Patterns of care in hospitalized vascular surgery patients at end of life

Dale G. Wilson, Sheena K. Harris, Heidi Peck, Kyle Hart, Enjae Jung, Amir Azarbal, Erica Mitchell, Gregory Landry, Gregory (Greg) Moneta

Research output: Contribution to journalArticle

9 Citations (Scopus)

Abstract

Importance: There is limited literature reporting circumstances surrounding end-of-life care in vascular surgery patients. Objective: To identify factors driving end-of-life decisions in vascular surgery patients. Design, Setting, and Participants: In this cohort study, medical recordswere reviewed for all vascular surgery patients at a tertiary care university hospital who died during their hospitalization from 2005 to 2014. Main Outcomes and Measures: Patient, family, and hospitalization variables potentially important to influencing end-of-life decisions. Results: Of 111 patients included (67 [60%] male; median age, 75 [range, 24-94] years), 81 (73%) were emergent vs 30 (27%) elective admissions. Only 15 (14%) had an advance directive. Of the 81 (73%) patients placed on comfort care, 31 (38%) had care withheld or withdrawn despite available medical options, 15 (19%) had an advance directive, and 28 (25%) had a palliative care consultation. The median time from palliative care consultation to death was 10 hours (interquartile range, 3.36-66 hours). Comparing the 31 patients placed on comfort care despite available medical options with an admission diagnosis-matched cohort, we found that more than 5 days admitted to the intensive care unit (odds ratio [OR], 4.11; 95%CI, 1.59-10.68; P < .001), more than 5 days requiring ventilator support (OR, 9.45; 95% CI, 3.41-26.18; P < .001), new renal failure necessitating dialysis (OR, 14.48; 95%CI, 3.69-56.86; P < .001), and new respiratory failure necessitating tracheostomy (OR, 23.92; 95%CI, 2.80-204; P < .001) correlated with transition to comfort care. Conclusions and Relevance: Palliative care consultations may be underused at the end of life. A large percentage of patients were transitioned to comfort measures despite available treatment, yet few presented with advance directives. In high-risk patients, discussions regarding extended stays in the intensive care unit, prolonged ventilator management, and possible dialysis and tracheostomy should be communicated with patients and families at time of hospitalization and advance directives solicited.

Original languageEnglish (US)
Pages (from-to)183-190
Number of pages8
JournalJAMA Surgery
Volume152
Issue number2
DOIs
StatePublished - Feb 1 2017

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Blood Vessels
Advance Directives
Odds Ratio
Palliative Care
Hospitalization
Referral and Consultation
Tracheostomy
Mechanical Ventilators
Intensive Care Units
Dialysis
Terminal Care
Tertiary Healthcare
Respiratory Insufficiency
Renal Insufficiency
Cohort Studies
Outcome Assessment (Health Care)

ASJC Scopus subject areas

  • Surgery

Cite this

Patterns of care in hospitalized vascular surgery patients at end of life. / Wilson, Dale G.; Harris, Sheena K.; Peck, Heidi; Hart, Kyle; Jung, Enjae; Azarbal, Amir; Mitchell, Erica; Landry, Gregory; Moneta, Gregory (Greg).

In: JAMA Surgery, Vol. 152, No. 2, 01.02.2017, p. 183-190.

