Table 1.

Patient and Conference Descriptions.

Case	Age, years	Sex	Diagnosis	Description	Transfer status	Death within 30 days
1	46	M	Brain injury	Admitted with large cerebrovascular accident (CVA) and fall, hospitalized at a community hospital for 15 days. After minimal improvement and inability to wean from mechanical ventilation, a request to transfer to TCC for further management was made. The teleconference established that family hoped for restorative goals with an ultimate goal to return home. Patient transferred and remained at TCC for 20 days before transferring to a long-term acute care facility near home	Transferred	No
2	70	F	Multisystem organ failure (MSOF)	Admitted with sepsis from a urinary source with bacteremia and subsequent multisystem organ dysfunction. Request to transfer for further management of sepsis. The teleconference with 2 sons and daughter present discussed patient had felt his quality of life was excellent prior to acute illness. Established restorative goals. Transferred to TCC and remained for 10 days. Transferred back to referral hospital for end-of-life care	Transferred	Yes
3	76	F	MSOF/end-stage renal disease (ESRD)	Admitted with sepsis of unclear etiology with multisystem organ dysfunction. Request to transfer to TCC for end-stage renal disease and need for acute dialysis. The teleconference details were not documented. Patient remained at TCC for 12 days. Family decided to discontinue or withhold life-prolonging treatments (ie, dialysis, no tracheostomy, no mechanical ventilation). Transferred back to local hospital for hospice services	Transferred	Yes
4	74	M	Colectomy/postoperative complications	Admitted with intestinal obstruction, underwent exploratory laparotomy with subsequent postoperative complications, and failure to liberate from the ventilator. Request to transfer to TCC due to inability to wean patient from ventilator. During the teleconference family described that the patient perceived his baseline quality of life to be poor. Family desired transfer to TCC for a second opinion from surgery and medical consultants for hopes of achieving restorative goals. Patient was transferred to TCC for 1 week and then transferred back to referral hospital once efforts proved to be ineffective. Patient died 1 week later after withdrawal of life-sustaining measures	Transferred	Yes
5	64	M	Cirrhosis/acute renal failure	Admitted with liver failure and progressive hepatorenal syndrome. Request to transfer to TCC for dialysis. The family teleconference revealed history of alcoholism and Hepatitis C infection. Very poor quality of life prior to admission. Wife wanted trial of dialysis. Patient transferred to TCC, underwent dialysis for 2 days. The patient had a rapid clinical decline in clinical status requiring increasing life support measures. Due to failure to improve, family decided to transition to treatment therapies directed at primarily at comfort. After withdrawal of life-sustaining measures, the patient was transferred home with hospice.	Transferred	Yes
6	67	F	Meningitis/cerebrovascular accident (CVA)	Admitted with bacterial meningitis to a local hospital. Course complicated by multiple large areas of stroke and progressive decline in clinical status despite therapies. Request to transfer to TCC for further management. During the family teleconference the patient’s children and spouse discussed with palliative care the patient’s poor prognosis and decision to withdraw life-sustaining measures at transferring hospital was made	No	Yes
7	55	M	Advanced amyotrophic lateral sclerosis (ALS)	Admitted with progressive ALS and respiratory failure. Intubated and request to transfer to TCC to assist with management. The family teleconference established goals to return home if possible. Agreed to palliative care support throughout hospitalization. The patient was transferred to TCC for 14 days then transferred back to local hospital with a long-term ventilator. Acute decline at patient’s local hospital and died within a week of transfer	Transferred	Yes
8	84	F	MSOF/ESRD	Admitted with sepsis and ESRD. Transfer requested for management of renal failure. Family teleconference: established patient was a nursing home resident prior to admission due to multiple chronic medical problems. Family goals were to return to previous functional status. The patient was transferred to our TCC and had acute decline in the first 24 hours. Family changed status to do-not-resuscitate (DNR) and patient died in the TCC intensive care unit	Transferred	Yes
9	57	M	CVA/pneumonia	Admitted with cerebrovascular accident at local hospital and subsequently developed acute pneumonia and respiratory failure. Transfer was requested for further subspecialty experience. The family teleconference confirmed that family wanted short-term intubation and trial of all therapies. The patient transferred to the TCC and was extubated on TCC hospital day #4, status changed to DNR/DNI transferred to floor and subsequently back to referral hospital for further management. The patient died at the local hospital several days later (reason not documented in TCC records)	Transferred	Yes
10	64	F	Chronic obstructive lung disease (COPD)	Admitted with COPD exacerbation and respiratory failure. Transfer was requested for further management with subspecialty experience. The family teleconference established that the patient had severe oxygen-dependent COPD, and although they had restorative goals they did not want the patient transferred if no additional therapies were available. The patient was ultimately extubated at the referral hospital and survived to discharge. Died at transferring hospital 7 months later after another COPD exacerbation	No	No
11	58	M	Metastatic esophageal and lung cancer	Admitted with respiratory failure. Request for transfer for further management. The family teleconference revealed history of metastatic esophageal and lung cancer. Goals were restorative and after discussion with family, palliative care and oncology specialists it was determined that further therapies did not align with this goal. Decision to transfer the patient to hospice services	No	Yes
12	73	M	COPD/congestive heart failure (CHF)	Admitted for COPD/CHF exacerbation and respiratory failure. Request for transfer to TCC was made for management of respiratory failure. Family teleconference established that the patient was in a nursing home prior to admission and had a poor quality of life. After discussion with palliative care, the family decided to continue with therapy with no escalation of care at their local hospital, changed status to DNR/DNI. Remained at the local hospital for care and died 3 days later	No	Yes

Abbreviations: CVA, cerebrovascular accident; TCC, tertiary care center; MSOF, multisystem organ failure; ESRD, end-stage renal disease; DNR, do-not-resuscitate; DNI, do-not intubate; COPD, chronic obstructive pulmonary disease; CHF, congestive heart failure.