Palliative Care for Trauma Patients: Today and into the Next Decade

Dear Editor:

Specialist palliative care (PC) should be integrated into standard trauma care. It is significant that the American College of Surgeons' (ACS) Trauma Quality Improvement Program advocates for the delivery of PC alongside life-sustaining trauma care, regardless of prognosis.¹ Although their focus is primary PC, there is, and will continue to be, a need for specialist PC.

We must respond with the research and clinical program development that supports all forms of PC for trauma patients. Assessing the PC needs of this population and the impact of specialist PC are crucial to move the field forward. The focus should be on two trauma subpopulations: (1) previously healthy severely injured patients and (2) chronically ill or frail injured patients. The two cases, hereunder, illustrate these two groups and the role a specialist PC team plays in trauma care.

Case 1

A 49-year-old male construction worker with no past medical history presented to a Level I trauma center after falling 6 meters from a crane. He sustained significant neurological injury, and the trauma team wondered whether he would survive. PC was consulted on hospital day 8 to help elicit goals of care and support the family. The patient and his wife were previously healthy and had never experienced a major hospitalization; they had never discussed their goals and values to guide decision making in the setting of serious illness. His wife struggled to make decisions on his behalf. She questioned whether hope for recovery was reason enough to continue with aggressive measures.

For patients such as the one described earlier prognosis is often uncertain. Patients and families lack experience with critical care or prior discussions of health-related preferences. The suddenness and psychological trauma associated with severe injury add to the challenges patients and families face when making medical decisions. By involving specialist PC, the trauma service creates an expanded interdisciplinary team to guide care toward interventions that support the patient's and family's values. In the case of our patient, we helped his wife place boundaries on his care to continue to support her hope for her husband's future recovery while avoiding interventions that would not achieve the goal of cognitive recovery.

Case 2

A 92-year-old woman with moderate dementia and osteoporosis presented to the emergency department after an unwitnessed fall. She was found to have an intracranial hemorrhage leading to left hemiparesis and an inability to communicate, follow commands, and swallow safely. The patient had never discussed her wishes with family but had a basic advance directive completed >20 years ago stating only that she would want to be full code. The trauma team consulted PC on hospital day 3 to help with goals of care as they questioned whether her advance directive truly reflected her wishes based on her decline for the past two decades. The family anticipated the patient's decline would be one of slow progression seen with dementia making urgent decisions regarding artificial nutrition and disposition difficult.

For patients such as the one described in Case 2 trauma is a part of their clinical decline and prognosis is poor. Acute injury represents a departure from the expected disease course and prior care planning for the chronic disease trajectory, if ever completed, may not directly apply to the current scenario. Acute interventions can be done reflexively but without nuanced discussion may ultimately become sources of regret. PC involvement helps to adjust expectations and helps families apply previously stated preferences to the current scenario. In this case, we helped the family adjust to the patient's rapid decline and allowed them to incorporate her value of independence into their ultimate decision to forgo additional invasive procedures and pursue hospice.

Our PC and trauma services have worked together to care for patients since 2015, and in our experience, we are welcome members of the care team. Beyond decision-making needs, these patients have a multitude of symptom and support needs throughout prolonged hospitalizations and postacute recovery periods. From our experience, specialty PC serves to support our trauma colleagues to augment the high-quality patient-centered care they provide.

To optimize PC delivery to trauma patients, we see three gaps in the literature. First, we lack a comprehensive PC needs assessment of this population to understand the roles of primary PC versus specialist PC. This study is imperative to create innovative strategies to routinely meet these needs. Second, we must understand barriers to and facilitators of PC in trauma, which is necessary to implement effective and lasting programs. And third, we must perform implementation research in community programs to ensure wide PC availability.

We also need to look ahead to the policy implications. The Centers for Medicare and Medicaid Services mandates PC involvement in ventricular assist device programs regardless of prognosis.² If benefits of PC involvement are demonstrated in trauma, we should advocate for a similar regulatory requirement to be implemented by the ACS as part of its Verification Review Committee process for trauma centers. At present, the ACS, through its Resources for Optimal Care of the Injured Patient, notes that PC physicians should be available as part of end-of-life care for trauma patients at Level I and II facilities but does not require PC presence.³ The ACS could strengthen its recommendation and require specialty PC involvement for an appropriate subset of patients seen at Level I trauma centers with a strong recommendation for availability and integration of specialty PC at Level II centers.

We must be bold in entering areas of health care that were not previously recognized to need specialist PC. We think that trauma is one such area and a more robust evidence base with contributions from specialist PC is required to propel the field forward.