Research output: Contribution to journalArticle

Wilson, Dale G. ; Harris, Sheena K. ; Peck, Heidi ; Hart, Kyle ; Jung, Enjae ; Azarbal, Amir ; Mitchell, Erica ; Landry, Gregory ; Moneta, Gregory (Greg). / Patterns of care in hospitalized vascular surgery patients at end of life. In: JAMA Surgery. 2017 ; Vol. 152, No. 2. pp. 183-190.
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abstract = "Importance: There is limited literature reporting circumstances surrounding end-of-life care in vascular surgery patients. Objective: To identify factors driving end-of-life decisions in vascular surgery patients. Design, Setting, and Participants: In this cohort study, medical recordswere reviewed for all vascular surgery patients at a tertiary care university hospital who died during their hospitalization from 2005 to 2014. Main Outcomes and Measures: Patient, family, and hospitalization variables potentially important to influencing end-of-life decisions. Results: Of 111 patients included (67 [60{\%}] male; median age, 75 [range, 24-94] years), 81 (73{\%}) were emergent vs 30 (27{\%}) elective admissions. Only 15 (14{\%}) had an advance directive. Of the 81 (73{\%}) patients placed on comfort care, 31 (38{\%}) had care withheld or withdrawn despite available medical options, 15 (19{\%}) had an advance directive, and 28 (25{\%}) had a palliative care consultation. The median time from palliative care consultation to death was 10 hours (interquartile range, 3.36-66 hours). Comparing the 31 patients placed on comfort care despite available medical options with an admission diagnosis-matched cohort, we found that more than 5 days admitted to the intensive care unit (odds ratio [OR], 4.11; 95{\%}CI, 1.59-10.68; P < .001), more than 5 days requiring ventilator support (OR, 9.45; 95{\%} CI, 3.41-26.18; P < .001), new renal failure necessitating dialysis (OR, 14.48; 95{\%}CI, 3.69-56.86; P < .001), and new respiratory failure necessitating tracheostomy (OR, 23.92; 95{\%}CI, 2.80-204; P < .001) correlated with transition to comfort care. Conclusions and Relevance: Palliative care consultations may be underused at the end of life. A large percentage of patients were transitioned to comfort measures despite available treatment, yet few presented with advance directives. In high-risk patients, discussions regarding extended stays in the intensive care unit, prolonged ventilator management, and possible dialysis and tracheostomy should be communicated with patients and families at time of hospitalization and advance directives solicited.",
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AU - Harris, Sheena K.

AU - Peck, Heidi

AU - Hart, Kyle

AU - Jung, Enjae

AU - Azarbal, Amir

AU - Mitchell, Erica

AU - Landry, Gregory

AU - Moneta, Gregory (Greg)

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N2 - Importance: There is limited literature reporting circumstances surrounding end-of-life care in vascular surgery patients. Objective: To identify factors driving end-of-life decisions in vascular surgery patients. Design, Setting, and Participants: In this cohort study, medical recordswere reviewed for all vascular surgery patients at a tertiary care university hospital who died during their hospitalization from 2005 to 2014. Main Outcomes and Measures: Patient, family, and hospitalization variables potentially important to influencing end-of-life decisions. Results: Of 111 patients included (67 [60%] male; median age, 75 [range, 24-94] years), 81 (73%) were emergent vs 30 (27%) elective admissions. Only 15 (14%) had an advance directive. Of the 81 (73%) patients placed on comfort care, 31 (38%) had care withheld or withdrawn despite available medical options, 15 (19%) had an advance directive, and 28 (25%) had a palliative care consultation. The median time from palliative care consultation to death was 10 hours (interquartile range, 3.36-66 hours). Comparing the 31 patients placed on comfort care despite available medical options with an admission diagnosis-matched cohort, we found that more than 5 days admitted to the intensive care unit (odds ratio [OR], 4.11; 95%CI, 1.59-10.68; P < .001), more than 5 days requiring ventilator support (OR, 9.45; 95% CI, 3.41-26.18; P < .001), new renal failure necessitating dialysis (OR, 14.48; 95%CI, 3.69-56.86; P < .001), and new respiratory failure necessitating tracheostomy (OR, 23.92; 95%CI, 2.80-204; P < .001) correlated with transition to comfort care. Conclusions and Relevance: Palliative care consultations may be underused at the end of life. A large percentage of patients were transitioned to comfort measures despite available treatment, yet few presented with advance directives. In high-risk patients, discussions regarding extended stays in the intensive care unit, prolonged ventilator management, and possible dialysis and tracheostomy should be communicated with patients and families at time of hospitalization and advance directives solicited.

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