Preferences and Predictions Regarding Palliative Care in the Trauma Intensive Care Unit

Abstract

Introduction In the older intensive care unit (ICU) trauma population, it is common to have to make decisions about end-of-life. We sought to demonstrate uncertainty of patients and providers in this area. Methods Our study is a prospective observational study of trauma patients 50 years and older admitted to the ICU. Patients or surrogates completed a survey including questions regarding end-of-life. Team members were surveyed with their expectation for patient outcome and appropriateness of palliative or comfort care. Patients were followed up for 6 months. Chi-square analysis and Fisher’s exact test were performed. Results 100 patients had data available for analysis. Surveys were completed by the patient for 39 while a surrogate completed the survey for 61 patients. There was a significant increase in uncertainty if a surrogate answered or if there had been no prior discussions about end-of-life. Nurse, resident, and attending predictions about hospital survival were similar with all groups predicting survival in 82%. 6-month survivors were only predicted to be alive 75% of the time. Ideas about comfort care were similar but there was more variation regarding a palliative care consult with nurses saying yes in 27% of surveys while physicians only said yes in 18%. Conclusions The significantly higher rates of uncertainty for both surrogates or in cases where no prior discussion had been had highlight the importance of having more conversations about end-of-life and documentation of advance directives prior to traumatic events. The difference in team member ideas about palliative care demonstrates a need for improved team communication.

Palliative Care in the Trauma and Surgical Critical Care Settings: A Narrative Review

“…The risk of bias of four included studies was classified as moderate, 2,6,17,19 and all eighteen remaining studies were classified as low (eTable 2 and eTable 3: Supplemental File). 3,5,[10][11][12]18,[20][21][22][23][24][25][26][27][28][29][30][31] Among crosssectional studies classified as moderate risk of bias, common concerns included lack of identification of possible confounding factors and lack of strategies to account for confounders.…”

“…A total of 22 studies were included in this review (eTable 1: Supplemental File, Figure 1). 2,3,5,6,10,11,12,[17][18][19][20][21][22][23][24][25][26][27][28][29][30][31] Five studies addressed the definitions and elements for palliative care in the trauma and surgical critical care setting, [17][18][19][20][21] Nine studies investigated approaches for palliative care, [10][11][12][22][23][24][25][26][27] and 8 studies evaluated the impact of palliative care on patient outcomes. 2,3,5,6,[28][29][30][31] These studies included 16 cross-sectional studies, 2,5,6,10,11,17-23,25-27,31, 3 retrospective cohort studies, 12,28,…”

“…17 Additional elements include effective communication, involvement of the patient in decision-making, family discussions, psychological and spiritual care, the establishment of goals of care, and end-of-life management. 6,[17][18][19][20][21] The importance of communication between members of the clinical team is highlighted by Kelley et al, who demonstrated that poor communication leads to increased uncertainty for patients and their surrogates. 20 A list of these essential elements of palliative care in the trauma and surgical critical care setting based on the common elements identified in the literature is reported in Table 1.…”

“…6,[17][18][19][20][21] The importance of communication between members of the clinical team is highlighted by Kelley et al, who demonstrated that poor communication leads to increased uncertainty for patients and their surrogates. 20 A list of these essential elements of palliative care in the trauma and surgical critical care setting based on the common elements identified in the literature is reported in Table 1.…”

Palliative Care in the Intensive Care Unit: Not Just End-of-life Care

“…In the context of palliative care in ICU, end-of-life decision may be required. One of the greatest difficulties in making end-of-life decisions lies in the uncertainty about what the patient would want [35]. When making decisions, it is very important to protect the rights and dignity of patients, their families and other parties in the society.…”