Palliative Care Consultations in Trauma Patients and Role of Do-Not-Resuscitate Orders: Propensity-Matched Study

2020 ◽  
Vol 37 (12) ◽  
pp. 1068-1075
Author(s):  
Alexander A. Fokin ◽  
Joanna Wycech ◽  
Jeffrey K. Katz ◽  
Alexander Tymchak ◽  
Richard L. Teitzman ◽  
...  
Keyword(s):  
Mechanical Ventilation ◽  
Palliative Care ◽  
Length Of Stay ◽  
Trauma Patients ◽  
Trauma Centers ◽  
Do Not Resuscitate ◽  
Palliative Care Consultation ◽  
Care Consultation ◽  
Do Not Resuscitate Orders

Objective: To delineate characteristics of trauma patients associated with a palliative care consultation (PCC) and to analyze the role of do-not-resuscitate (DNR) orders and related outcomes. Methods: Retrospective study included 864 patients from 2 level one trauma centers admitted between 2012 and 2019.  Level 1 trauma centers are designated for admission of the most severe injured patients. Palliative care consultation group of 432 patients who received PCC and were compared to matched control (MC) group of 432 patients without PCC. Propensity matching covariates included Injury Severity Score, mechanism of injury, gender, and hospital length of stay (HLOS). Analysis included patient demographics, injury parameters, intensive care unit (ICU) admissions, ICU length of stay (ICULOS), duration of mechanical ventilation, timing of PCC and DNR, and mortality. Palliative care consultation patients were further analyzed based on DNR status: prehospital DNR, in-hospital DNR, and no DNR (NODNR). Results: Palliative care consultation compared to MC patients were older, predominantly Caucasian, with more frequent traumatic brain injury (TBI), ICU admissions, and mechanical ventilation. The average time to PCC was 5.3 days. Do-not-resuscitate orders were significantly more common in PCC compared to MC group (71.5% vs 11.1%, P < .001). Overall mortality was 90.7% in PCC and 6.0% in MC ( P < .001). In patients with DNR, mortality was 94.2% in PCC and 18.8% in MC. In-hospital DNR-PCC compared to NODNR-PCC patients had shorter ICULOS (5.0 vs 7.3 days, P = .04), HLOS (6.2 vs 13.2 days, P = .006), and time to discharge (1.0 vs 6.3 days, P = .04). Conclusions: Advanced age, DNR order, and TBI were associated with a PCC in trauma patients and resulted in significantly higher mortality in PCC than in MC patients. Combination of DNR and PCC was associated with shorter ICULOS, HLOS, and time from PCC to discharge.

Code status and outcomes in patients with cancer and COVID-19: A COVID-19 and cancer consortium (CCC19) registry analysis.

2021 ◽  
Vol 39 (15_suppl) ◽  
pp. 12035-12035
Author(s):  
Elizabeth Trice Loggers ◽  
Elizabeth Marie Wulff-Burchfield ◽  
Ishwaria Mohan Subbiah ◽  
Ali Raza Khaki ◽  
Pamela Egan ◽  
...  
Keyword(s):  
Palliative Care ◽  
Length Of Stay ◽  
Hospital Admission ◽  
Do Not Resuscitate ◽  
Code Status ◽  
Factors Associated ◽  
Patients With Cancer ◽  
Palliative Care Consultation ◽  
Care Consultation ◽  
Ecog Ps

12035 Background: In-hospital mortality among patients with cancer (pts) and COVID-19 infection is high. The frequency of, and factors associated with, do-not-resuscitate (DNR) or do-not-intubate (DNI) orders at hospital admission (HA), and their correlation with care, has not been well studied. In November 2020, we began collecting this information for pts who were hospitalized at initial presentation in the CCC19 registry (NCT04354701). Methods: We investigated: 1. the frequency of, and factors associated with, DNR/DNI orders at HA; 2. change in code status during HA; and 3. the correlation between DNR/DNI orders and palliative care consultation (PC), mortality or length of stay (LOS). We included hospitalized, adult pts with cancer and COVID-19 from 57 participating sites. Reported characteristics include age, ECOG performance status (PS), and cancer status. Comparative statistics include 2-sided Wilcoxon rank sum and Fisher’s exact tests. Results: 744 pts had known baseline and/or changed code status (CS); most (79%) maintained their baseline CS (Table). Those with DNR±DNI orders at HA were older (median age 79 vs 69 yrs, p<0.001) and more likely to have: ECOG PS 2+ vs 0-1 (45% vs 22%, OR 3.95, p<0.001), metastatic disease (45% vs 35%, OR 1.72, p=0.005) and progressing cancer (32% vs 16%, OR 2.69, p<0.001), but equally likely to have received systemic anticancer therapy in the prior 3 months (38% vs 45%, p=0.15). N=192 pts with a change in CS from full to DNR±DNI were younger (median age 73), had better PS (37% ECOG PS 2+), and were less likely to have progressing cancer (23%) than those with DNR±DNI orders at baseline. However, their LOS was significantly longer, median 9 vs 6 days, p<0.001. Compared to those with DNR±DNI orders at HA, pts whose CS changed to DNR±DNI were more likely to die, OR 2.94, 95% CI 1.76-4.97, p<0.001. PC was obtained in 106 (14%) pts and associated with transition to DNR±DNI in 47 (44%), affirmation of admission CS in 58 (55%), and reversal in 1 (1%). Median LOS for pts receiving PC was 11 vs 6 days, p<0.001. Conclusions: In our sample, the majority of patients with cancer and COVID-19 were full code at hospital admission. DNR±DNI status, whether at baseline or assigned during the hospital course, was associated with worse prognosis. Longer length of stay for patients changing code status and/or receiving palliative care consultation was observed likely suggesting earlier palliative care consultation is an important, but likely underutilized component in the care of patients with cancer and COVID-19.[Table: see text]

