Communication and Palliation in Trauma Critical Care: Impact of Trainee Education and Mentorship

The value of compassion: Healthcare savings of palliative care consults in trauma

BACKGROUND

The effects of palliative care (PC) consultation on patient costs and hospitalization metrics in the adult trauma population are unclear.

STUDY DESIGN

We interrogated our Level I trauma center databases from 1/1/19 to 3/31/21 for patients age ≥18 admitted to the trauma service. Patients undergoing PC consult were matched using propensity scoring to those without PC consultation based on age, admission Glasgow Coma Scale score, Injury Severity Score and Head Abbreviated Injury Scale. Total costs, total cost per day, hospital length of stay (LOS), ICU LOS, intubation days, discharge disposition, and rates of nephrology consultation and tracheostomy/feeding tube placements were compared.

RESULTS

140 unique patients underwent PC consultation and were matched to a group not receiving PC consult during the same period. Median total costs in the PC cohort were $39,532 compared to $70,330 in the controls (p<0.01).  Median costs per day in the PC cohort were $3,495 vs $17,970 in the controls (p<0.01).  Median costs per ICU day in the PC cohort were $3,774 vs $17,127 in the controls (p<0.01).  Mean hospital LOS (15.7 vs 7 days), ICU LOS (7.9 vs 2.9 days), and ventilator days (5.1 vs 1.5) were significantly higher in the PC cohort (all p<0.01).  Rates of nephrology consultation (8.6 vs 2.1%, p = 0.03) and tracheostomy/feeding tube placements (12.1 vs 1.4%, p<0.01) were also higher in the PC group.  Patients were more likely to discharge to hospice if they received a PC consult (33.6 vs 2.1%, p<0.01).  Mean time to PC consult was 7.2 days (range 1 hour to 45 days). LOS post-consult correlated positively with time to PC consultation (r = 0.27, p<0.01).

CONCLUSION

Expert PC services are known to alleviate suffering and avert patient goal- and value-incongruent care. While trauma patients demand significant resources, PC consultation offered in concordance with life-sustaining interventions is associated with significant savings to patients and the healthcare system. Given the correlation between LOS following PC consult and time to PC consult, savings may be amplified by earlier PC consultation in appropriate patients.

Palliative Care in the Trauma and Surgical Critical Care Settings: A Narrative Review

BACKGROUND

We aimed to conduct a narrative review of available literature to understand the use of palliative care in the trauma and surgical critical care setting.

METHODS

PubMed, EMBASE, and Google Scholar databases were searched for studies investigating the use of palliative care in the trauma and surgical critical care setting. The search included all studies published through January 9th, 2022. The risk of bias of included studies was assessed using the Joanna Briggs Institute Critical Appraisal Checklist tools. Outcomes were summarized in tables and synthesized qualitatively.

RESULTS

A total of 22 studies were included in this review. Key elements of successful palliative care include communication, shared decision-making, family involvement, pain control, establishing a patient's prognosis, and end-of-life management. Approaches to implementation based upon these key elements include best-case/worst-case scenarios, consultation trigger systems, and integrated institutional palliative care programs. Palliative care may reduce hospital length of stay, improve symptom management, and increase patient satisfaction, but the impact on mortality is unclear.

CONCLUSION

The core elements of palliative care have been identified and palliative care has been shown to improve outcomes in trauma and surgical critical care. However, the approaches for implementation still require development. The underutilization of palliative care for trauma patients reveals the need for refining criteria for use of palliative care and improvement in the education of surgical critical care teams to provide primary palliative care services.