At times, patient and family wishes may conflict with trauma care, which focuses on cure and aggressive resuscitation for the acutely injured patient.1,2 In fact, a focused study on dying patients and their decision makers concluded that while patients prefer comfort, life-sustaining treatments or procedures were often used.3 Palliative Medicine provides a patient-centered service, focusing on patients' wishes in establishing a treatment plan. Excellent communication with the family and physicians, symptom management, and assistance with decision making are part of the principles of Palliative Medicine.4–6
It is well known that geriatric patients account for a generous portion of all trauma admissions. Although many providers agree that Palliative Medicine is an important asset, many do not have adequate knowledge of the role of Palliative Medicine, perceive they do not have enough time to include Palliative Medicine, or have misconceptions that Palliative Medicine is only end-of-life care.1,7–10 Moreover, a recent study examining physician-reported barriers to end-of-life conversations revealed that 99.99% of physicians surveyed perceived at least 1 barrier conducting end-of-life conversations with patients and their families.11
Review of the literature claims that Palliative Medicine is underutilized.1,2,5,8,9,12–17 However, there has been recent reported success in incorporating Palliative Medicine with other hospital services.1,2,6,7,9,10,15 Perspectives on challenges and benefits to providing Palliative Medicine have also been examined.1,2,7,10,18 Incorporating Palliative Medicine with other hospital services can increase patient and family satisfaction.6,18 Other benefits include decreased time to identification of poor prognoses, the establishment of resuscitation goals, and reduction of nonbeneficial resources.6,16
Review of the literature has limited information specific to trauma and Palliative Medicine working in tandem. A recent review of more than 5000 trauma patients at a level 1 trauma center showed that one-third of the patients were aged 65 years or older, but only 15% of those patients received a Palliative Medicine Consultation (PMC).17 Notably, 90% of the geriatric patients in that study who received a PMC did not undergo tracheostomy and percutaneous endoscopic gastrostomy.17 A prospective study examining intensive care unit (ICU) trauma patients and a structured Palliative Medicine intervention at admission found that the structured intervention resulted in earlier consensus around goals of care and reduced length of stay (LOS) for dying patients.2
The purpose of this project was to evaluate the impact of PMC on geriatric trauma patients' outcomes after the implementation of an institutional practice management guideline requiring PMC on or before post-trauma day (PTD) 2. It was hypothesized that geriatric trauma patients with a PMC will have better symptom management, clearer advance care goals, and therefore a shorter LOS than geriatric trauma patients without a PMC.
This is an institutional review board–approved, retrospective, descriptive, correlational study undertaken at a regional level I trauma center in Northeast Ohio. Patients who were 65 years or older, admitted to trauma services in the surgical ICU between July 1, 2013, and November 30, 2014, were included. Exclusion criteria included patients younger than 65 years, not admitted to the surgical ICU, or expired within 24 hours of hospital admission. Data were obtained from a medical records request, the Trauma Registry, and chart abstraction.
Variables of interest included patient demographics; presence of PMC; time (in days) from admission to PMC; evidence of management of the following 4 symptoms: pain, constipation, nausea/vomiting, and anxiety/agitation; evidence of an advance directive discussion; an update or change in code status; LOS in surgical ICU (in days) and total LOS in the hospital (in days); discharge disposition; Abbreviated Injury Scores (AIS); and Injury Severity Score (ISS).
Discharge dispositions were grouped by the patients' implied level of function at discharge. First, home independently, home with home health, and rehab dispositions were grouped as one. Next, skilled nursing facility (SNF) and long-term acute care dispositions were grouped because these patients are highly dependent on others to function. Finally, death and hospice dispositions were grouped because the ultimate outcome was death.
Data were entered into Microsoft Excel® 2010 (Microsoft Corporation, Redmond, Washington) and transferred into SPSS Statistics 22.0 (IBM Corp, Armonk, NY) for analysis. Statistical analyses included descriptive statistics, analysis of variance, and the chi-square test. Statistical significance was established with an α of .05.
A total of 202 surgical ICU patients were included with a mean age of 78.74 years (range: 65-101 years). Females comprised 49.0% of the sample (99/202). Palliative Medicine was consulted for 48.0% of included patients during the study period (97/202). Overall, the advance directive discussions were documented in 50.5% of patients (102/202), and the code status was updated or changed in 28.7% (58/202).
The most common discharge disposition was to a SNF (37.6%). Approximately 20% died, or were discharged to hospice services (41/202). Less than 10% of patients were discharged home with no home health services (15/202). Of patients who received a PMC, 17.5% (17/97) were discharged home or to an acute rehab facility compared with 49.5% (52/105) of patients who did not receive a PMC. Discharge to a SNF or to a long-term acute care facility accounted for 47.4% (46/97) of patients who received a PMC and 43.8% (46/105) of patients who did not receive a PMC. However, death with or without hospice services accounted for 35.1% (34/97) of patients with a PMC and 6.7% (7/105) of patients who did not receive PMC. All of these differences were statistically significant (P < .001) and presented in Table 1.
