Challenges in the Development and Implementation of Older Adult Trauma Prognostication Tools to Facilitate Shared Decision-Making

Introduction

Older trauma patients (> 65 years old) have a higher risk of mortality compared to the younger trauma patient population.¹ Still, greater than 50% survive to discharge and up to 85% of those return to prehospital or independent function.^{1, 2} The 15% who do not fully recover to baseline present a unique challenge to the medical community. These patients have different anatomy, physiology, and decreased ability to recover from a traumatic event.³ Today’s older aged adults value autonomy, engagement, and control over their lives.⁴ Their values and quality of life are threatened by traumatic injury. An initial aggressive treatment approach is warranted when a patient presents in extremis and information about patient history is still being gathered, but transition to alternate strategies is challenging when a poor prognosis becomes clear.

Barriers to Shared Decision-Making

Medical providers may be unaware of the expectations patients/families have when interacting with healthcare systems, especially in an emergency setting.^5. Effective communication with patients and their families is critical to determining goals of care and what patients consider a meaningful outcome. Trauma surgeons assume the goal of treatment is to restore a state of normalcy for patients and struggle when return to baseline function is not possible.⁶ Shockingly, one in ten older patients still has an operation in the last week of life, suggesting that mortality, morbidity and complications after surgery are difficult to predict.⁷ Invasive procedures and prolonged intensive care unit stays lead to decline in baseline function and quality of life. Goals of care conversations attempt to align treatment strategies with patient values and preferences. Surgeon specialists are less likely to consult palliative care even when the patient’s chance of recovery was uncertain to avoid the perception of “giving up.”⁶ A policy driven goals of care process, such a guidelines for palliative care consultation, improves communication with patients and families, but has not been widely adopted.⁸

When the older trauma patient presents to the hospital, the trauma team and patient/family are at a severe disadvantage. The providers have no previous relationship with the patient. Difficult conversations must take place during an unexpected and critical moment. Limited time is available to understand the complex interpersonal family dynamics and psychosocial factors that may be exacerbated by traumatic events. Families are not always up-to-date on their loved one’s current medical status and the subsequent decline after trauma that represents the cumulation of years of decline in vitality. Tragically, only 15–25% of adults complete advance directives in general. Patients prefer to discuss advance directives when still healthy and with a doctor who has known them over time, as opposed to during an acute illness with a new medical team.⁹

Patients expect their primary care physician to initiate the discussion rather than bringing up the difficult topic themselves.⁹ The most successful advance directive programs target patients who perceived themselves as high risk (recently hospitalized, older, already receiving specialty care) and involve intensive training for the physicians.⁹ Primary care physicians may have traditionally had very limited time constraints for these conversations. However, as demonstrated by COVID-19 restrictions, many conversations can be accomplished successfully on a virtual visit.¹⁰ Trauma surgeons are faced with delivering a life or death prognosis with limited data. If clinical urgency allows, a cohesive team approach with communication between the primary care physician and the trauma surgeon may help facilitate goal concordant care.

Shared Decision-Making Tools

Numerous studies have attempted to provide a comprehensive shared decision-making tool to facilitate communication with older adult trauma patients.^{11, 12} Shared decision making is “an approach where clinicians and patients share the best available evidence when faced with the task of making decisions, and where patients are supported to consider options, to achieve informed preferences.”¹³ Structured conversations using clinical decision support systems facilitate shared decision making.¹⁴ We previously developed the Elderly Mortality after Trauma (EMAT) predictive model for in-hospital mortality based on 1.2 million patients in the National Trauma Databank (NTDB).¹² EMAT is available on a free downloadable mobile application as a tool for bedside counseling of patients and families. In the EMAT predictive model, pre-hospital do not resuscitate (DNR) advance directive was the strongest predictor of in-hospital death.¹² Like other predictive models, it only predicts in-hospital mortality, omitting critical variables such as frailty and pre-hospital medications. EMAT does not currently predict in-hospital complications, discharge disposition, long-term patient reported outcome measures (PROMs) or even 1-year mortality.

Future Directions

Weekly morbidity and mortality conferences are often plagued by questions regarding non-beneficial treatments and associated poor outcomes. Yet, change in practice is slow and the same cases seem to reoccur over a cycle of weeks to months. Outcomes that appear clear in hindsight are extremely challenging in the moment. The culture in America is do everything and ask questions later or never. In contrast to the “do-everything” physician, some intensivists present a generalized dismal prognosis due to advanced age and recommend transition from life-prolonging treatment to a treatment plan based on comfort due to their own biases or personal experiences.^{15, 16} Families are left completely dependent on the physician’s recommendation or asked to make an independent and uninformed decision with minimal understanding of the medical facts. The mutual understanding and consensus between parties is sadly missing.

More comprehensives models need to be developed to aid in shared-decision making conversations as more older patients experience trauma. Predictive models require thousands of patients with variables not readily available in most trauma registries, such as six-month mortality and baseline functional status, to create an accurate, clinically useful model for this population. The currently available databanks, National Trauma Databank (NDTB) and Trauma Quality Improvement Program (TQIP) lack the important long-term variables needed to create meaningful models. Traditional variables, such as systolic blood pressure and Injury Severity Score (ISS), lack sensitivity in older adults due to differences in baseline physiology. Multi-center large scale studies are needed to refine and validate prognostic models.

The medical community has a duty to tackle barriers to shared decision-making from a research and clinical perspective. On the research side, a qualitative mixed methods approach is needed (Fig. 1). We propose a stepwise process to first develop elderly specific national databases tracking long-term outcomes and patient reported-outcome measures. Next, predictive models should be developed to predict these measures and integrate the models into shared-decision making conversations. Existing trauma-specific measurement tools need to be prospectively validated and tailored to the geriatric population. Collaborative research with palliative care, geriatrics, internal medicine specialists are needed to create better predictive models using variables that are specific to older adults and translate those models into meaningful conversations with patients and families. In the geriatric burn literature, a high cutoff of the Baux score was established leading to low return-to-home rates and was used as a decision-making aid when setting goals of care.¹⁷ Similar cutoffs in the older adult patient population could be used as triggers for palliative care consultation and to facilitate shared decision-making conversations.

Fig. 1 –

Strategic Roadmap to Older Adult Patient-Centered Care.

On the clinical side, evidence-based guidelines are needed to guide older aged trauma care. Using the research above, goal-directed solutions must be developed, implemented and tracked nationally. For example, shared-decision making conversations should be tracked, required and could take place during routine trauma care, such as during the tertiary survey. Like other risk-adjusted complications tracked by TQIP, such as pulmonary embolism or wound infection, we suggest individualized trauma center tracking of geriatric medicine consults, goals of care conversations, palliative care consults, non-favorable discharges, intensive care days, death and complications to set standards for older aged trauma which could take place under the American College of Surgeons Geriatric Surgery Verification Program. Events representing discordant care, such as invasive surgery and subsequent rapid transition to from a life-prolonging approach to comfort-based approach, should be tracked and studied. Next, strategies must be developed to avoid them.