Elizabeth J. Lilley

Palliative Care Interventions for Surgical Patients: A Systematic Review

IMPORTANCE Inpatient palliative care improves symptom management and patient satisfaction with care and reduces hospital costs in seriously ill patients. However, the role of palliative care in the treatment of patients undergoing surgery (surgical patients) remains poorly defined. OBJECTIVE To characterize the content, design, and results of interventions to improve access to palliative care or the quality of palliative care for surgical patients. EVIDENCE REVIEW This systematic review was conducted according to PRIMSA guidelines. Articles were identified through searches of PubMed, PsycINFO, EMBASE, and CINAHL as well as manual review of references. Eligible articles included experimental, quasi-experimental, and observational studies published in English from January 1, 1994, through October 31, 2014, in which patient outcomes of palliative care interventions for adult surgical patients were reported. Data on the study setting, design, intervention, participants, and results were extracted from the final study set and analyzed from December 22, 2014, to February 7, 2015. FINDINGS A total of 3838 abstracts were identified and screened by 2 reviewers, 77 articles were reviewed in full text, and 25 articles (22 unique interventions involving 8575 unique patients) met the study criteria. Interrater agreement was good (κ = 0.78). Nine single-institution retrospective cohort studies, 7 single-institution prospective cohort studies, 7 single-institution randomized clinical studies, and 2 multicenter randomized clinical studies were included. Nineteen of the 23 single-site studies were performed at academic hospitals. Given the heterogeneity of study methods and measures, meta-analysis was not possible. Preoperative decision-making interventions were associated with decreased mortality in 4 studies. Three studies reported improved quality of communication; 4, improved symptom management; and 7, decreased use of health care resources and decreased cost. However, many studies were small, performed in academic settings, and methodologically flawed and did not measure clinically meaningful outcomes. CONCLUSIONS AND RELEVANCE The sparse evidence regarding interventions to introduce or improve palliative care for surgical patients is further limited by methodologic flaws. Rigorous evaluations of standardized palliative care interventions measuring meaningful patient outcomes are needed.

Surgical Disparities: A Comprehensive Review and New Conceptual Framework

Received February 11, 2016; Revised April 8, 2016; Acc 2016. From the Center for Surgery and Public Health: Departm Brigham and Women’s Hospital, Harvard Medical Schoo TH Chan School of Public Health, Boston, MA (Torain Hisam, Lilley, Najjar, Changoor, Rose, Zogg, Haider); the tute on Minority Health and Health Disparities (Dankw tional Institutes of Health (Maddox), Bethesda, MD; Do Health Sciences Medical College, Karachi, Pakistan (Hisa ment of Surgery, Johns Hopkins University School of Medi MD (Kodadek); and the Department of Surgery, Eastern V School, Norfolk, VA (Britt). Correspondence address: Adil H Haider, MD, MPH, FA Surgery and Public Health, 1620 Tremont St, Suite MA 02120. email: ahhaider@partners.org

Palliative Care in Surgery: Defining the Research Priorities

Objective: To describe the existing science of palliative care in surgery within three priority areas and expose specific gaps within the field. Background: Given the acute and often life-limiting nature of surgical illness, as well as the potential for treatment to induce further suffering, surgical patients have considerable palliative care needs. Yet these patients are less likely to receive palliative care than their medical counterparts and palliative care consultations often occur when death is imminent, reflecting poor quality end-of-life care. Methods: The National Institutes of Health and the National Palliative Care Research Center convened researchers from several medical subspecialties to develop a national agenda for palliative care research. The surgeon work group reviewed the existing surgical literature to identify critical knowledge gaps. Results: To date, evidence to support the role of palliative care in surgical practice is sparse and palliative care research in surgery is encumbered by methodological challenges and entrenched cultural norms that impede appropriate provision of palliative care. Priorities for future research on palliative care in surgery include: 1) measuring outcomes that matter to patients, 2) communication and decision making, and 3) delivery of palliative care to surgical patients. Conclusions: Surgical patients would likely benefit from early palliative care delivered alongside surgical treatment to promote goal-concordant decision making and to improve patients’ physical, emotional, social and spiritual well-being and quality of life. We propose a research agenda to address major gaps in the literature and provide a road map for future investigation.