Patients with a PMC were significantly more likely to have a documented advance directive discussion (93.1% vs 6.9%; P < .001) and a code status update or change (84.5% vs 15.5%; P < .001) (Figure 1). The average hospital LOS was 9.10 days (range: 1-30 days) and the average ICU LOS was 7.78 days (range: 1-30 days). The mean time from admission to PMC was 2.91 days (range: 0-15 days). The surgical ICU LOS was greatly reduced for patients with a PMC on or before PTD 2 (m = 6.40 vs m = 11.81; P = .001) (Figure 2). Total hospital LOS was greatly reduced for patients with a PMC on or before PTD 2 (m = 7.92 vs m = 13.11; P = .001) (Figure 2). Patients who received a PMC were significantly older than those without (m = 82.47 vs 75.29; P < .001). Patients with a PMC had better symptom management than patients without a PMC (3.65 out of 4 symptoms vs 3.47 out of 4 symptoms, P = .023). The average ISS was 17.86 (range: 0-57). There was a significant difference in the ISS between patients with and without PMC (m = 19.59 vs m = 16.25, respectively, P = .015), but there was no significant difference in AIS. Table 2 shows injury characteristic details.
By assisting families with complex decision making, evidenced in significantly higher rates of documented advance directive discussions and code status updates, PMC by PTD 2 reduced ICU and total hospital LOS by almost a week in this population. In addition, pain, constipation, nausea/vomiting, and agitation/anxiety symptoms were better managed in patients who received a PMC. Palliative Medicine traditionally addresses other symptoms such as shortness of breath, appetite, pruritus, and insomnia. However, the management of these symptoms was not collected for this study.
A study by Grudzen et al13 in 2012 found that only a minority of consultations originated from emergency providers and consultation was on average initiated 6 to 9 days into a patient's hospital stay. Our study supports this, as less than half of eligible patients received a PMC and the average time to consultation was approximately 3 days. In 2015, Toevs and colleagues (cited in London17) reported a 15% PMC rate,17 and another study led by Walker et al15 in 2013 reported a 46% PMC rate. Our study exceeded this rate, with 48% of eligible surgical ICU patients receiving a PMC. However, if we had included geriatric patients who did not require intensive care, our PMC rate would have likely decreased.
Palliative Medicine has been previously reported to reduce LOS.2,15 Our study also confirms this finding and mirrors the results of a 2013 study by Walker et al, 15 who saw an ICU LOS reduction from 11 days to 7 days. In 2015, Toevs et al reported a significant reduction in the number of tracheostomy and percutaneous endoscopic gastrostomy procedures performed on geriatric patients when Palliative Medicine was consulted in their care.17 These procedures were not specifically examined in our analysis, but the significantly higher rates of advance directive discussions, reduced LOS, and higher rate of death in the PMC group could imply a reduction of nonbeneficial resources. Although, indeed, patients with a PMC were statistically more severely injured than patients without a PMC per their ISS, there is little clinical difference between patients with an ISS of 16 and 19. This is indicated by the lack of significance in AIS between the groups.
Patients who received a PMC were significantly older, had significantly higher ISS, and had a significantly higher rate of death than patients who did not have a PMC. This indicates that Palliative Medicine is being used as hospice services, rather than a complimentary service to trauma standard of care. This could be partly due to misconceptions that consulting Palliative Medicine is a sign of defeat rather than cure and is also in-line with misconceptions, lack of knowledge, and other barriers reported in the literature.10,11,18 Further evidence that Palliative Medicine does not increase mortality and is not limited to end-of-life care is our overall 20% mortality rate, which is similar to the reported geriatric trauma mortality rate in the ICU.2,6,16
Pathway to Palliative Medicine Consultation
At the level I trauma center in which this study took place, the pathway to PMC is via a practice management guideline. This simple, all inclusive, institutional guideline requires that Palliative Medicine be consulted on or before PTD 2 for all patients aged 65 years or older that are admitted to trauma services. Although the geriatric trauma patients are followed by a multidisciplinary team, all PMCs in this study were initiated by trauma services personnel, whether it was a resident, nurse practitioner, or attending physician. With the use of electronic medical records, a geriatric trauma order set was created and included a PMC as part of the order set. The compliance with this policy is reviewed quarterly at the Geriatric Trauma Subcommittee meetings, which are encouraged by the American College of Surgeons-–College on Trauma.
Geriatric trauma ICU patients benefit from a PMC in a representative sample of older adults. Palliative Medicine is significantly more likely to be consulted for older geriatric patients and for patients who are more severely injured. This indicates that Palliative Medicine is used as a hospice service and is underutilized in the trauma population. Advance directive discussions and code status updates are significantly more likely to be documented when Palliative Medicine is consulted. Length of stay is significantly reduced when the institutional practice management guideline of early PMC is followed.
The introduction of Palliative Medicine into a patient's care team is an opportunity to focus on the patient's goals of care, thereby reducing nonbeneficial resources. Education regarding the benefits and misconceptions of Palliative Medicine should be presented to all patient care team members. The inclusion of Palliative Medicine in all aspects of geriatric care should be encouraged by institutional leadership as well as governing, regulatory, and accrediting agencies.
