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Original Investigation
Association of VA Surgeons
January 2, 2020

Palliative Care and End-of-Life Outcomes Following High-Risk Surgery

Author Affiliations
  • 1Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, California
  • 2Office of Research, Patient Care Services, Stanford Healthcare, Stanford, California
  • 3Section of Palliative Care, Division of Primary Care and Population Health, Department of Medicine, Stanford University, Stanford, California
  • 4Department of Anesthesiology, Perioperative & Pain Medicine, Stanford University, Stanford, California
  • 5Quantitative Sciences Unit, Stanford University, Stanford, California
  • 6Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, California
  • 7Stanford–Surgery Policy, Improvement Research and Education Center, Department of Surgery, Stanford University, Stanford, California
  • 8Department of Surgery, Quality and Compliance, University of Nebraska Medical Center, Omaha
  • 9Veterans Integrated Service Network 23, Nebraska–Western Iowa VA Medical Center, Omaha
  • 10Hospice and Palliative Care Program, Hospice and Palliative Care Unit Department of Veteran Affairs, Lebanon VA Medical Center, Lebanon, Pennsylvania
  • 11Section of General Internal Medicine, VA Boston Health Care System, Boston, Massachusetts
  • 12Division of General Internal Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
  • 13Department of Psychosocial Oncology and Palliative Care, Dana Farber Cancer Institute, Boston, Massachusetts
  • 14Section of Palliative Care, Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, California
JAMA Surg. Published online January 2, 2020. doi:10.1001/jamasurg.2019.5083
Key Points

Question  What is the role of palliative care in the care of patients undergoing high-risk surgery and the association between palliative consultations and end-of-life outcomes of patients who died after surgery?

Findings  In this cross-sectional study, receiving a palliative care consultation was associated with better overall care, communication, and support in the last month of life for patients who died within 90 days of high-risk surgery. Despite this, palliative care was not commonly used in a national cohort of patients undergoing high-risk operations.

Meaning  Providing palliative care for patients undergoing high-risk surgery may improve patient and family experiences at the end of life, per the results of this study.

Abstract

Importance  Palliative care has the potential to improve care for patients and families undergoing high-risk surgery.

Objective  To characterize the use of perioperative palliative care and its association with family-reported end-of-life experiences of patients who died within 90 days of a high-risk surgical operation.

Design, Setting, and Participants  This secondary analysis of administrative data from a retrospective cross-sectional patient cohort was conducted in the Department of Veterans Affairs (VA) Healthcare System. Patients who underwent any of 227 high-risk operations between January 1, 2012, and December 31, 2015, were included.

Exposures  Palliative-care consultation within 30 days before or 90 days after surgery.

Main Outcomes and Measures  The outcomes were family-reported ratings of overall care, communication, and support in the patient’s last month of life. The VA surveyed all families of inpatient decedents using the Bereaved Family Survey, a valid and reliable tool that measures patient and family-centered end-of-life outcomes.

Results  A total of 95 204 patients underwent high-risk operations in 129 inpatient VA Medical Centers. Most patients were 65 years or older (69 278 [72.8%]), and the most common procedures were cardiothoracic (31 157 [32.7%]) or vascular (23 517 [24.7%]). The 90-day mortality rate was 6.0% (5740 patients) and varied by surgical subspecialty (ranging from 278 of 7226 [3.8%] in urologic surgery to 875 of 6223 patients [14.1%] in neurosurgery). A multivariate mixed model revealed that families of decedents who received palliative care were 47% more likely to rate overall care in the last month of life as excellent than those who did not (odds ratio [OR], 1.47 [95% CI, 1.14-1.88]; P = .007), after adjusting for patient’s characteristics, surgical subspecialty of the high-risk operation, and survey nonresponse. Similarly, families of decedents who received palliative care were more likely to rate end-of-life communication (OR, 1.43 [95% CI, 1.09-1.87]; P = .004) and support (OR, 1.31 [95% CI, 1.01-1.71]; P = .05) components of medical care as excellent. Of the entire cohort, 3374 patients (3.75%) had a palliative care consultation, and 770 patients (0.8%) received it before surgery. Of all decedents, 1632 (29.9%) had a palliative care consultation, with 319 (5.6%) receiving it before surgery.

Conclusions and Relevance  Receipt of a palliative consultation was associated with better ratings of overall end-of-life care, communication, and support, as reported by families of patients who died within 90 days of high-risk surgery. Yet only one-third of decedents was exposed to palliative care. Expanding integration of perioperative palliative care may benefit patients undergoing high-risk operations and their families.

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