Reduction in Potentially Inappropriate Interventions in Trauma Patients following a Palliative Care Consultation

2020 ◽  
Author(s):  
Joanna Wycech ◽  
Alexander A. Fokin ◽  
Jeffrey K. Katz ◽  
Alexander Tymchak ◽  
Richard L. Teitzman ◽  
...  
Keyword(s):  
Palliative Care ◽  
Trauma Patients ◽  
Palliative Care Consultation ◽  
Care Consultation

Development and implementation of a palliative care consultation tool

2012 ◽  
Vol 10 (3) ◽  
pp. 171-175 ◽  
Author(s):  
Alexei Trout ◽  
Kenneth L. Kirsh ◽  
John F. Peppin
Keyword(s):  
Palliative Care ◽  
Length Of Stay ◽  
Screening Tool ◽  
Average Length ◽  
Hospital Costs ◽  
Initial Attempt ◽  
Palliative Care Consultation ◽  
Time Period ◽  
Care Consultation ◽  
Chi Square Analysis

AbstractObjective:Palliative care services are becoming more commonplace in hospitals and have the potential to reduce hospital costs through length of stay reduction and remediation of symptoms. However, there has been little systematic attempt to identify when a palliative care consultation should be triggered in a hospital, and there is some evidence that these services are under-utilized and not fully understood.Method:In an initial attempt to address when a consultation might be appropriate, we attempted to pilot test a novel palliative care screening tool to help guide clinician judgment in this regard. A one-page, face-valid instrument was developed using expert opinion.Results:The sample comprised 33 men (44.6%) and 41 women (55.4%) with an average age of 63.4 years (SD = 13.8) and an average length of stay of 22.7 days (SD = 10.1). The most significant symptom was pain, indicated as moderate-to-severe in 23 patients (31%). This was followed by fatigue (n = 10, 13.5%) and nausea (n = 6, 8.1%). At unit entry, 20 patients (33%) had moderate or severe pain. Upon discharge, this number had been reduced to 12/60 (20%). Chi-Square analysis showed a significant decrease in pain rankings overall (χ2 = 36.3, p < 0.0001). The average total tool score was 7.5 (SD = 3.1). Using an initial threshold of 12 to trigger a palliative care referral, 64 patients (86.5%) would not have received a referral and 10 (13.5%) would have. Of these 10 patients, 2 (20%) did not receive a palliative care consultation while they were hospitalized.Significance of results:The tool we developed increased consultations over the time period in which it was used, compared with the same time period 1 year prior. Although the threshold developed for triggering referrals seemed artificially high, the implementation of the screening tool did increase referrals.

Ethnicity, race, and advance directives in an inpatient palliative care consultation service

2012 ◽  
Vol 11 (1) ◽  
pp. 5-11 ◽  
Author(s):  
Glenn B. Zaide ◽  
Renee Pekmezaris ◽  
Christian N. Nouryan ◽  
Tanveer P. Mir ◽  
Cristina P. Sison ◽  
...  
Keyword(s):  
Palliative Care ◽  
African Americans ◽  
Advance Directives ◽  
Advance Directive ◽  
Race And Ethnicity ◽  
Primary Diagnosis ◽  
Do Not Resuscitate ◽  
Palliative Care Consultation ◽  
Care Consultation ◽  
The Impact

AbstractObjective:Although race and ethnic background are known to be important factors in the completion of advance directives, there is a dearth of literature specifically investigating the effect of race and ethnicity on advance directive completion rate after palliative care consultation (PCC).Method:A chart review of all patients seen by the PCC service in an academic hospital over a 9-month period was performed. Data were compiled using gender, race, ethnicity, religion, and primary diagnosis. For this study, advance directives were defined as: “Do Not Resuscitate” (DNR) and/or “Do Not Intubate” (DNI).Results:Of the 400 medical records reviewed, 57% of patients were female and 71.3% documented their religion as Christian. The most common documented diagnosis was cancer (39.5%). Forty-seven percent reported their race as white. White patients completed more advance directives than did nonwhite patients both before (25.67% vs. 12.68%) and after (59.36% vs. 40.84%) PCC. There was a significantly higher proportion of whites who signed an advance directive after a PCC than of nonwhites (p = 0.021); of the 139 whites who did not have an advance directive at admission, 63 signed an advance directive after a PCC compared with 186/60 nonwhites (45% vs. 32%, respectively, p = 0.021). Further analysis revealed that African Americans differed from whites in the likelihood of advance directive execution rates pre-PCC, but not post-PCC.Significance of results:This study demonstrates the impact of a PCC on the completion of advance directives, on both whites and nonwhites. The PCC Intervention significantly reduced differences between whites and African Americans in completing advance directives, which have been consistently documented in the end-of-life literature.

