What is going on in the EPIC project

(Enhancing Palliative Care in ICU)

A New Approach to Palliative Care in Intensive Care Units

EPIC stands for Enhancing Palliative Care in the ICU. The EPIC project aims to integrate palliative care into Intensive Care Units (ICUs) across Europe. The project brings together leading institutions from across Europe to improve the quality of life for critically ill patients and their families. The project started in January 2024 and is now well into its second year. This article focuses on the EPIC clinical study. For more information on consortium partners and associated activities, please go to https://epic4icu.eu/.

The EPIC harmonised palliative care model.

The EPIC model is a Europe-wide harmonised and recommended palliative care practice for ICU and is based on the model described by Curtis et al. (1). ICU clinicians provide primary palliative care (PC) including symptom management, communication and family support. Specialist PC experts can provide advice in more complex cases (figure 1)

To prepare ICU clinicians as well as PC experts for this practice model, both groups need to be familiar with each other’s respective cultures and attitudes. Therefore, EPIC has developed and implemented education for ICU staff, specific training for PC experts and a comprehensive trigger list as intervention measures.

The clinical study

The clinical study started in October 2024 and is expected to run for approx. 3 years. It is a controlled, cluster-randomized, non-blinded, cross-over study in a stepped-wedge design. The study is carried out in more than 25 ICUs in 5 European countries (Germany, Greece, Czech Republic, Italy and Israel).

Patients and relatives

All consecutive adult non – cancer patients who have been treated at least 72 hours are eligible if the treating physicians considers them to be in need

of specialized PC. This need is based on several considerations by the treating physician including significant disagreement about ICU treatment, consideration of therapy limitations or an expectation of benefit from a specialized PC consultation. Relatives of enrolled patients are also invited to participate. All patients or their respective legal surrogates and relatives provide written informed consent.

Study flow

All ICUs start in the observation phase. Compared to standard care, no telemedical PC consultation is provided. At a randomly determined date, each ICU crosses over to the intervention phase. In the crossover month, ICU staff are educated, a comprehensive trigger list is provided and PC consultants are trained. In the intervention period, PC consultations provide telemedical consultations. Three months after ICU discharge, a follow-up interview is conducted with surviving patients and relatives by telephone.

Intervention measures

Education

ICU physicians and nurses are educated to improve the attitudes, understanding and self-confidence regarding PC. The education consists of e-learning and online interactive seminars. The 45-minute e-learning allows participants to acquire, reflect and test their new knowledge. In one-hour seminars participants can discuss their learning and transfer it into daily practice based on own cases.

Trigger list

The EPIC study group developed a 7-item trigger list to help ICU teams identify when to involve PC. The list was created by top palliative and intensive care experts from 7 countries using the Delphi process. Triggers include situations like persistent symptoms (pain, dyspnea), repeated ICU admissions, life-limiting diagnoses, and patient or family requests. The collaborative effort and systematic approach ensure that the final list is comprehensive, relevant, and practical for clinical implementation.

Specific training for PC experts who provide consultations

This unique training developed from literature and expert input consists of asynchronous online training and monthly synchronous booster sessions. The aim is to provide a structured and standardised protocol for consultations targeted to the requirements of ICU clinicians and with the focus on patient-centred care.

Expected Outcomes

The EPIC clinical study aims to demonstrate the effectiveness and cost-effectiveness of the PC model. The main study hypothesis is that the intervention will reduce the mean length of stay in the ICU by 2 days compared to the standard of care. The health economic approach hypothesis that healthcare costs in the intervention group are shown to be reduced by the equivalent of the cost of one ICU day, while patient quality of life is at least maintained.

Summary

The clinical study is expected to fill gaps in our knowledge about PC interventions. It is the first European multicentre study of PC intervention in the ICU. The study’s strengths are its easily scalable standardised practice model, the use of telemedicine to reach areas without access to PC, and the standardised education of both ICU clinicians and PC specialists to understand each other’s different practices and cultures.

EPIC is funded by the European Union’s HORIZON Europe research and innovation programme under Grant number: 101137221, by the Swiss State Secretariat for Education, Research and Innovation (SERI) under contract number 24.00021 (EPIC) and by the UKRI grant number 10115894.

Figure 1

Legend to figure 1: The EPIC model of standardised palliative care in ICU, developed from (1).

References

(1) Curtis JR, Higginson IJ, White DB. Integrating palliative care into the ICU: a lasting and developing legacy. Intensive Care Med. 2022 Jul;48(7):939-942. doi: 10.1007/s00134-022-06729-7