BACKGROUND: Palliative Care (PC) is indicated in patients with functional dependency and advanced care needs in addition to those with life-threatening conditions. Older trauma patients have PC needs due to increased risk of mortality and poor long-term outcomes. We hypothesized that older trauma patients discharged alive with poor outcomes are not easily identified nor receive PC interventions.
METHODS: Prospective observational study of trauma patients 55 years or older. Patients with poor functional outcomes defined by discharge Glasgow Outcome Scale Extended (GOSE) 1-4 or death at 6-month follow-up were analyzed for rate and timing of PC interventions including goals of care conversation (GOCC), do-not-resuscitate (DNR) order, do not intubate (DNI) order, and withdrawal of life supporting measures. Logistic regression was performed for having and timing of GOCC.
RESULTS: Three hundred fifteen (54%) of 585 patients had poor outcomes. Of patients who died, 94% had GOCC compared with 31% of patients who were discharged with GOSE 3 or 4. In patients who died, 85% had DNR order, 18% had DNI order, and 56% had withdrawal of ventilator. Only 24% and 9% of patients with GOSE of 3 or 4, respectively, had DNR orders. Fifty percent of the patients who were dead at 6-month follow-up had GOCC during initial hospitalization. The median time to DNR in patients that died was 2 days compared with 5 days and 1 day in GOSE 3 and 4 (p = 0.046). Age, injury severity scale, and preexisting limited physiological reserve were predictive of having a GOCC.
CONCLUSION: The PC utilization was very high for older trauma patients who died in hospital. In contrast, the majority of those who were discharged alive, but with poor outcomes, did not have PC. Development of triggers to identify older trauma patients, who would benefit from PC, could close this gap and improve quality of care and outcomes.
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.
BACKGROUND: Older trauma patients have increased risk of adverse in-hospital outcomes. We previously demonstrated that low pre-injury Palliative Performance Scale (PPS) independently predicted poor discharge outcomes. We hypothesized that low PPS would predict long-term outcomes in older trauma patients.
METHODS: Prospective observational study of trauma patients aged > 55 admitted between 7/2016-4/2018. Pre-injury PPS was assessed at admission; low PPS was defined as <70. Primary outcomes were mortality and functional outcomes, measured by GOSE, at discharge and 6 months. Poor functional outcomes were defined as GOSE < 4. Secondary outcomes were patient-reported outcomes at 6 months: EQ-5D and SF-36. Adjusted relative risks (aRRs) were obtained for each primary outcome using multivariable modified Poisson regression, adjusting for PPS, age, race/ethnicity, gender, and injury severity.
RESULTS: In-hospital data were available for 516 patients; mean age 70 years and median ISS 13. 30% had low PPS. 6% (n=32) died in hospital, and half of survivors (n=248) had severe disability at discharge. Low PPS predicted hospital mortality (aRR 2.6, 95% CI 1.2-5.3) and poor outcomes at discharge (aRR 2.0, 95% CI 1.7-2.3). Six-month data were available for 176/203 (87%) patients who were due for follow-up. Functional outcomes improved in 64% at 6 months. However, 63% had moderate to severe pain, and 42% moderate to severe anxiety/depression. Mean GOSE improved less over time in low-PPS patients (7% vs. 24%; p<0.01). Low PPS predicted poor functional outcomes at 6 months (aRR 3.1, 95% CI 1.8-5.3) while age and ISS did not.
CONCLUSIONS: Pre-injury PPS predicts mortality and poor outcomes at discharge and 6 months. Despite improvement in function, persistent pain and anxiety/depression were common. Low-PPS patients fail to improve over time compared to high-PPS patients. Pre-injury PPS can be used on admission for prognostication of short- and long-term outcomes and is a potential trigger for palliative care in older trauma patients.
LEVEL OF EVIDENCE: Prognostic study - level II.
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.