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

Abstract

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.

Timing is everything: Early versus late palliative care consults in trauma

“…On the other hand, continuing prolonged courses of aggressive ICU care can also be considered value-congruent and may not necessarily exceed suffering restrictions for some patients 23 . Palliative care providers are experts at uncovering such patient values and making global patient-centered care-plan recommendations, 29 which many times includes deescalation in code status, 12,33 thereby averting expensive value-incongruent treatments. Other times, PC experts recommend continued aggressive and expensive care, as they have no preconceived agenda other than to honor the patient's values 29,34 …”

Ethik der Reanimation und Entscheidungen am Lebensende

“…Jüngste Erkenntnisse aus RCT unterstützen die Verwendung von videobasierten Entscheidungshilfen sowohl im Pflegeheim als auch im Krankenhaus, mit deren Hilfe die Häufigkeit von nichtvorteilhaften Maßnahmen wahrscheinlich verringert wird [ 25 – 28 ]. Unsere jüngsten retrospektiven Studien und eine Übersichtsarbeit zur Prävalenz legen nahe, dass Patientenverfügungen und/oder DNACPR-Entscheidungen mit einer reduzierten Anwendung lebenserhaltender Maßnahmen verbunden sind [ 29 – 34 ].…”

Managerial and organisational prerequisites for the integration of palliative care in the intensive care setting: A qualitative study

“…Death is not unexpected in most intensive care situations; most cases of death in intensive care are categorized as end‐of‐life care and associated with a ‘do not resuscitate’ order (Fan & Hsieh, 2020). The clinical code of a ‘do not resuscitate’ order may be used as a way to indicate a change in the care pathway from a curative approach to a ‘palliative phase’ (Fokin et al, 2020; Higginson et al, 2015); however, its intent is separate from palliation and a palliative approach goes beyond the withholding of treatment.…”