13.1 Goals of Care, Perioperative Care, and Transitions of Care
Key Takeaways
- Goals-of-care conversations in the ICU should occur within 72 hours of admission and incorporate patient values, prognosis, and treatment-limitation decisions that directly influence pharmacotherapy choices (e.g., palliative vs. curative antibiotics).
- Perioperative ICU care requires medication management across three phases: preoperative (beta-blockade, anticoagulation bridging, fasting-status meds), intraoperative (anesthesia selection, vasopressor choice), and postoperative (pain, nausea/VTE prophylaxis).
- Transitions of care (admission, transfer, discharge) carry high medication error risk; structured medication reconciliation by pharmacists reduces errors by ~75% and adverse events by 30%.
- Step-down transfer requires explicit communication of infusion titration parameters, anticoagulation plan, antimicrobial duration, and TPN weaning to prevent medication discontinuation errors.
Last updated: July 2026
Goals of Care, Perioperative Care, and Transitions of Care
Goals of Care (ECO 2A3)
Goals-of-care conversations align treatment intensity with patient values, prognosis, and expected outcomes. The Society of Critical Care Medicine recommends such conversations within 72 hours of ICU admission and at significant clinical changes.
Pharmacist Role in Goals of Care
| Decision | Pharmacist Contribution |
|---|---|
| Treatment limitation | Adjust medication regimens to comfort-focused: opioids, benzodiazepines, anticholinergics |
| Antibiotic continuation | Weigh prognosis, futility, and patient preference; palliative antibiotic use may focus on symptom relief rather than cure |
| Anticoagulation | Continue for VTE/AFib prophylaxis unless bleeding risk prohibitive; deprescribe when prognosis <2 weeks |
| Artificial nutrition | Reassess after 7-10 days if not improving; risk of aspiration vs. benefit |
| Statin discontinuation | STOP-STAT RCT: continuation in critical illness offered no mortality benefit; deprescribe when prognosis is poor |
| Steroid continuation | Continue physiologic doses; avoid high-dose without indication |
Decision Aids and Documentation
- POLST (Physician Orders for Life-Sustaining Treatment): portable medical orders following patient across care settings.
- Advance directives: patient-prepared documents.
- Code status documentation: in EHR and visible to all clinicians.
- Family meeting facilitation: pharmacist participation improves deprescribing and antibiotic stewardship.
Perioperative Care (ECO 2A4)
Preoperative ICU Optimization
| Chronic Medication | Pre-op Decision |
|---|---|
| Beta-blockers | Continue (DECREASE trials); avoid initiation within 24h of surgery (risk of stroke/hypotension) |
| Statins | Continue; consider initiating in vascular surgery (POISE-2 trial evidence) |
| ACE inhibitors/ARBs | Hold morning of surgery (hypotension risk) |
| Diuretics | Hold morning of surgery |
| Insulin | Continue basal at 75-80% of usual; hold rapid-acting |
| Antiplatelets | Continue for recent PCI (BMS <3 months, DES <6 months); hold for elective non-cardiac surgery |
| DOACs | Hold 24-48h (apixaban) to 48-72h (rivaroxaban) per renal function and bleeding risk |
| Warfarin | Bridge with heparin if high VTE/TE risk; stop 5 days pre-op, target INR <1.5 |
| Levothyroxine | Continue morning of surgery with sip of water |
| Corticosteroids | Continue; stress-dose hydrocortisone 100 mg IV q8h if chronic daily dose >20mg for >3 weeks |
Intraoperative Considerations
- Anesthesia depth: BIS monitoring; avoid over-sedation in elderly (post-op delirium risk).
- Vasopressor selection: phenylephrine for SVT; norepinephrine for septic shock intraoperative; vasopressin for vasoplegia.
- Antifibrinolytics: TXA 1 g IV at incision and 1 g at 3 hours in cardiac and major orthopedic surgery reduces bleeding.
- Antibiotic prophylaxis: repeat dose if surgery >4 hours or blood loss >1500 mL.
Postoperative ICU Care
- Pain: multimodal — acetaminophen, regional/neuraxial, ketamine adjunct, opioid sparing.
- PONV: ondansetron + dexamethasone + haloperidol triple therapy for high-risk.
- VTE prophylaxis: start 12-24h post-op per surgical service; enoxaparin preferred over UFH in surgical patients (meta-analyses).
- Delirium prevention: minimize benzodiazepines; orient patient; early mobilization.
- Glycemic control: target 140-180 mg/dL; avoid hyperglycemia and hypoglycemia.
- Stress ulcer prophylaxis: only if mechanically ventilated >48h or coagulopathy.
Transitions of Care (ECO 2A5)
Three Critical Transition Points
- Admission to ICU: reconcile outpatient, ED, and pre-admission medications; identify held meds, new allergies, anticoagulation status, controlled substances.
- ICU to step-down or floor transfer: explicit transfer orders including titration parameters, anticoagulation plan, antibiotic duration, TPN weaning, and oxygen weaning plan.
- Discharge to home/SNF: medication list reconciliation, deprescribing, patient education, follow-up appointments, post-ICU clinic referral.
Pharmacist-Led Reconciliation
Pharmacist-led reconciliation reduces medication errors by 75-90% (multiple meta-analyses):
| Component | Action |
|---|---|
| Collect | Home med list from EHR, pharmacy fill records, family interview |
| Compare | Each home med vs. current orders: continue, hold, modify, stop |
| Communicate | Document changes with rationale; alert team of held meds needing resumption |
| Counsel | Patient and family at discharge with teach-back |
| Follow-up | Phone call within 48-72h post-discharge reduces readmission |
High-Risk Medications at Transitions
- Anticoagulants: wrong dose, double coverage, missed bridge.
- Insulin: sliding scale alone insufficient; basal/bolus correction required.
- Opioids: duplicate prescriptions from hospital and outpatient prescribers.
- Antibiotics: incomplete duration documentation leads to premature discontinuation.
- Immunosuppressants: wrong dose in transplant handoffs.
- Antiretrovirals: interactions with new meds, missed doses.
- Antiepileptics: dose changes with initiation/discontinuation of interacting meds.
Medication Reconciliation Tools
- MedRec forms: structured collection sheets.
- EHR reconciliation modules: with drop-downs for actions.
- Pharmacy fill history: from pharmacy benefit manager or state PDMP.
- Discrepancy documentation: flag unresolved discrepancies at each transition.
Clinical Scenario
A 68-year-old with HFrEF (EF 30%), CKD 3 (CrCl 35), AFib on apixaban, and T2DM is admitted post-emergency cholecystectomy for gangrenous cholecystitis. Post-op course complicated by AKI (CrCl 25). Pre-ICU meds: apixaban 5 mg BID, carvedilol 12.5 mg BID, lisinopril 10 mg daily, furosemide 40 mg daily, empagliflozin 10 mg daily, insulin glargine 20 units nightly. What is the appropriate transition plan?
Answer: Hold apixaban (AKI + post-op bleeding risk); start VTE prophylaxis with enoxaparin 30 mg SC daily (CrCl 25, post-op). Hold lisinopril and empagliflozin (AKI, hypotension risk). Continue carvedilol (avoid withdrawal) and furosemide (may need increase if volume overload). Convert insulin glargine to IV insulin infusion or continue at 75% dose with correctional rapid-acting protocol, target 140-180 mg/dL. Document all changes with rationale; resume held meds as renal function and clinical status normalize.
Test Your Knowledge
A patient on long-term warfarin (INR 2.5) for AFib requires urgent cholecystectomy. The surgeon asks for perioperative anticoagulation guidance. What is the most appropriate plan?
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