Intensity of treatment, end-of-life care, and mortality for older patients with severe traumatic brain injury

BACKGROUND The Eastern Association for the Surgery of Trauma (EAST) recommends that clinicians consider limiting further aggressive treatment in geriatric patients with severe traumatic brain injury (TBI) who do not improve in 72 hours (nonresponders) owing to their poor prognosis. However, little is known about how these guidelines are followed in practice. This study compared mortality and patient care among geriatric patients with severe TBI classified as “responders” and “nonresponders” 72 hours after injury. METHODS Retrospective review of patients 65 years or older at a Level I trauma center with severe TBI (GCS < 8) from 2011 to 2014. We compared in-hospital mortality, end-of-life (EOL) decision making, discharge functional status, and 12-month survival in responders (GCS > 8 at 72 hours) and nonresponders (GCS ⩽ 8 at 72 hours). RESULTS Of 90 patients, 29 (32%) died within 3 days of injury, 29 (32%) were nonresponders, and 32 (34%) were responders. An additional 19 patients (21%) died before hospital discharge, of whom 17 (89%) were nonresponders. Nonresponders had higher odds of in-hospital death (odds ratio, 31.8; 95% confidence interval [CI], 3.71–272.9; p = 0.002). Family meetings to discuss goals of care were more common in the nonresponder group (p < 0.001) and fewer nonresponders were full code at discharge or death (p < 0.001). There were no significant differences in functional status at discharge. Among patients discharged alive, there were no differences in 12-month survival. CONCLUSION The responder/nonresponder dichotomy identifies patients with higher in-hospital mortality outcomes and is associated with differences in EOL decision making. However, functional impairment and poor survival were prevalent, irrespective of neurologic status at 72 hours. LEVEL OF EVIDENCE Prognostic/epidemiologic study, level III; therapeutic study, level IV.

Using a Palliative Care Framework for Seriously Ill Surgical Patients The Example of Malignant Bowel Obstruction

In the recent report Dying in America: Addressing Key End of Life Issues, 1 the Institute of Medicine declared improving access to palliative care for seriously ill patients a national priority to address the crisis of low-value health care for patients near the end of life. Patients report comfort, symptom control, and dignity as central to achieving a “good death,” yet increasing numbers experience pain, unwanted health care transitions, and intensive care near the end of life. Surgeons play a critical role as providers of end-of-life care. Among Medicare decedents, almost one-third have surgery in the year before death, many in the last week of life, 2 and up to 25% of patients diagnosed as having stage IV cancer undergo a surgical procedure. Palliative care, an approach to care focused on improving quality of life for patients with lifethreatening illness and their families, is associated with improved symptom management, improved communication, and fewer care transitions for seriously ill patients. Although surgeons routinely care for seriously ill patients, the role of palliative care in surgery remains poorly defined. 3 Herein, we use malignant bowel obstruction (MBO) as an example of how surgeons can integrate principles of palliative care to support surgical care for patients with life-threatening illness. Management of MBO exemplifies the convergence of surgery and palliative care. Although survival varies based on cancer type and prognostic features, MBO is typically a late complication of advanced cancer, with life expectancy limited to weeks or months after onset. 4 Patient suffering can be immense with their remaining days fraught with high symptom burden, impaired quality of life, and hospitalization. Depending on anatomical features of the obstruction, surgical palliation via resection, bypass, or venting gastrostomy may offer select patients significant gains in quality of life. 4,5 However, substantial personal cost may accompany the pursuit of symptom relief in the form of prolonged recovery or burdensome complications, diminishing the benefits of treatment. As surgeons are increasingly called on to provide palliative interventions to seriously ill patients, their patients would benefit from strategies commonly used in palliative care to deliver goal-concordant care that is informed by patients’ values and health care priorities.

Routine inclusion of long-term functional and patient-reported outcomes into trauma registries: The FORTE project

