Advance care planning and goals of care discussions in perioperative care: a scoping review

BACKGROUND

Advance care planning is well established in general medical wards, but its implementation in anaesthesia and perioperative care presents unique challenges. Effective communication and shared decision-making regarding treatment limitations are essential to clarify care goals and provide timely, high-quality end-of-life care. Terminally ill patients with complex care needs can experience a higher risk of postoperative mortality during anaesthesia.

METHODS

This scoping review examines the literature describing when and how advance care planning has been studied in perioperative care, focusing on patient characteristics, the content of advance care planning discussions, and impact on patient outcomes. The study follows PRISMA-ScR guidelines. Articles were collected from MEDLINE, CENTRAL, and CINAHL databases, using search terms from MeSH and synonyms for anaesthesia, surgery and perioperative care, advance care planning, living wills or advance directives, goals of care and terminal care, resuscitation orders, shared decision-making, and palliative care discussions.

RESULTS

Advance care planning documentation varies across surgical specialties and settings, with higher rates in emergency and palliative surgery. Patient factors, such as age and comorbidities, impact completion of advance care planning. Structurally, the presence of interdisciplinary teams, increased decision-making aids, and structured discussions improve implementation. Barriers included a lack of consistency in terminology, poor timing of needed conversations, a lack of cultural sensitivities, and patient fears of abandonment and palliative care.

CONCLUSIONS

Further research is required to determine the most appropriate and beneficial methods and outcomes for implementing advance care planning into perioperative and end-of-life care, ensuring appropriate, timely, and patient-oriented care delivery.

The 2023 WSES guidelines on the management of trauma in elderly and frail patients

BACKGROUND

The trauma mortality rate is higher in the elderly compared with younger patients. Ageing is associated with physiological changes in multiple systems and correlated with frailty. Frailty is a risk factor for mortality in elderly trauma patients. We aim to provide evidence-based guidelines for the management of geriatric trauma patients to improve it and reduce futile procedures.

METHODS

Six working groups of expert acute care and trauma surgeons reviewed extensively the literature according to the topic and the PICO question assigned. Statements and recommendations were assessed according to the GRADE methodology and approved by a consensus of experts in the field at the 10th international congress of the WSES in 2023.

RESULTS

The management of elderly trauma patients requires knowledge of ageing physiology, a focused triage, including drug history, frailty assessment, nutritional status, and early activation of trauma protocol to improve outcomes. Acute trauma pain in the elderly has to be managed in a multimodal analgesic approach, to avoid side effects of opioid use. Antibiotic prophylaxis is recommended in penetrating (abdominal, thoracic) trauma, in severely burned and in open fractures elderly patients to decrease septic complications. Antibiotics are not recommended in blunt trauma in the absence of signs of sepsis and septic shock. Venous thromboembolism prophylaxis with LMWH or UFH should be administrated as soon as possible in high and moderate-risk elderly trauma patients according to the renal function, weight of the patient and bleeding risk. A palliative care team should be involved as soon as possible to discuss the end of life in a multidisciplinary approach considering the patient's directives, family feelings and representatives' desires, and all decisions should be shared.

CONCLUSIONS

The management of elderly trauma patients requires knowledge of ageing physiology, a focused triage based on assessing frailty and early activation of trauma protocol to improve outcomes. Geriatric Intensive Care Units are needed to care for elderly and frail trauma patients in a multidisciplinary approach to decrease mortality and improve outcomes.

Interventions of Advanced Lung Cancer Patient Receiving Chemotherapy by Computed Tomography Image Information Data Analysis-Based Soothing Care Plans

The objective of this study was to investigate the intervention effect of computed tomography (CT) image information data on patients with advanced lung cancer treated with chemotherapy under palliative care program. The research subjects were 60 patients with advanced lung cancer who received palliative care in our hospital from January 1, 2019, to January 1, 2021. All patients were grouped according to the evaluation criteria of solid tumor efficacy, including 28 patients in the remission group and 32 patients in the nonremission group. Texture analysis was performed on the CT images of the two groups of patients. The gray-scale cooccurrence matrix parameters, the maximum diameter of the lesion, and the CT value of the CT images of the two groups of patients before and after palliative care were compared. The results showed that after the palliative care, the combined mean, combined energy, and inverse moment of the three gray cooccurrence matrix parameters of the two groups of patients were decreased, and the combined entropy and contrast were increased. The absolute value of the gray-scale cooccurrence matrix Δ parameter of the patients in the remission group was greater than that in the nonremission group. The Δ combined entropy, Δ contrast, and Δ correlation of the two groups of patients were significantly different, and the difference in Δ contrast was the largest. It suggested that the gray-scale cooccurrence matrix parameter can evaluate the effect of soothing care, and the contrast was the best evaluation parameter. The maximum diameter of the lesions in the remission group before and after palliative care was reduced by 1.23 cm, and the degree of reduction was significantly better. The CT value was reduced by 6.22 HU, and the degree of reduction was significantly higher than that in the nonremission group. There was a significant difference in the data between the two groups (P < 0.05). Therefore, the CT image information data had a better evaluation effect on patients with advanced lung cancer under the palliative care program and can be applied to the clinical evaluation of the palliative care effect, which had good clinical value.

Curative Effect of Early Full Nursing Combined with Postdischarge Continuation Nursing on Patients after Craniocerebral Trauma

Early full nursing helps patients with some dysfunctions speed up the reorganization of central nervous system functions and coordinate muscle and limb activities. Postdischarge continuation nursing for patients who have not fully recovered after being discharged from the hospital can transfer nursing work from the hospital to the family to meet their nursing needs. In this study, early full nursing combined with postdischarge continuation nursing was used for patients with traumatic brain injury to explore its efficacy and its impact on patients' motor function, quality of life, and complications. The results of the study show that the total effective rate of the observation group (95.92%) was higher than that of the control group (85.71%). At discharge and 1 month, 3 months, and 6 months after discharge, the upper limb Fugl-Meyer score, lower limb Fugl-Meyer score, ARAT score, FIM score, 4 dimensions of GQOLI-74 score, and Barthel index scores of the observation group were higher than those of the control group in the same period. The postoperative complication rate (10.20%) of the observation group was lower than that of the control group (26.53%). Early full nursing combined with postdischarge continuation nursing can improve the rehabilitation effect, effectively promote the recovery of motor function in patients with traumatic brain injury, improve the quality of life, and reduce postoperative complications.

Racial and ethnic disparities in withdrawal of life-sustaining treatment after non-head injury trauma

BACKGROUND

Little is known about potential disparities in end-of-life care in trauma. We examined racial/ethnic differences in withdrawal of life-sustaining treatment (WLST) in non-head injury trauma.

METHODS

We retrospectively analyzed the National Trauma Databank (2017-2018), including patients ≥ 18 years without head injury. We performed a bivariate analysis by WLST status and used logistic regression to estimate adjusted odds of WLST by racial/ethnic group.

RESULTS

Of 942,914 identified, 20,052 (2.1%) died. Of those who died, WLST occurred in 29.9%. The adjusted odds of WLST were lower in Blacks (OR 0.48, 95% CI 0.41-0.57) and Hispanics (OR 0.71, 95% CI 0.57-0.89) than Whites. The predicted probability of WLST in Black patients remained lower than Whites at 30 days.

CONCLUSIONS

Among non-head injured dying patients, Blacks and Hispanics are less likely to utilize WLST than Whites. Further investigation into the socio-cultural norms and institutional distrust influencing these differences is imperative.