Benefits of Early Utilization of Palliative Care Consultation in Trauma Patients

Abstract

OBJECTIVES:

To determine the effects of palliative care consultation if performed within 72 hours of admission on length of stay (LOS), mortality, and invasive procedures.

DESIGN:

Retrospective observational study.

SETTING:

Single-center level 1 trauma center.

PATIENTS:

Trauma patients, admitted to ICU with palliative care consultation.

INTERVENTION:

None.

MEASUREMENTS AND MAIN RESULTS:

The ICU LOS was decreased in the early palliative care (EPC) group compared with the late palliative care (LPC) group, by 6 days versus 12 days, respectively. Similarly, the hospital LOS was also shorter in the EPC group by 8 days versus 17 days in the LPC group. In addition, the EPC group had lower rates of tracheostomy (4% vs 14%) and percutaneous gastrostomy tubes (4% vs 15%) compared with the LPC group. There was no difference in mortality or discharge disposition between patients in the EPC versus LPC groups. It is noteworthy that the patients who received EPC were slightly older, but there were no other significant differences in demographics.

CONCLUSIONS:

EPC is associated with fewer procedures and a shorter amount of time spent in the hospital, with no immediate effect on mortality. These outcomes are consistent with studies that show patients’ preferences toward the end of life, which typically involve less time in the hospital and fewer invasive procedures.

KEY POINT

Question: The study aims to determine the impact of palliative care performed within 72 hours of admission, compared with palliative care consultation performed after admission.

Findings: This is a retrospective observational study. Early palliative care (EPC) was associated with a decrease in both hospital and ICU length of stay and a decrease in the rates of tracheostomy and PEG tube placement. However, there was no difference in mortality between patients who received EPC and those who did not.

Meaning: EPC is associated with patients spending less time in the hospital and fewer procedures with no change in mortality.

Palliative care, traditionally associated with end-of-life care for individuals with terminal illnesses, has gained recognition in recent years as a valuable tool in improving the quality of life and reducing suffering in patients (1, 2). Trauma patients often face physical and emotional challenges that can be debilitating, and palliative care offers a holistic approach to addressing these issues. The release of the 2017 Palliative Care Best Practice Guidelines, as part of the Trauma Quality Improvement Program, recommends that all critically ill patients be screened for palliative care needs within 24 hours and that patients or their decision-makers have a formal goals-of-care conversation within 72 hours of admission if appropriate (3, 4).

Early integration of palliative care can have a significant impact on patients’ quality of life and overall health. It provides patients with the necessary support and resources to manage symptoms, alleviate suffering, and improve physical and emotional well-being (5). It also helps patients, and their families better understand their condition and make informed decisions for the future. However, delaying palliative care until later in the treatment process can result in missed opportunities and a less comprehensive approach to patient care.

This article examines whether differences exist in the utilization of palliative care in an early versus late setting from the time of admission. We hypothesize that early palliative care (EPC) will be associated with shorter hospital and ICU length of stays (LOSs) and fewer life-saving treatments when compared with late palliative care (LPC).

MATERIALS AND METHODS

The study was reviewed by the Sanford Health System institutional review board (IRB) and approved on July 20, 2022 (early vs LPC consults: impact of early vs LPC consultation on disposition for trauma population; IRB ID MOD0007115). The study was conducted according to the amended Declaration of Helsinki. A retrospective chart review was conducted of patients admitted to Sanford Health adult level-I trauma center between June 2012 and February 2020. All patients over the age of 18 years old who had received a palliative care consultation were included. Patients were then categorized according to the time from admission to palliative care, with EPC consultation being less than 72 hours from admission, or LPC consultation being greater than 72 hours from admission.

Variables from the chart review included demographic characteristics, patient outcomes, and life-prolonging treatment. Patient outcomes recorded were 1) LOS in the ICU, 2) length of hospital stay, 3) discharge disposition, and 4) mortality. Life-sustaining treatments included tracheostomy, percutaneous endoscopic gastrostomy (PEG), laparoscopic gastric/jejunostomy tube placement, intubation, cardiopulmonary resustation (CPR), and hemodialysis.

Patient outcomes and receipt of life-prolonging treatments were compared between EPC and LPC patients using Kruskal-Wallis or Chi-square tests. Significance level was at p value of less than 0.05. Analyses were conducted using R-Studio (RStudio Team, PBC, Boston, MA).

RESULTS

The study included 506 patients who met the inclusion criteria, of whom 43% (n = 220) had an EPC consultation. The mean age of the EPC group was found to be significantly different from that of the LPC consultation group, with 74.2 years compared with 72.8 years, respectively (p = 0.018). Among the EPC group, 56.6% were male, 88.1% were identified as White, and the mean Injury Severity Score was 15.4. Except for age, demographic characteristics were consistent with the LPC group (Table 1).

TABLE 1.

Demographic Information

	Early (n = 286)	Late (n = 220)	p
Age			0.018a
Mean (sd)	74.2 (19.9)	72.8 (16.3)
Gender			0.653
Female	124 (43.4%)	91 (41.4%)
Male	162 (56.6%)	129 (58.6%)
Race			0.477
Black, indegenous, and people of color	27 (9.4%)	17 (7.7%)
White	252 (88.1%)	194 (88.2%)
Unknown/other	7 (2.4%)	9 (4.1%)
Injury Severity Score			0.522
Mean (sd)	15.4 (10.5)	16.6 (11.6)

^ap < 0.05.

