The High Burden of Palliative Care Needs among Older Emergency General Surgery Patients

Dear Editor:

A growing number of older adults with chronic, life-limiting illness are hospitalized with acute surgical conditions, such as small bowel obstruction, cholecystitis, and intestinal ischemia. Among those who undergo surgery, over 40% experience major morbidity or mortality within 30 days, and among those over age 85 years, 50% will die within one year.¹ Meanwhile, others who don't have surgery are frequently deemed inoperable, because their underlying disease is too advanced for surgical intervention to confer any palliative or survival benefit. In either case, hospitalization for an acute surgical condition is often an inflection point in the health trajectory of an older and seriously ill patient, signifying physical and functional decline, as well as the need for palliative care. Nonetheless, the palliative care needs and use of palliative care consults in hospitalized older patients with acute surgical conditions have not been described. Therefore, we sought to measure the prevalence of established clinical indicators for palliative care or hospice eligibility, as well as in-hospital, 6-month, and 12-month mortality rates among older patients evaluated by acute care surgeons in our hospital.

From January 2, 2014 through June 30, 2014, we prospectively enrolled consecutive patients, age ≥65 years, evaluated by the emergency general surgery service EGS at a single academic hospital. Baseline poor performance status (limited self-care or in chair/bed >50% of day); advanced organ failure (ventricular assist device, oxygen-dependent pulmonary disease, end-stage renal disease); poor nutrition (weight loss >10% in six months, albumin <2.5 g/dL, BMI <23); and malignancies were determined from the medical record. Health-related quality of life (HRQOL) was measured for clinically appropriate, English-speaking patients using the Medical Outcomes Study 12-item Short-Form (MOS SF-12).

The cohort consisted of 173 patients, mean age 77 years (range 65–101 years). The majority were women (57%), white (86%), and evaluated in the emergency department (ED) (67%). Small bowel obstruction (26%), biliary disease (17%), and nonischemic colitis (10%) were the most frequent diagnoses. Palliative care needs were common: 69% had ≥1 clinical indicator and 33% had ≥2 clinical indicators (see Table 1). SF-12 was completed for 97 patients: Mean scores for all domains and physical and mental component summary scores were below population norms. During the hospital stay, 56% underwent operations, 5% received inpatient palliative care, and 5% died in-hospital. Among in-hospital survivors, 62% were discharged to institutional settings. Mortality at 6 and 12 months was 20% and 37%, respectively.

Table 1.

Comparison of Patients Grouped by Vital Status at 12 Months

		All patients (n = 173)	12-month decedents (n = 64)	12-month survivors (n = 109)	p
Clinical indicators of palliative care needs
Limited self-care, >50% of day in bed/chair, %		23.1	29.7	19.3	0.12
Severe heart failure or VAD		3.5	3.1	3.7	1.00
O2-dependent lung disease		4.6	7.8	2.8	0.15
End-stage renal disease		5.2	9.4	2.8	0.08
Current cancer diagnosis		30.6	45.3	22.0	<0.01
Known metastatic cancer		11.6	20.3	6.4	<0.01
Progressive weight loss		12.1	15.6	10.1	0.28
Albumin <2.5 g/dL		11.0	18.8	6.4	0.01
Underweight (BMI <23)a		24.9	37.3	20.6	0.02
Patient-reported HRQOL
MOS SF-12b	PCS component, mean (SD)	34.8 (13.1)	32.8 (11.2)	35.7 (13.9)	0.12
	MCS component, mean (SD)	48.7 (14.4)	44.5 (16.1)	50.6 (13.2)	0.18

^aBMI not recorded for 12 patients.

^bMOS SF-12 completed for 97 patients.

BMI, body mass index; HRQOL, health-related quality of life; MCS, mental component summary score; MOS SF-12, Medical Outcomes Study 12-item Short-Form; PCS, physical component summary score; SD, standard deviation; VAD, ventricular assist device.

To our knowledge, this is the first study quantifying clinical indicators of palliative care needs among hospitalized older adults with acute surgical conditions. Although most patients survived the hospital stay, institutional discharge was common and postdischarge mortality was high. Despite the predominance of advanced illness and impaired HRQOL, only 5% received inpatient palliative care consultations and only two patients were discharged to hospice. Our findings underscore the need to improve access to specialized palliative care for older patients with acute surgical conditions, and highlight opportunities for palliative care clinicians to partner with surgeons caring for these patients. Further work is needed to develop targeted interventions to integrate palliative care into emergency surgical practice.