Palliative Care and End-of-Life Outcomes Following High-risk Surgery

Abstract

IMPORTANCE Palliative care has the potential to improve care for patients and families undergoing high-risk surgery.OBJECTIVE To characterize the use of perioperative palliative care and its association with family-reported end-of-life experiences of patients who died within 90 days of a high-risk surgical operation. DESIGN, SETTING, AND PARTICIPANTSThis secondary analysis of administrative data from a retrospective cross-sectional patient cohort was conducted in the Department of Veterans Affairs (VA) Healthcare System. Patients who underwent any of 227 high-risk operations between January 1, 2012, and December 31, 2015, were included.EXPOSURES Palliative-care consultation within 30 days before or 90 days after surgery. MAIN OUTCOMES AND MEASURESThe outcomes were family-reported ratings of overall care, communication, and support in the patient's last month of life. The VA surveyed all families of inpatient decedents using the Bereaved Family Survey, a valid and reliable tool that measures patient and family-centered end-of-life outcomes. RESULTS A total of 95 204 patients underwent high-risk operations in 129 inpatient VA Medical Centers. Most patients were 65 years or older (69 278 [72.8%]), and the most common procedures were cardiothoracic (31 157 [32.7%]) or vascular (23 517 [24.7%]). The 90-day mortality rate was 6.0% (5740 patients) and varied by surgical subspecialty (ranging from 278 of 7226 [3.8%] in urologic surgery to 875 of 6223 patients [14.1%] in neurosurgery).A multivariate mixed model revealed that families of decedents who received palliative care were 47% more likely to rate overall care in the last month of life as excellent than those who did not (odds ratio [OR], 1.47 [95% CI, 1.14-1.88]; P = .007), after adjusting for patient's characteristics, surgical subspecialty of the high-risk operation, and survey nonresponse. Similarly, families of decedents who received palliative care were more likely to rate end-of-life communication (OR, 1.43 [95% CI, 1.09-1.87]; P = .004) and support (OR, 1.31 [95% CI, 1.01-1.71]; P = .05) components of medical care as excellent. Of the entire cohort, 3374 patients (3.75%) had a palliative care consultation, and 770 patients (0.8%) received it before surgery. Of all decedents, 1632 (29.9%) had a palliative care consultation, with 319 (5.6%) receiving it before surgery.CONCLUSIONS AND RELEVANCE Receipt of a palliative consultation was associated with better ratings of overall end-of-life care, communication, and support, as reported by families of patients who died within 90 days of high-risk surgery. Yet only one-third of decedents was exposed to palliative care. Expanding integration of perioperative palliative care may benefit patients undergoing high-risk operations and their families.

The Meaning of Words and Why They Matter During End-of-Life Conversations

“…Palliative consultation is associated with an overall improvement in EOL care, communication, and support, according to families of deceased patients. 14 It has also been shown to enhance patients' quality of life and mood, improve documentation of resuscitation preferences, and lead to less aggressive care at the EOL, including less chemotherapy. 15 Integration of palliative care in the care of patients hospitalized with acute heart failure has been associated with improved quality of life, decreased symptom burden and depressive symptoms, and increased participation in advance care planning.…”

When to Consider Deferral of Surgery in Acute Type A Aortic Dissection: A Review

“…In a recent Veterans Affairs study evaluating 95,204 patients who underwent high-risk surgery, only 770 (0.8%) received a palliative care consultation before surgery. 62 Of all the patients who died within 90 days, 29.9% had received a palliative care consultation, and 5.6% received consultation before surgery. Families of these patients reported an overall significant increase in satisfaction with end-of-life care, communication, and support.…”

Primary palliative care for surgeons: a narrative review and synthesis of core competencies

“…Studies are underway to evaluate routine inclusion of specialist PC for cancer patients undergoing non-palliative oncologic surgery (98). Prior research within the Veterans Affairs (VA) medical system has shown that the survivors of high-risk surgical procedures who died and received an inpatient PC consultation were more likely to rate their loved ones' overall care, EOL communication and support as excellent when compared to families of decedents who did not receive PC (99). A corollary study within the VA system demonstrated that surgical patients were less likely to receive a PC consult than medical patients, despite the fact that 22% of the patients had at least one major surgical procedure in their final year of life (100).…”