Characteristics and Procedures Among Adults Discharged to Hospice After Gastrointestinal Tract Surgery in California

Greenberg, Anya L.; Lin, Joseph A.; Colley, Alexis; Finlayson, Emily; Bongiovanni, Tasce; Wick, Elizabeth C.

doi:10.1001/jamanetworkopen.2022.20379

JAMA Netw Open

2022

DOI: 10.1001/jamanetworkopen.2022.20379

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Characteristics and Procedures Among Adults Discharged to Hospice After Gastrointestinal Tract Surgery in California

Anya L. Greenberg

Joseph A. Lin

Alexis Colley

et al.

Abstract: IMPORTANCE Hospice care is associated with improved quality of life and goal-concordant care.Limited data suggest that provision of hospice services after surgery is suboptimal; however, literature in this domain is in its nascency, leaving gaps in our understanding of patients who enroll in hospice after surgery.OBJECTIVE To characterize the transition to hospice after gastrointestinal tract surgery and identify areas that warrant further attention and intervention. DESIGN, SETTING, AND PARTICIPANTSThis retro… Show more

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Cited by 5 publications

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“…Elsewhere in JAMA Network Open , Greenberg et al leverage California Patient Discharge Data to characterize patients who enrolled in hospice after gastrointestinal tract surgery. The authors identified 2688 patients discharged to hospice after surgery for a digestive disorder in California between January 1, 2015, and December 31, 2019.…”

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“…The analysis by Greenberg et al reveals multiple opportunities to elicit patient values and discuss future care among patients with gastrointestinal tract cancer undergoing surgical intervention and suggests that such conversations should begin at the time of diagnosis and continue even after hospice discharge. Unfortunately, for this cohort, it is unknown whether these conversations occurred and whether patient values were respected.…”

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Surgery at the End of Life—Aggressive But Necessary?

Millis

Suwanabol

2022

JAMA Netw Open

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In the 3 years preceding this surgical hospitalization, this cohort had a mean of 2.21 hospital admissions per patient, with 3594 of 5953 admissions (60.4%) within 1 year of hospice enrollment. Younger patients, those who belonged to racial and ethnic minority groups, those with limited English proficiency, and/or those insured through Medicaid were more likely to be readmitted after hospice enrollment. Using the Distressed Community Index as a measure of economic status, those in the midtier, at-risk, or distressed group had significantly higher rates of readmission.This work highlights the challenge in using large data sets to capture the nuances of care at the end of life. As the authors emphasize, surgical care specifically is associated with worse quality of life, common misconceptions about curative intent, and poor communication resulting in goaldiscordant care. Although certainly true, this study may not be fully equipped to support these assertions. Furthermore, when considering the trajectory of cancer, their findings speak in favor of surgery's role at the end of life. In end-of-life care literature, overtreatment is defined as a medical intervention that is extremely unlikely to help a patient, is misaligned with a patient's wishes, or both. 2 With respect to the latter definition, large data sets do not capture patient wishes, and conclusions about the merit of surgery are not possible. Large data sets are potentially capable of assessing the ability of an intervention to help, but this requires first asking, "What are we helping?" Overtreatment would be evident if the goal of surgery was to prolong life in a patient with terminal cancer. However, interventions performed for symptomatic relief in a patient facing life-threatening cancer are in accordance with the priorities of palliative care. 3 The authors found that bowel resection, gastric bypass, and fecal diversion were the most frequently performed operations, implying that surgery was provided with palliative intent. Without these interventions, patients would likely require hospitalization and experience a painful death.The authors report that 88.9% of their cohort underwent urgent or emergent operations, supporting the critical need for advance care discussions with attention to the likely natural course of patients' disease (ie, period of gradual progression followed by becoming increasingly symptomatic and finally, a short period of evident decline) before they present for surgery. 4 However, the data source does not capture whether these discussions might already be happening, which is arguably feasible given the numerous hospitalizations before the surgical intervention. Furthermore, although there may be a typical cancer trajectory, cancer can also be insidious and unpredictable. As such, it may not be truly accurate to conclude that surgery near death is a failure in the care pathway leading to untimely or aggressive care.For decades, experts have voiced concerns about the methodological difficulties in using big data for end-of-life...

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Surgery at the End of Life—Aggressive But Necessary?

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Suwanabol

2022

JAMA Netw Open

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Characteristics and Procedures Among Adults Discharged to Hospice After Gastrointestinal Tract Surgery in California

Cited by 5 publications

References 49 publications

Surgery at the End of Life—Aggressive But Necessary?

Surgery at the End of Life—Aggressive But Necessary?

The relationship between neighborhood socioeconomic status and short-term outcomes following colon resection

Aggressive anticancer treatment in the last 2 weeks of life

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