Goals of Care Discussions for the Imminently Dying Trauma Patient

Abstract

Background: A structured family meeting (FM) is recommended within 72 h of admission for trauma patients with high risk of mortality or disability. Multidisciplinary FMs (MDFMs) may further facilitate decision-making. We hypothesized that FM within three hospital days (HDs) or MDFM would be associated with increased use of comfort measures. Materials and methods:We reviewed all adult trauma deaths at an academic level 1 trauma center from December 2014 to December 2017. Death in the first 24 h or on nonsurgical services were excluded. Demographics, injury characteristics, FM characteristics, and outcomes such as length of stay (LOS) were recorded. Early FM was defined as occurring within three HDs; MDFM required attendance by two or more specialty teams.Results: A total of 177 patients were included. Median LOS was 6 d (interquartile range 4-12). FMs were documented in 166 patients (94%), with 57% occurring early. MDFM occurred in 49 (28%), but usually occurred later (median HD 5 and interquartile range 2-8). Early FM was associated with reduced LOS (5 versus 11 d, P < 0.001), ventilator days (4 versus 9 d, P < 0.001), and deaths during a code (1.2% versus 13.2%, P < 0.001). MDFM was associated with higher use of comfort measures (88% versus 68%, P < 0.05). Of patients who transitioned to comfort care status (n = 130, 73.4%), code status change occurred earlier if an early FM occurred (5 versus 13 d, P < 0.001).Conclusions: MDFM is associated with increased comfort care measures, whereas early FM is associated with reduced LOS, ventilator days, death during a code, and earlier comfort care transition.

Implementation of a Surgical Intensivist Model Increases Palliative Care Consultation in the Care of Trauma ICU Patients

“…16 Early goals of care discussions and multidisciplinary family meetings are associated with increased comfort care measures for imminently dying trauma patients. 17 Additionally, there is an increasing proportion of geriatric trauma patients; and age can be a major factor in deciding whether to implement palliative care during admission to the ICU. 10 In our study, the surgical intensivist-led team took care of more geriatric patients over 65 years of age.…”

Critical Care Documentation for the Dying Trauma Patient: Are We Recognizing Our Own Efforts?

“…Request for palliative care consultation at our institution is provider-dependent and often occurs in close proximity to death. 7 We theorize that palliative care consultation is called to help transition to comfort measures when it is determined that further care is futile and the intensivist ceases to document CCT. We did not access hospital billing data for this study and could not determine if 99 291 or 99 292 was actually billed, or whether these codes were attributed to other teams, such as palliative care.…”

“…A single-center retrospective cohort study analyzing critical care documentation in trauma patients at the end of life was performed at our mature, urban, academic, level 1 trauma center. 7 Criteria were selected to identify dying patients who would be eligible for critical care billing prior to death. We screened all adult patients who were included in our prospectively maintained trauma registry and identified all patients who died between December 2014 and December 2017.…”

Making your geriatric and palliative programs a strength: TQIP guideline implementation and the VRC perspective

“…The needs assessment was performed as a retrospective review over a 3-year period to identify potential areas for improvement. 16 We studied the use of multidisciplinary team meetings, palliative care consult use, and code status changes in trauma patients who died of all ages. This study demonstrated that early multidisciplinary care had tangible benefits: fewer patients died as 'full code', and there was more use of comfort measures; we also noted these services were used earlier in younger patients but were delayed in older patients.…”