This study has several limitations. First, it is a retrospective chart review and not a prospective, randomized clinical trial. Second, this study only included patients who required intensive care and who were acutely injured. A more inclusive geriatric population may have further elucidated the utilization of Palliative Medicine in the trauma population. Third, information used in this project was based on chart documentation. Perhaps, more advance directive discussions occurred than what we reported. This could be due to documentation issues on the part of the providers.
- Palliative Medicine consultation is underutilized in the geriatric trauma population.
- Palliative Medicine is more likely to be consulted in older, severely injured patients.
- When consulted early in a patient admission, palliative medicine establishes clearer patient care goals, resulting in a significantly reduced LOS.
The authors thank Renee Merrell and the Trauma Registry at St Elizabeth Youngstown Hospital for providing Abbreviated Injury and Injury Severity Scores. Also, we thank Kayla Puntel, BSN, for her assistance with data collection.
1. Lamba S, Pound A, Rella JG, Compton S. Emergency medicine resident education in palliative care: a needs assessment. J Palliat Med. 2012;15(5):516–520. doi:10.1089/jpm.2011.0457.
2. Mosenthal AC, Murphy PA, Barker LK, Lavery R, Retano A, Livingston DH. Changing the culture around end-of-life care in the trauma intensive care unit. J Trauma. 2008;64(6):1587–1593. doi:10.1097/TA.0b013e318174f112.
3. Lynn J, Teno JM, Phillips RS, et al. Perceptions by family members of the dying experience of older and seriously ill patients. SUPPORT Investigators. Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments. Ann Intern Med. 1997;126(2):97–106.
4. Mosenthal AC, Murphy PA. Trauma care and palliative care: time to integrate the two? J Am Coll Surg. 2003;197(3):509–516.
5. Quest TE, Marco CA, Derse AR. Hospice and palliative medicine
: new subspecialty, new opportunities. Ann Emerg Med. 2009;54(1):94–102. doi:10.1016/j.annemergmed.2008.11.019.
6. Owens D. The role of palliative care in trauma. Crit Care Nurs Q. 2012;35(3):223–227. doi:10.1097/CNQ.0b013e3182542d38.
7. Meo N, Hwang U, Morrison RS. Resident perceptions of palliative care training in the emergency department. J Palliat Med. 2011;14(5):548–555. doi:10.1089/jpm.2010.0343.
8. Lamba S, Nagurka R, Zielinski A, Scott SR. Palliative care provision in the emergency department: barriers reported by emergency physicians. J Palliat Med. 2013;16(2):143–147. doi:10.1089/jpm.2012.0402.
9. Mosenthal AC, Weissman DE, Curtis JR, et al. Integrating palliative care in the surgical and trauma intensive care unit: a report from the improving palliative care in the intensive care unit (IPAL-ICU) project advisory board and the center to advance palliative care. Crit Care Med. 2012;40(4):1199–1206. doi:10.1097/CCM.0b013e31823bc8e7.
10. Tilden LB, Williams BR, Tucker RO, MacLennan PA, Ritchie CS. Surgeons' attitudes and practices in the utilization of palliative and supportive care services for patients with a sudden advanced illness. J Palliat Med. 2009;12(11):1037–1042. doi:10.1089/jpm.2009.0120.
11. Periyakoil VS, Neri E, Kraemer H. No easy talk: a mixed methods study of doctor reported barriers to conducting effective end-of-life conversations with diverse patients. PLoS One. 2015;10(4):e0122321. doi:0.1371/journal.pone.0122321.
12. Rosenberg M, Lamba S, Misra S. Palliative medicine
and geriatric emergency care: challenges, opportunities, and basic principles. Clin Geriatr Med. 2013;29(1):1–29. doi:10.1016/j.cger.2012.09.006.
13. Grudzen CR, Hwang U, Cohen JA, Fischman M, Morrison RS. Characteristics of emergency department patients who receive a palliative care consultation. J Palliat Med. 2012;15(4):396–399. doi:10.1089/jpm.2011.0376.
14. Hua MS, Li G, Blinderman CD, Wunsch H. Estimates of the need for palliative care consultation across United States intensive care units using a trigger-based model. Am J Respir Crit Care Med. 2014;189(4):428–436. doi:10.1164/rccm.201307-1229OC.
15. Walker KA, Mayo RL, Camire LM, Kearney CD. Effectiveness of integration of palliative medicine
specialist services into the intensive care unit of a community teaching hospital. J Palliat Med. 2013;16(10):1237–1241. doi:10.1089/jpm.2013.0052.
16. Toevs CC. Palliative medicine
in the surgical intensive care unit and trauma. Surg Clin North Am. 2011;91(2):325–331, viii. doi:10.1016/j.suc.2010.12.008.
17. London S. Palliative consults empower geriatric trauma
patients. ACS Surgery News. 2015;11(1):23.
18. Stone SC, Mohanty S, Grudzen CR, et al. Emergency medicine physicians' perspectives of providing palliative care in an emergency department. J Palliat Med. 2011;14(12):1333–1338. doi:10.1089/jpm.2011.0106.