Article 1
Adherence to the TQIP Palliative Care Guidelines Among Patients With Serious Illness at a Level I Trauma Center in the US. JAMA Surg. 2022 Dec 1;157(12):1125-1132.
This single-center retrospective review examined adherence to American College of Surgeons Trauma Quality Improvement Program (TQIP) guidelines encouraging trauma services to deliver palliative care in parallel with life sustaining treatment. These guidelines strongly recommend having and documenting goals of care (GOC) discussions within 72 hours of admission.
The authors performed a retrospective review of 674 consecutive patients admitted both before and after institutional guidelines were amended to reflect TQIP recommendations. 474 patients whose burden of injury met criteria for serious illness conversation were reviewed. These patients were further subdivided into pre- and post-guideline groups. Medical records were reviewed for presence of GOC documentation within 72 hours of admission and during hospitalization. Interestingly, there was no difference between groups at 72 hours (19% vs 18.9%) or during admission (26.2% vs 24.8%) The authors did note that the presence of mechanical ventilation and multiple serious illness criteria significantly increase the odds ratio of GOC documentation (ventilation - 6.42; 95% CI, 3.49-11.81) (multiple criteria - 4.07; 95% CI, 2.25-7.38).
This article highlights that simply having guidelines may not be sufficient to facilitate adherence in the absence of systems-level interventions. In this retrospective analysis, it is impossible to discern if GOC conversations were not had or were performed but not captured in the electronic record. This limits the applicability of the findings. The authors further highlight that screenings for palliative care delivery are limited and may not capture critical vulnerable groups; palliative interventions and discussions may not be routinely captured in the EMR; and that GOC often focuses primarily on code status, but fail to address other elements of palliative care. Thus, GOC documentation may be a poor surrogate quality measure. This dataset, though admittedly limited, might serve as an initial benchmarking for adherence to TQIP national best practice guidelines and promotes interesting discussion regarding quality metrics in surgical palliative care, specifically surrounding the trauma patient. It highlights the need for ongoing research, QI, and standardization of palliative care delivery in the acute phases of admission after significant traumatic injury.
Article 2
Palliative Care in Severe Neurotrauma Patients in the Intensive Care Unit. Dolmans RGF, Robertson FC, Eijkholt M, et al. Neurocrit Care. 2023 Dec;39(3):557-564.
Severe traumatic brain injury is a significant source of mortality and morbidity in all age groups. They frequently require large amounts of intensive care resources; patient prognosis can be difficult to ascertain early in a patient’s course; and decision-making is often requires assistance by family as surrogates. The authors highlight the role of palliative care as both a philosophy and approach to providing non-curative focused aspects of this complex care. They highlight the barriers to more frequent and early use of palliative care in the neurotrauma population, including improper associations with oncology, hospice care, and end-of-life situations. This has been shown to lead to late and less frequent utilization of palliative care in the neurotrauma populations.
When applied to neurotrauma patients, the authors highlight physical, psychological, social, cultural, ethical, and legal aspects of palliative care specific to the neurotrauma population. For example, uncertainty regarding brain-injured patients’ perception of pain can limit its proper treatment validated tools that incorporate facial expressions, body movement, and compliance with mechanical ventilation to facilitate appropriate sedation and analgesia can be used. They highlight the psychosocial concepts of the “hidden” or “secondary” patients: the family members. These close contacts may have varying mechanisms of coping, feelings of guilt regarding treatment decisions, and financial/insurance concerns regarding the injury of their family member, all of which can be supported with a palliative care philosophy. Indeed, they recommend assigning social workers to specifically stricken families, if necessary. Spiritual, cultural, and religious aspects of care can affect family members interpretation of life, death, and rituals of dying which can be assisted by chaplaincy or spiritual care teams. Lastly, there are ethical and legal implications of resuscitation, mechanical ventilation, and the withdrawal and withholding of futile interventions that can make family discussions regarding decision-making difficult.
The authors discuss barriers in implementing a palliative plan including uncertain prognoses which can postpone the creation and implementation of a palliative care plan. This is complicated by the fact that there is a lack of advanced directives or pre-existing familial goals of care discussions in a majority of trauma patients and their families. These types of issues are also well addressed by the use of palliative care philosophies. Lastly, the authors discuss communications skills that can be implemented by the critical care team when providing palliative care, including five goals of communication, and the best case-worst case framework.
Article 3
Palliative Care Consultations in Trauma Patients and Role of Do-Not-Resuscitate Orders: Propensity-Matched Study. Fokin AA, Wycech J, Katz JK, Tymchak A, Teitzman RL, Koff S, Puente I. Am J Hosp Palliat Care. 2020 Dec;37(12):1068-1075.
Palliative care has been a topic of discussion and debate in the surgical patient population with increasing frequency. Up to 20% of ICU patients meet the palliative care consult criteria, yet only 2.1% to 14.7% of those patients receive palliative care consultation during their in-patient stay. Additionally, Do-Not-Resuscitate discussion for surgical and trauma patients tends to happen less frequently and later on in patient’s stay, leading to longer length of stay, unnecessary procedures and unintentional psychosocial effect on the patient’s loved ones.
The study by Fokin et al., compares two groups of trauma patients, those who received Palliative Care Consultation during their hospital stay and matched control group. They compared a multitude of variables, including patients’ Do-Not-Resuscitate status. This retrospective cohort study included 864 adult trauma patients, and attempted to look at patient characteristics associated with palliative care consult and Do-No-Resuscitate status.
Primary findings revealed that patients who received palliative care consults tended to be older, with lower Glasgow Coma Scale scores, lower Revised Trauma Scores, and had a higher incidence of traumatic brain injury. Interestingly, Palliative Care Consult group required Intensive Care Unit and mechanical ventilation more frequently, but the ICU length of stay and duration of mechanical ventilation was the same for both groups. Another interesting finding discussed is those patients in the Palliative Care Consult group with no Do-Not-Resuscitate orders had a longer length of stay, longer ICU length of stay, increased ventilator days and increased time to death. These patients were also less likely to get discharged to hospice.
Overall, this study demonstrates the importance of early Palliative Care Consultation in adult trauma patients. As well as presence or absence of Do-Not-Resuscitate orders and its influence on outcomes, discharge disposition and length of stay.
