65 The challenge of de-escalating care; transfer from ICU to a ward setting for end of life care

Background The Palliative Care Team (PCT) in an acute hospital are referred patients from the regional Intensive Care Unit (ICU) who have had withdrawal of active treatment and are being discharged to a ward for end of life care (EOLC). Transfer between teams and wards is a challenging time. ICU patients are often on intravenous (IV) infusions of drugs which require conversion to the subcutaneous (SC) route. Aim The aim of this review is to assess the care pathway and symptom control of patients in ICU who are recognized to be dying, who are being transferred from ICU to a ward for EOLC. Methods Retrospective audit. PCT database was searched over a 12 month period to identify patients. Literature search and data collection completed. Results 9 patients were eligible for inclusion. 3 patients were referred to PCT but not seen as they died on day of referral. All patients with PCT input in ICU had a continuous subcutaneous infusion (CSCI) commenced prior to discharge, and were well symptom controlled for remainder of admission. One patient was identified as having uncontrolled symptoms; they had been discharged from ICU on a weekend and had no PCT input. 3 patients had IV infusions of opioid and/or midazolam converted to CSCI with a 40–50% dose reduction which maintained symptom control. Conclusions This review highlights that early PCT input into ICU discharges for EOLC facilitates better symptom control. Out of hours transfers are highlighted as a time of risk. The IV to SC conversions used here were tolerated well, however a 50% dose reduction is not seen as standard as the management of this conversion will vary depending on the prescriber’s assessment of the patient. Further review of this care pathway and prescribing practice is merited to allow development of guidance.