Many critically ill patients with COVID-19 need specialty level palliative care to manage symptoms, conduct goals of care conversations, and facilitate medical decision making in ethically and emotionally charged situations. During the apex of the COVID-19 crisis in New York, the Adult Palliative Care Service at Columbia University Irving Medical Center (CUIMC)/NewYork-Presbyterian (NYP) received a 7-fold increase in consultation requests. This unprecedented increase in demand outpaced the palliative care team's ability to respond. We describe the rapid development and implementation of a scalable virtual consultation model staffed by out-of-state palliative care specialist volunteers.
Background: Older patients with traumatic brain injury (TBI) have higher mortality and morbidity than their younger counterparts. Palliative care (PC) is recommended for all patients with a serious or life-limiting illness. However, its adoption for trauma patients has been variable across the nation. The goal of this study was to assess PC utilization and intensity of care in older patients with severe TBI. We hypothesized that PC is underutilized despite its positive effects.
Materials and methods: The National Inpatient Sample database (2009-2013) was queried for patients aged =55 y with International Classification of Diseases, Ninth Revision codes for TBI with loss of consciousness =24 h. Outcome measures included PC rate, in-hospital mortality, discharge disposition, length of stay (LOS), and intensity of care represented by craniotomy and or craniectomy, ventilator use, tracheostomy, and percutaneous endoscopic gastrostomy.
Results: Of 5733 patients, 78% died in hospital with a median LOS of 1 d, and 85% of the survivors were discharged to facilities. The overall PC rate was 35%. Almost 40% of deaths received PC, with nearly half within 48 h of admission. PC was used in 26% who had neurosurgical procedures, compared with 35% who were nonoperatively managed (P = 0.003). PC was associated with less intensity of care in the entire population. For survivors, those with PC had significantly shorter LOS, compared with those without PC.
Conclusions: Despite high mortality, only one-third of older patients with severe TBI received PC. PC was associated with decreased use of life support and lower intensity of care. Significant efforts need to be made to bridge this quality gap and improve PC in this high-risk population.
- Modern surgeons play a complex role as both providers and gatekeepers when it comes to meeting the palliative needs of their patients.
- Surgical palliative care is delivered by surgical teams as a component of routine surgical care, and includes management of physical and psychosocial symptoms, as well as basic communication about prognosis and treatment options and identification of patient goals and values; in addition, specialty palliative care for surgical patients may be provided through a range of consultative or integrative models.
- A common fallacy in surgical culture is for surgical intervention and palliation to be re-garded as mutually exclusive or sequential strategies in the trajectory of a patient’s care.
- Because it is difficult to measure palliative care provided by surgeons as a component of routine surgical practice, the evidence base for concurrent palliative care in surgery is sparse.
- Reconceptualizing opportunities to offer palliative care to surgical patients in terms of the phases of the perioperative continuum may help integrate palliative care throughout the clinical trajectory.
BACKGROUND: End-stage renal disease (ESRD) is a life-limiting condition that is often complicated by acute abdominal emergency. Palliative care (PC) has been shown to improve the quality of life in patients with serious illness and yet is underutilized. We hypothesize that ESRD patients with abdominal emergency have high unmet PC needs.
OBJECTIVE: To characterize the outcomes of ESRD patients with acute surgical abdomen, define PC utilization patterns, and identify areas of unmet PC needs.
DESIGN: Retrospective study querying the National Inpatient Sample database (2009-2013).
SETTING AND SUBJECTS: Subjects were identified using ICD-9 codes for those aged =50 with preexisting diagnosis of ESRD with an acute abdominal emergency diagnosis of gastrointestinal perforation, obstruction, or ischemia.
MEASUREMENTS: Outcomes included PC rate, in-hospital mortality, discharge disposition, and intensity of care. Multivariable logistic regression analysis was used to identify predictors of PC.
RESULTS: A total of 9363 patients met the inclusion criteria; 24% underwent surgery, 16% died in hospital, and 43% were discharged to dependent living. Among in-hospital deaths, 23% received PC. Only 4% of survivors with dependent discharge received PC. Surgical mortality was 26%. PC was less utilized in surgical patients than nonsurgical patients. PC was associated with shorter hospital stay. Predictors of PC included increasing age, severity of underlying illness, white race, teaching hospitals, and the Western region.
CONCLUSIONS: Patients with ESRD admitted for acute abdominal emergency have high risk for mortality and functional dependence. Despite this, few receive PC and have a high utilization of nonbeneficial life support at the end of life.
BACKGROUND: When patients with dementia develop acute surgical abdomen, patients, surrogates, and surgeons need accurate prognostic information to facilitate goal-concordant decision making. Palliative care can assist with communication, symptom management, and family and caregiver support in this population. We aimed to characterize outcomes and patterns of palliative care utilization among patients with dementia, presenting with abdominal surgical emergency.
METHOD: We retrospectively queried the National Inpatient Sample for patients aged >50 years with dementia and acute abdominal emergency who were admitted nonelectively 2009-2013, utilizing ICD-9-CM codes for dementia and surgical indication. We characterized outcomes and identified predictors of palliative care utilization.
RESULTS: Among 15,209 patients, in-hospital mortality was 10.2%, the nonroutine discharge rate was 67.2%, and 7.5% received palliative care. Patients treated operatively were less likely to receive palliative care than those who did not undergo operation (adjusted OR = 0.50; 95% CI 0.41–0.62). Only 6.4% of patients discharged nonroutinely received palliative care.
CONCLUSION: Patients with dementia and acute abdominal emergency have considerable in-hospital mortality, a high frequency of nonroutine discharge, and low palliative care utilization. In this group, we discovered a large gap in palliative care utilization, particularly among those treated operatively and those who are discharged nonroutinely.