Article 1
Timing is everything: early versus late palliative care consults in trauma. Spencer AL, Miller PR 3rd, Russell GB, Cornea I, Marterre B. J Trauma Acute Care Surg. 2023 May 1;94(5):652-658.
This is a retrospective single-institution study examining the use of early (<=3d from admission) vs late palliative care (PC) consultation in adult trauma patients over 27 months. The authors looked at 60 early PC (mean 1.27 days to consult) and 94 late PC (mean 10.38 days to consult) patients – prior to excluding 8 patients for missing data, the total patients receiving a PC consult amounted to 3.3% of the institution’s 5,171 trauma patients. The group found that though injury characteristics and medical comorbidities were similar between groups, the late PC group tended to be younger (69.9 vs 75.3 years, p=0.04). They also had longer LOS (despite the fact that 3 days were subtracted from these patients’ LOS to provide a fair comparison to the early group) (17.5 vs 7.0 days, p<0.01), and concordant higher median hospital costs. The early group had shorter LOS, fewer ventilator days, and lower rates of trach (1.7% vs 11.7%, p-0.03) and feeding tube (1.7% vs 11.7%, p=0.03) placement, despite similar mortality rates (30.0% vs 27.7%, p=0.86). Adding in-hospital mortality to hospice discharges revealed a similar result (63.3% total mortality + hospice in early group, 61.7% for late).
This study adds some much-needed evidence to the relatively sparse literature on PC in trauma. While the body of literature on this topic is certainly growing in recent years, PC is generally underused (as noted in the authors’ introduction). It would have been great to know more about the differences between groups – were there aspects of clinical status that tended to prompt PC consultations (early or late)? What exactly took place during or following these consultations – i.e., were late consultations more focused on defining goals of care and directed towards comfort-focused care? These questions should be addressed in future work in this area, as this may help inform decision-making and help increase the use of PC. Nonetheless, this is an important manuscript that effectively demonstrates the benefit of early PC for trauma patients.
Article 2
Primary palliative care in acute care surgery: an American Association for the Surgery of Trauma Critical Care Committee and Palliative Care Committee clinical consensus document. Kodadek LM, Cook M, Young J, Cottrell-Cumber S, Farrell MS, Jawa R, Kirsch JM, Nohra EA, Haruta A, Lueckel S, Maerz LL, Toevs CC, Sanchez SE, Kaupa KL, et al. Trauma Surgery & Acute Care Open. Volume 10, Issue 1.
This is a clinical consensus document from the AAST Critical Care and Palliative Care committees. In it, the authors provide guidance around primary palliative care, or the provision of palliative care by the primary (surgical) team, as opposed to a palliative care specialist. They make a series of recommendations, including consistent screening with the “surprise question” or the ACS TQIP Palliative Care Best Practices Guidelines within 24 hours of admission and the use of the REMAP framework or best case/worst case for delivering bad news. The document also contains guidance on competencies for acute care surgeons, including the ability to comfortably have difficult conversations and elicit accurate and appropriate goals of care (GOC) from patients and surrogates. Finally, the authors make recommendations on when specialty palliative care services should be involved, including “complex” needs and care transitions, refractory pain, conflict between providers and/or families, or geriatric patients. Additional recommendations on capacity and decision-making surrounding procedures are made.
As noted above, palliative care is severely underutilized in trauma and acute care surgery patients, and this consensus document is a wonderful summary of salient points and recommendations which will hopefully lower the barrier to increased use. It may be that surgical teams will still feel underprepared or uncomfortable providing this care themselves, but this both serves as a good starting point and provides specific guidance on when to involve specialists.
Article 3
Surprise Question in Trauma Research Group. Would you be surprised? Prospective multicenter study of the Surprise Question as a screening tool to predict mortality in trauma patients. Hoffman MR, Slivinski A, Shen Y, Watts DD, Wyse RJ, Garland JM, Fakhry SM. Journal of Trauma and Acute Care Surgery. 2024 Jan 1;96(1):35-43.