BACKGROUND The National Academies of Sciences, Engineering, and Medicine (formerly the Institute of Medicine) recently recommended inclusion of postdischarge health-related quality of life (HRQoL) and patient-reported outcomes (PROs) metrics to benchmark the quality of trauma care. Currently, these measures are not routinely collected at most trauma centers. We sought to determine the feasibility and value of adding such long-term outcome measures to trauma registries. METHODS As part of the FORTE (Functional Outcomes and Recovery after Trauma Emergencies) project, we included patients with an Injury Severity Score of 9 or greater, admitted to the Brigham and Women’s Hospital in Boston, MA, who were identified retrospectively using the institutional trauma registry and contacted 6 or 12 months after injury to participate in a telephone survey evaluating HRQoL (Short Form 12 [SF-12]), PROs (Trauma Quality of Life), posttraumatic stress disorder, return to work, residential status, and health care utilization. RESULTS Data were collected for 171 of 394 eligible patients: 85/189 (45%) at 6 months and 86/205 (42%) at 12 months; 25%/29% (6/12 months) patients could not be contacted, 15%/16% (6/12 months) declined to participate, and 15%/13% (6/12 months) were interested in participating at another time but were not reached again. Approximately 20% patients screened positive for posttraumatic stress disorder, and half had not yet returned to work. There were significant reductions in SF-12 physical composite scores relative to population norms (mean, 50 [SD, 10]) at 6 months (mean, 44; 95% confidence interval [CI], 41–47) and 12 months (45; 95% CI, 42–47); no difference was noted in the SF-12 mental composite scores (6 months: 51 [95% CI, 48–54]; 12 months: 50 [95% CI, 46–53]). CONCLUSIONS Trauma patients reported considerable impairment 6 and 12 months after injury. Routine collection of PROs and HRQoL provides important data regarding trauma outcomes beyond mortality and will enable the development of quality improvement metrics that better reflect patients’ postinjury experiences. Improved and alternate methods for collection of these data need to be developed to enhance response rates before widespread adoption across trauma centers in the United States. LEVEL OF EVIDENCE Prognostic/epidemiologic, level II; Therapeutic, level III.

End-of-Life Care in Older Patients After Serious or Severe Traumatic Brain Injury in Low-Mortality Hospitals Compared With All Other Hospitals

Importance More than 80% of older patients die or are seriously impaired within 1 year after severe traumatic brain injury (TBI). Given their poor survival, information about end-of-life care is a relevant marker of high-value trauma care for these patients. In-hospital mortality is commonly used to measure quality of trauma care; however, it is not known what type of end-of-life care hospitals with the best survival outcomes provide to those who die. Objective To determine whether end-of-life care for older patients with TBI is correlated with in-hospital mortality. Design, Setting, and Participants A retrospective cohort study using 2005-2011 national Medicare claims from acute care hospitals was conducted. Medicare beneficiaries aged 65 years or older who were admitted with serious or severe TBI were included. Transferred patients, those treated at low-volume hospitals, and those who died on the date of admission were excluded. Low-mortality hospitals were those in the lowest quartile for in-hospital mortality using standardized mortality rates adjusting for age, sex, race/ethnicity, comorbidity, and injury severity. Patients at low-mortality hospitals were compared with patients at all other hospitals. The study was conducted from January 2005 to December 2011. Data analysis was conducted between August 2016 and February 2017. Main Outcomes and Measures End-of-life care outcomes for patients who died in hospital or 30 days or less after discharge included gastrostomy and tracheostomy placement during the TBI admission and enrollment in hospice. Results Of 363 hospitals included in the analysis, 91 (25.1%) were designated as low-mortality. The cohort included 34 691 patients (median age, 79 years; interquartile range, 72-84 years; 40.8% women). Of these patients, 55.8% of those at low-mortality hospitals and 62.5% at all other hospitals died in the hospital or 30 days or less after discharge (P < .01). Among patients who died in the hospital (n = 16 994), end-of-life care was similar at low-mortality hospitals and all other hospitals. For patients who survived the TBI admission and died 30 days or less after discharge (n = 4027), those at low-mortality hospitals underwent fewer gastrostomy (15.9% vs 24.0%; adjusted OR, 0.61; 95% CI, 0.52-0.72) or tracheostomy (18.2% vs 24.9%; adjusted OR, 0.71; 95% CI, 0.60-0.83) procedures and received more hospice care (66.3% vs 52.5%; adjusted OR, 1.72; 95% CI, 1.50-1.96). Conclusions and Relevance For older patients with serious or severe TBI, hospitals with the lowest in-hospital mortality perform fewer high-intensity treatments at the end of life and enroll more patients in hospice without increasing cumulative mortality 30 days or less after discharge.

