Improving Prognostic Communication and Symptom Management at a Respiratory LTACH: A Pilot in Palliative Care
Bibliographic record
Abstract
Abstract Introduction: Long Term Acute Care Hospitals (LTACHs) treat patients with prolonged, serious, and complex medical illnesses that require ongoing hospitalization. These include those requiring tracheostomy, continued mechanical ventilation, gastrostomy, or dialysis after critical illness. While these patients have opted to continue medical therapy with the aim for recovery or life prolongation, there is an unmet need for discussing prognosis, addressing potentially unrealistic expectations, or alleviating physical, psychological, spiritual, and social symptoms. About two-thirds of U.S. LTACHs lack access to a palliative care physician. One LTACH specializing in pulmonary rehabilitation and ventilator weaning initiated a pilot palliative care program to assess unmet needs. Methods: Retrospective chart review of patients admitted between 3/1/2023 and 12/31/2023 at a single LTACH. Palliative care consultation was performed by one provider board-certified in pulmonary, critical care, and palliative medicine already practicing pulmonary & critical care at the facility. Results: Of 201 unique patients (52.7% male), 62.7% had a tracheostomy, and 77% of these were ventilated. At discharge, 41.2% were weaned from a ventilator, and 50% were further decannulated. Mortality was 24.4%, with an average length of stay of 46.7 days ± 43.8 days. Palliative care was consulted for 46 patients (22.9% service penetration). 81.8% of consultations were referred by another pulmonologist. 69.2% consultations occurred on the floor and 30.8% in the ICU. Consultation requests included goals of care (87%), family support (78%), and symptom management (43%). 42 (91.3%) patients received a goals of care meeting, 38.1% resulting in code status changes. Palliative care accounted for 57.3% of all goals of care documentation, with 33.3% of the remainder documented by a single individual. Among patients who did not survive, 32.7% had no documented goals of care. The Edmonton Symptom Assessment System, showed that 32.6% had five or more mild symptom domains and 48.7% had three or more severe symptom domains. Demographics included 69.2% English-speaking, 10.0% Armenian, and 10.0% Spanish; 58.2% White, 12.9% BIPOC, 10.9% Asian; and 57.3% Christian, 7.5% Jewish; and of mixed insurance (36.8% private and public, 38.3% private only, 8.5% public only). Conclusions: Significant gaps in goals-of-care documentation, especially among non-survivors, underscore the critical role of palliative care in ensuring goal-concordant care. Increased efforts to improve symptom relief and psychosocial support are warranted for LTACH patients undergoing ventilator weaning.
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How this classification was reachedexpand
Full frame machine prediction
Teacher imitationNot calibrated prevalence, not ground truth. Human validation pending. The Gemma side is a direct model label for every work in the frame, read from the title-only record. The Codex side is a classifier learned from the 10,348 direct Codex labels and calibrated to design-weighted sample rates; fields without enough sample support carry no Codex call. Candidate is the union of the two sides; consensus is their intersection. These outputs are machine_predicted_unvalidated and are not human labels.
Distilled classifier scores by category (both heads)
| Category | Codex | Gemma |
|---|---|---|
| Metaresearch | 0.004 | 0.006 |
| Meta-epidemiology (narrow) | 0.000 | 0.000 |
| Meta-epidemiology (broad) | 0.000 | 0.001 |
| Bibliometrics | 0.000 | 0.000 |
| Science and technology studies | 0.002 | 0.001 |
| Scholarly communication | 0.001 | 0.001 |
| Open science | 0.001 | 0.002 |
| Research integrity | 0.001 | 0.002 |
| Insufficient payload (model declined to judge) | 0.003 | 0.000 |
Machine scores (provisional)
The two teacher heads of the student model, read on this work. A score orders the frame for review; it never asserts a category, and the validation status ships verbatim with every row.
Baseline scores from an immature model (maturity gate not passed, 7 training rounds). Scores rank; they never assert a category.
score_only:v0-immature-baseline · verbatim from the scoring run: score_only means the number may rank works, and no category label ships from itClassification
machine, unvalidatedMachine predicted; a candidate call from one source (direct Gemma or distilled Codex), not a consensus.
How this classification was reached, model by model and score by score, is at the end of the page under "How this classification was reached".