Reduction in Potentially Inappropriate Interventions in Trauma Patients following a Palliative Care Consultation

Abstract

Background: Palliative care is expanding as part of treatment, but remains underutilized in trauma settings. Palliative care consultations (PCC) have shown to reduce nonbeneficial, potentially inappropriate interventions (PII), as decision for their use should always be made in the context of both the patient's prognosis and the patient's goals of care. Objective: To characterize trauma patients who received PCC and to analyze the effect of PCC and do-notresuscitate (DNR) orders on PII in severely injured patients. Setting/Subjects: Retrospective cohort study of 864 patients admitted to two level 1 trauma centers: 432 patients who received PCC (PCC group) were compared with 432 propensity score match-controlled (MC group) patients who did not receive PCC. Measurements: PCC in a consultative palliative care model, PII (including tracheostomy and percutaneous endoscopic gastrostomy) rate and timing, DNR orders. Results: PCC rate in trauma patients was 4.3%, with a 5.3-day average time to PCC. PII were done in 9.0% of PCC and 6.0% of MC patients ( p = 0.09). In the PCC group, 74.1% of PII were done before PCC, and 25.9% after. PCC compared with MC patients had significantly higher mechanical ventilation (60.4% vs. 18.1%, p < 0.001) and assisted feeding requirements (14.1% vs. 6.7%, p < 0.001). We observed a statistically significant reduction in PII after PCC ( p = 0.002). Significantly less PCC than MC patients had PII following DNR (26.3% vs. 100.0%, p = 0.035). Conclusions: PCC reduced PII in severely injured trauma patients by factor of two. Since the majority of PII in PCC patients occurred before PCC, a more timely administration of PCC is recommended. To streamline goals of care, PCC should supplement or precede a DNR discussion.

Timing is everything: Early versus late palliative care consults in trauma

“…Multidisciplinary family conferences were associated with higher institution of comfort measures, and code status deescalation occurred earlier with early family meetings 39 . Finally, a 2020 study showed that the majority of invasive procedures had already been undertaken before PC consultation, which occurred at a mean time of 5.3 days after hospital admission 12 …”

“…39 Finally, a 2020 study showed that the majority of invasive procedures had already been undertaken before PC consultation, which occurred at a mean time of 5.3 days after hospital admission. 12 Therefore, 5 days after injury appears to be too late, and 3 days is the most frequently reported recommendation for integration of PC specialists, particularly in the ICU. 40 The delay to PC consultation, given the mean time to consult of 6.83 days in our study, is consonant with a recent qualitative study describing the adoption of concordant PC by ICU physicians, as representative of what they deemed the "nascent" phase of expert PC incorporation, possibly because of "a perception that there's nothing that a palliative care physician can do that an ICU physician can't do."…”

“…A more recent propensity-matched study also noted relatively low rates of PC consultation (<5%) in trauma patients and that average time to specialty consult in their patients was 5.3 days 12 —much longer than the 72-hour benchmark proposed by the ACS COT. In addition, researchers found that the majority of “potentially inappropriate interventions” were performed before PC consult, suggesting that earlier PC consultation may be more beneficial 12 . Other leaders in the field of surgical PC have also inquired about the timing of PC consultation specifically in traumatic brain injury, asking, “palliative care too soon, or too late?” 13 Studies examining early PC consultation in trauma are few, however, even in the geriatric population 14 …”

“…11 This left the majority of their surviving patients who had poor functional outcomes without the benefits of expert PC. 11 A more recent propensity-matched study also noted relatively low rates of PC consultation (<5%) in trauma patients and that average time to specialty consult in their patients was 5.3 days 12 -much longer than the 72-hour benchmark proposed by the ACS COT. In addition, researchers found that the majority of "potentially inappropriate interventions" were performed before PC consult, suggesting that earlier PC consultation may be more beneficial.…”

“…In addition, researchers found that the majority of "potentially inappropriate interventions" were performed before PC consult, suggesting that earlier PC consultation may be more beneficial. 12 Other leaders in the field of surgical PC have also inquired about the timing of PC consultation specifically in traumatic brain injury, asking, "palliative care too soon, or too late?" 13 Studies examining early PC consultation in trauma are few, however, even in the geriatric population.…”