%) at the Montefiore APCU compared to 137 other academic medical centers in the US. The creation of the APCU resulted in statistically significant reductions in both the ICU mortality rate and the length of stay as terminally ill patients were transitioned out of the ICU.

Hospitals in the U.S. are increasingly developing units focused on palliative care in order to meet the needs of advanced and terminally ill patients and their families. This report recommends hospitals offer full palliative services in order to provide the best care for terminally ill patients facing complex, long-term health challenges.


About The Rev. Thomas C. Jackson

Ordained to the priesthood in December, 2010.
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