Statistically significant differences were observed for ICU and hospital LOS (Fig. 1). The mean ICU LOS for EPC was 6 days, and the hospital LOS was 8 days, whereas LPC had a mean ICU LOS of 12 days and hospital LOS of 17 days (p < 0.001). Figure 2 displays the life-prolonging treatments that were administered to the patients, revealing that EPC patients had a lower rate of tracheostomy 3.8% versus 14.1% (p < 0.001). This trend was also seen in PEG tube placement at 4.2% in EPC compared with LPC at 15.5% (p < 0.001). No significant difference was found regarding the rates of CPR, intubation, or hemodialysis between the two groups (Fig. 2).

Figure 1.

Length of stay (LOS) in ICU and hospital: represented as mean number of days. *p < 0.001.

Figure 2.

Life-sustaining treatments: represented as percent average. *p < 0.001. CPR = cardiopulmonary resustation, PEG = percutaneous endoscopic gastrostomy.

Patient outcomes, mortality, and discharge disposition were not statistically different between the groups. Mortality rates were 36.7% in EPC and 35.4% in LPC (p = 0.473). In addition, a similar proportion of patients being discharged to long-term healthcare (5.2 vs 7.7), short-term rehabilitation (17.1 vs 18.6), home (14.3 vs 10.5), and hospice (25.9 vs 29.5) for EPC and LPC, respectively (p = 0.377).

DISCUSSION

While approximately 73% of hospitals offer palliative care services, underutilization is still a significant concern (5–9). Our study adds to the current literature by comparing the effects of early and LPC on hospital and ICU LOS and the use of life-sustaining treatments.

Demographic characteristics, ISI, and primary payor were homogenous in our patient population. Slightly higher mean age was observed in the EPC patient homogeneous (74.2) than in the LPC patient (72.8) although this difference was not clinically significant. Future studies should evaluate the impact of palliative consult timing on a more diverse patient population.

Findings from this study indicate that a palliative care consultation within 72 hours is associated with a decrease in both hospital and ICU LOS. Both statistically and clinically significant, LOS decreased patients’ stay by half for EPC patients. This is consistent with the recent work by Spencer et al who similarly showed a decrease in the hospital and ICU LOS with EPC consultation (10), findings echoed in other studies (11, 12). Just as important, a shorter LOS is aligned with the patient wishes of having less time within the ICU and hospital (13).

Tracheostomy and PEG tube placement was found to be significantly lower when palliative care was consulted early in a patient’s course, with only 4% of EPC patients getting a tracheostomy or PEG compared with LPC, where 14% had tracheostomy and 15% had PEG tube placement. Recent work by Spencer et al (10) also showed this trend which showed a decrease in tracheostomy and surgical feeding tubes from 11.7% compared to 1.7%, as well as findings published by Kupensky et al (14, 15), indicating lower rates of tracheostomy and PEG tubes in patients who had EPC. Conversely, our study did not find any difference in the more acute procedures, including rates of CPR, intubation, or hemodialysis. Many of these procedures occur in acute situations where there is often not enough time for palliative care consultation. Some patients may demonstrate need for one of these interventions within several days, and for these patients, the timing of palliative care consultation may not play the same role or may have a different point of inflection.

Mortality rates were similar between the two groups with no significant difference found. Mortality for EPC was 36%, and for LPC, it was 35% (p = 0.473). Consistent with published work by Spencer et al (10), our findings suggest that the time of palliative care consultation had no impact on the mortality rates of the two groups. Although there was a slight trend for patients with EPC to have discharge to home, statistical significance was not reached, and there was no difference between other discharge dispositions.

Our study shows that the timing of the palliative care consultation matters. Although the American College of Surgeons recommends that all critical trauma patients be assessed within 24 hours and have a goals-of-care conversation within 72 hours, this can be easily overlooked if the benefits of timing are unknown. Our findings indicate that the initiation of EPC consultation decreases the patients’ stay both in the ICU and within the hospital. Patients have lower rates of tracheostomy and PEG tube placements while still having no change in mortality. Although studies consistently show that spending less time in the hospital and ICU is more in line with patients’ wishes, approximately 20% of patients will have an ICU stay within the last 6 months of life (16, 17). Studies also regularly show that many patients’ wishes toward the end of their life are to have less invasive procedures, less time in the hospital, and more time at home, and to not prolong the dying process (13, 18, 19). Given the findings of our study and existing literature discussing patient preferences regarding end-of-life care, health systems should follow the Acute Care Surgery’s recommendations to include palliative care consult.

Although our study did not evaluate cost, predictive model by Khandelwal et al (20) suggested a potential decrease in ICU cost of 11% if palliative care consultation and advance care planning became standard of care. This is further supported by the recent work by Spencer et al (10) which showed an average decrease in median cost of $35,511 per patient with the use of EPC consultation. These beneficial results may help to change the viewpoint of some surgeons toward palliative care consultations and improve utilization (2, 8, 21).

Although it has not been firmly established yet what the impact of the timing of palliative care consultation is on trauma patients, our study and others show that EPC consultation is likely beneficial, with an inflection point of 72 hours. There may not be much benefit in acute consultation of less than 24 hours, given that interventions at this point are often made in life-saving attempts and before the family or decision-makers need time to grasp what has happened. However, there is a benefit for palliative care to be involved as part of the care team before 72 hours in terms of LOS and decreasing invasive procedures, with no impact on mortality for these patients.

LIMITATIONS

The limitations of this study are that it is a retrospective study from a single center, thus subject to the biases of retrospective reviews. Our study population is a relatively homogenous patient population. Although the data were collected and confirmed through chart review, it is dependent on the initial documentation at the time of encounter.