Cost analysis of a prospective multi-site cohort study of palliative care consultation teams for adults with advanced cancer: Where do cost-savings come from?

2017 ◽  
Vol 31 (4) ◽  
pp. 378-386 ◽  
Author(s):  
Peter May ◽  
Melissa M Garrido ◽  
J Brian Cassel ◽  
Amy S Kelley ◽  
Diane E Meier ◽  
...  
Keyword(s):  
Palliative Care ◽  
Cohort Study ◽  
Length Of Stay ◽  
Advanced Cancer ◽  
Intervention Group ◽  
Cost Savings ◽  
Early Palliative Care ◽  
Palliative Care Consultation ◽  
Consultation Team ◽  
Care Consultation

Background: Studies report cost-savings from hospital-based palliative care consultation teams compared to usual care only, but drivers of observed differences are unclear. Aim: To analyse cost-differences associated with palliative care consultation teams using two research questions: (Q1) What is the association between early palliative care consultation team intervention, and intensity of services and length of stay, compared to usual care only? (Q2) What is the association between early palliative care consultation team intervention and day-to-day hospital costs, compared to a later intervention? Design: Prospective multi-site cohort study (2007–2011). Patients who received a consultation were placed in the intervention group, those who did not in the comparison group. Intervention group was stratified by timing, and groups were matched using propensity scores. Setting/participants: Adults admitted to three US hospitals with advanced cancer. Principle analytic sample contains 863 patients ( nUC = 637; nPC EARLY = 177; nPC LATE = 49) discharged alive. Results: Cost-savings from early palliative care accrue due to both reduced length of stay and reduced intensity of treatment, with an estimated 63% of savings associated with shorter length of stay. A reduction in day-to-day costs is observable in the days immediately following initial consult but does not persist indefinitely. A comparison of early and late palliative care consultation team cost-effects shows negligible difference once the intervention is administered. Conclusion: Reduced length of stay is the biggest driver of cost-saving from early consultation for patients with advanced cancer. Patient- and family-centred discussions on goals of care and transition planning initiated by palliative care consultation teams may be at least as important in driving cost-savings as the reduction of unnecessary tests and pharmaceuticals identified by previous studies.

Life-Sustaining Procedures, Palliative Care Consultation, and Do-Not Resuscitate Status in Dying Patients With COPD in US Hospitals

2018 ◽  
Vol 33 (3) ◽  
pp. 159-166 ◽  
Author(s):  
Jay J. Shen ◽  
Eunjeong Ko ◽  
Pearl Kim ◽  
Sun Jung Kim ◽  
Yong-Jae Lee ◽  
...  
Keyword(s):  
Palliative Care ◽  
Statistical Significance ◽  
Cohort Analysis ◽  
Temporal Trends ◽  
Care Utilization ◽  
Do Not Resuscitate ◽  
Dying Patients ◽  
Palliative Care Consultation ◽  
Care Consultation ◽  
The Impact

Aim: Little is known regarding the extent to which dying patients with chronic obstructive pulmonary disease (COPD) receive life-sustaining procedures and palliative care in US hospitals. We examined temporal trends and the impact of palliative care on the use of life-sustaining procedures in this population. Materials and Methods: A retrospective nationwide cohort analysis was performed using weighted National Inpatient Sample (NIS) data obtained from 2010 to 2014. Decedents ≥18 years of age at the time of death and with a principal diagnosis of COPD were included. We examined the receipt of life-sustaining procedures, defined as1 ventilation (intubation, mechanical ventilation, and noninvasive ventilation),2 vasopressor use (infusion and intravascular monitoring),3 nutrition (enteral and parenteral infusion of concentrated nutrition),4 dialysis, and5 cardiopulmonary resuscitation as well as palliative care consultation and do not resuscitate (DNR). We used compound annual growth rates (CAGRs) and the Rao-Scott correction of the χ2 statistic to determine the statistical significance of temporal trends of life-sustaining procedures, palliative care utilization, and DNR status. Results: Among 37 312 324 hospitalizations, 38 425 patients were examined. The CAGRs of life-sustaining procedures were 6.61% and −9.73% among patients who underwent multiple procedures and patients who did not undergo any procedure, respectively (both P < .001). The CAGRs of palliative consultation and DNR were 5.25% and 36.62%, respectively (both P < .001). Conclusions: Among adults with COPD dying in US hospitals between 2010 and 2014, the utilization of life-sustaining procedures, palliative care, and DNR status increased.

Sign in / Sign up

Export Citation Format

Share Document