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Original Investigation
Pacific Coast Surgical Association
November 02, 2016

Patterns of Care in Hospitalized Vascular Surgery Patients at End of Life

Author Affiliations
  • 1Division of Vascular Surgery, Department of Surgery, Knight Cardiovascular Institute, Oregon Health and Science University, Portland
  • 2Decedent Affairs, Oregon Health and Science University, Portland
JAMA Surg. Published online November 2, 2016. doi:10.1001/jamasurg.2016.3970
Key Points

Question  Why do vascular surgery patients and their families choose comfort care, and how well are we using palliative care teams and advance directives?

Findings  This cohort study of medical records of patients at the end of life found that most vascular surgery patients who die while hospitalized are placed on comfort measures, but few had advance directives or a palliative care consultation. Number of days in the intensive care unit or receiving mechanical ventilation, needing a tracheostomy, or requiring dialysis correlated with transition to comfort care.

Meaning  Preoperative advance care planning may improve care in older, sicker patients at the end of life.

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 records were 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 Of the 81 (73%) patients placed on comfort care, 31 (38%) had care withheld or withdrawn despite available medical options, 15 (19%) had an advance directive, and 28 (25%) had a palliative care consultation.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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