The EPIC study (“Enhancing Palliative Care in Intensive Care Units”) is a large European clinical trial designed to evaluate whether the early integration of palliative care (PC) into ICU treatment improves outcomes for patients, relatives and healthcare professionals. The study responds to growing recognition that ICU patients and their families often experience severe physical, psychological, social and spiritual distress, while ICU staff frequently face moral and emotional strain. Although previous research suggests that palliative care can reduce ICU length of stay (LOS) and improve symptom management without increasing mortality, the use of PC in ICUs remains inconsistent and underdeveloped, especially across Europe.
The study is based on the premise that intensive care medicine traditionally prioritises life-prolonging interventions, often viewing death as a treatment failure. However, many critically ill patients experience substantial suffering, uncertainty and difficult treatment decisions. Palliative care aims to improve quality of life through symptom relief, communication support, psychosocial care and assistance with decision-making. Despite evidence supporting integration of PC into ICU practice, there are still limited robust data concerning its clinical effectiveness and cost-effectiveness, particularly in relation to telemedicine-based delivery models.
The EPIC study investigates whether a system-based, harmonised model of early palliative care integration can improve ICU outcomes. The intervention combines clinician education, bedside support tools and telemedicine consultations provided by palliative care specialists. The study specifically focuses on non-cancer ICU patients because cancer patients often already receive specialised palliative services and follow different clinical pathways, which could confound the study’s results.
The trial included approximately 2,000 patients from multidisciplinary ICUs in five European countries: Germany, Greece, Italy, the Czech Republic and Israel. ICUs were organised into clusters, and all began in an observation phase where standard treatment is delivered. At randomised time points, clusters transitioned through a one-month crossover phase into the intervention phase. During the crossover phase, ICU staff received training in palliative care and interventionists were prepared to conduct telemedicine consultations.
Eligible participants were adults who remained in the ICU for more than 72 hours, were not expected to die within 24 hours, and were judged by ICU physicians to require specialised palliative care. This judgement was based on factors such as disagreement about treatment intensity, consideration of limiting life-sustaining treatment, or anticipated benefit from specialist palliative consultation for patients, relatives or staff.
The intervention itself has several components. First, ICU clinicians participate in a blended-learning educational programme involving e-learning modules and webinars designed to improve knowledge, attitudes and communication skills relating to palliative care. Second, ICU teams receive bedside tools, including a checklist identifying triggers for palliative care needs and factsheets outlining recommended practices and relevant legal guidance. Third, trained palliative care specialists conduct telemedicine consultations with ICU teams using secure audio-visual systems. These consultations address physical symptoms such as pain, delirium and breathlessness, as well as psychological distress, social concerns, spiritual issues and end-of-life communication. Consultants also support shared decision-making and discussions about patient values, goals and treatment preferences.
The researchers emphasise implementation support and fidelity monitoring to ensure consistency across sites. Local “champions” help facilitate collaboration between ICU and palliative care teams, while regular audits, training sessions and feedback loops monitor adherence to the protocol. Quarterly reviews assess teleconsultation quality and compliance with the intervention framework.
The study’s primary outcome was ICU length of stay, measured from admission until final ICU discharge during the index hospitalisation. The researchers hypothesised that the intervention would reduce ICU LOS by at least two days compared with standard care. Secondary outcomes include ICU mortality, hospital mortality, use of invasive therapies, delirium incidence, treatment limitation decisions, health-related quality of life and discharge destination.
The trial also placed strong emphasis on patient-centred and family-centred outcomes. Three months after ICU discharge, patients and relatives were interviewed regarding symptom control, communication quality, satisfaction with decision-making and emotional distress. Standardised measures assess anxiety, depression and quality of life. Relatives were also asked about their inclusion in treatment decisions, perceptions of support and whether care aligned with the patient’s wishes.
Another major component of the study is the evaluation of healthcare resource use and economic consequences. Researchers collect detailed cost data relating to ICU stays, interventions, rehabilitation, outpatient services and informal care provided by family members. The study aims to determine whether the intervention is cost-effective from healthcare system, institutional and societal perspectives. Costs will be analysed alongside clinical outcomes and quality-adjusted life years.
Clinician well-being was also assessed. ICU physicians and nurses complete repeated surveys measuring burnout, moral distress, ethical climate and perceptions of inappropriate therapy. The study investigates whether improved palliative care integration reduces stress and enhances ethical decision-making among ICU staff.
EPIC has the potential to improve patient care, family experiences, staff well-being and resource utilisation across European ICUs. By combining education, structured assessment tools and telemedicine consultations, the study aims to establish a scalable and sustainable model for integrating palliative care into intensive care medicine.
Source: BMJ
Image Credit: Euroanaesthesia