In this multicenter, prospective, cohort study, Hoffman et al sought to determine if trauma team members could use the Surprise Question (SQ) (“Would I be surprised if the patient died within the next year?”) to accurately predict 1-year mortality in trauma patients. The SQ is an established screening method to identify patients with limited life expectancy and thus, allow healthcare providers to identify patients who may benefit from timely palliative care interventions. Adult trauma patients ≥18 years of age without preexisting comfort care or hospice care who presented ED of 11 Levels I and II trauma centers between July 2020 and February 2021 were screened for eligibility. Patients were excluded if they were discharged from or died in the ED. Within 24 hours of admission trauma team members were asked the SQ. Primary outcomes were the PPV, NPV, and accuracy of the SQ.
A total of 1,172 patients were included in the final analysis with a median age of 57 years (IQR, 36-74 years), median comorbidity count of 1 (IQR, 1-3), a median ISS of 10 (IQR, 5-14), and a median GCS of 15 (IQR, 15-15). Approximately 1/3 of patients were predicted to die within 1 year regardless of provider type. The PPV of the SQ was only 30.5% regardless of provider type, while the NPV was high (95.1%) among all provider types. The overall accuracy was 73.8%. When stratified by patient age, the PPV increased in association with older patient age, while the NPV and overall accuracy decreased with older patient age. There was no significant association between the clinicians’ prediction on 1-year mortality and ISS.
The American College of Surgeons Trauma Quality Improvement Program Palliative Care Best Practice Guidelines published in 2017 recommended screening for palliative care needs within the first 24 hours of admission and notably recommended incorporation of the SQ in this screening. The SQ is a well-studied and effective screening method in multiple patient populations to identify patients who may benefit from early palliative care involvement, yet this is the first study to assess the SQ exclusively in trauma patients. This study suggests that the effectiveness of the SQ is currently limited in this patient population. The authors suggest that this may be due to overestimation of injury effects, preinjury conditions, and/or team bias. The associations of PPV, NPV and overall accuracy of the SQ with patient age is notable in the context of a previous study demonstrating decreased and later utilization of palliative care in younger trauma patients when compared to older patients, regardless of severity (Wycech et al. 2021). This study lays the foundation for further research assessing methods for identifying optimal patients for early palliative care interventions and suggests that more research is needed to determine the optimal time to screen trauma patients with the SQ.
Article 4
A Quality Improvement Initiative to Implement Focused Family Meetings in the Surgical Intensive Care Unit: Does It Matter? Maniar Y, Chalasani H, Messerole K, Beck L, Stright A, Petrone P, Islam S, Joseph DK. The American Journal of Surgery. 2025 Feb;91(2):208-216.
Family meetings are often difficult to implement for every patient in the ICU and end-of-life care discussions and palliative care consults are not universally implemented by surgeons, making communication goals less likely to be achieved. Maniar et al implemented a QI initiative at NYU Langone Hospital – Long Island in an attempt to overcome the barriers associated with conducting family meetings in the SICU. The authors developed a Focused Family Meeting (FFM) algorithm incorporating illness severity and family’s psychological stress to identify optimal targets for family meetings. The agenda for the meetings were obtained from a previously published family meeting toolkit. Patients that met criteria for a family meeting were randomized to a multidisciplinary FFM (intervention group) or standard of care.
During the study period from January to December 2022, 58/912 (6%) patients admitted to the SICU met criteria for the FFM. Surveys were ultimately only able to be completed for 19 patients in the intervention group and 17 patients in the non-intervention group. Among the 17 patients in the non-intervention group, 9 of them had a family meeting outside of the protocol at the discretion of the ICU physician. No statistically significant difference between the responses of the intervention and non-intervention groups in regard to patient and family satisfaction with communication was observed. On a Likert scale of 1-4, the median response for all questions in both groups was 4, indicating overall satisfaction across groups.
The authors conclude that these results may suggest that family meetings may not be as important in improving communication with families; rather incorporating routine evaluations of family needs in the SICU and focusing on communication skills may improve overall satisfaction with communication. While this QI initiative did not show any significant difference in satisfaction with communication between the intervention and non-intervention groups, the study is limited by its small sample size and single institution design. Additionally, more than half of the patients in the non-intervention group had a family meeting outside of the protocol. Conducting additional and larger-scale qualitative research is needed to determine the type and setting of communication that families of trauma and surgical patients find the most beneficial. Furthermore, further research is also required to parse out optimal methods for screening patients and families for family meetings as well as optimal modes of delivery in this patient population.