Survival, Healthcare Utilization, and End-of-life Care Among Older Adults With Malignancy-associated Bowel Obstruction: Comparative Study of Surgery, Venting Gastrostomy, or Medical Management

Objective: To compare survival, readmissions, and end-of-life care after palliative procedures compared with medical management for malignancy-associated bowel obstruction (MBO). Background: MBO is a late complication of intra-abdominal malignancy for which surgeons are frequently consulted. Decisions about palliative treatments, which include medical management, surgery, or venting gastrostomy tube (VGT), are hampered by the paucity of outcomes data relevant to patients approaching the end of life. Methods: Retrospective study using 2001 to 2012 Surveillance, Epidemiology, and End Results-Medicare data of patients 65 years or older with stage IV ovarian or pancreatic cancer who were hospitalized for MBO. Multivariate competing-risks regression models were used to compare the following outcomes: survival, readmission for MBO, hospice enrollment, intensive care unit (ICU) care in the last days of life, and location of death in an acute care hospital. Results: Median survival after MBO admission was 76 days (interquartile range 26–319 days). Survival was shorter after VGT [38 days (interquartile range 23–69)] than medical management [72 days (23–312)] or surgery [128 days (42–483)]. As compared to medical management, patients treated with VGT had fewer readmissions [subdistribution hazard ratio 0.41 (0.29–0.58)], increased hospice enrollment [1.65 (1.42–1.91)], and less ICU care [0.69 (0.52–0.93)] and in-hospital death [0.47 (0.36–0.63)]. Surgery was associated with fewer readmissions [0.69 (0.59–0.80)], decreased hospice enrollment [0.84 (0.76–0.92)], and higher likelihood of ICU care [1.38 (1.17–1.64)]. Conclusions: VGT is associated with fewer readmissions and lower intensity healthcare utilization at the end of life than do medical management or surgery. Given the limited survival, regardless of management, hospitalization with MBO carries prognostic significance and presents a critical opportunity to identify patients’ priorities for end-of-life care.

The High Burden of Palliative Care Needs among Older Emergency General Surgery Patients

Dear Editor: A growing number of older adults with chronic, life-limiting illness are hospitalized with acute surgical conditions, such as small bowel obstruction, cholecystitis, and intestinal ischemia. Among those who undergo surgery, over 40% experience major morbidity or mortality within 30 days, and among those over age 85 years, 50% will die within one year. Meanwhile, others who don’t have surgery are frequently deemed inoperable, because their underlying disease is too advanced for surgical intervention to confer any palliative or survival benefit. In either case, hospitalization for an acute surgical condition is often an inflection point in the health trajectory of an older and seriously ill patient, signifying physical and functional decline, as well as the need for palliative care. Nonetheless, the palliative care needs and use of palliative care consults in hospitalized older patients with acute surgical conditions have not been described. Therefore, we sought to measure the prevalence of established clinical indicators for palliative care or hospice eligibility, as well as in-hospital, 6-month, and 12-month mortality rates among older patients evaluated by acute care surgeons in our hospital. From January 2, 2014 through June 30, 2014, we prospectively enrolled consecutive patients, age ‡65 years, evaluated by the emergency general surgery service EGS at a single academic hospital. Baseline poor performance status (limited self-care or in chair/bed >50% of day); advanced organ failure (ventricular assist device, oxygen-dependent pulmonary disease, end-stage renal disease); poor nutrition (weight loss >10% in six months, albumin <2.5 g/dL, BMI <23); and malignancies were determined from the medical record. Healthrelated quality of life (HRQOL) was measured for clinically appropriate, English-speaking patients using the Medical Outcomes Study 12-item Short-Form (MOS SF-12). The cohort consisted of 173 patients, mean age 77 years (range 65–101 years). The majority were women (57%), white (86%), and evaluated in the emergency department (ED) (67%). Small bowel obstruction (26%), biliary disease (17%), and nonischemic colitis (10%) were the most frequent diagnoses. Palliative care needs were common: 69% had ‡1 clinical indicator and 33% had ‡2 clinical indicators (see Table 1). SF-12 was completed for 97 patients: Mean scores for all domains and physical and mental component summary

High Burden of Palliative Care Needs of Older Adults During Emergency Major Abdominal Surgery: Palliative Care Needs in Emergency Surgery

To quantify preoperative illness burden in older adults undergoing emergency major abdominal surgery (EMAS), to examine the association between illness burden and postoperative outcomes, and to describe end‐of‐life care in the year after discharge.