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Table 1.  Demographic Characteristics of All Patients Who Died on the Vascular Surgery Service
Demographic Characteristics of All Patients Who Died on the Vascular Surgery Service
Table 2.  Factors Relating to In-Hospital Care for Patients Who Died on the Vascular Surgery Service and Were Placed on Comfort Care, Excluding Those Who Died in the Operating Room
Factors Relating to In-Hospital Care for Patients Who Died on the Vascular Surgery Service and Were Placed on Comfort Care, Excluding Those Who Died in the Operating Room
Table 3.  Factors Relating to In-Hospital Care for All Patients Who Died on the Vascular Surgery Service and Received a Palliative Care Consultation, Excluding Those Who Died in the Operating Room
Factors Relating to In-Hospital Care for All Patients Who Died on the Vascular Surgery Service and Received a Palliative Care Consultation, Excluding Those Who Died in the Operating Room
Table 4.  Demographic Characteristics of Patients Choosing Comfort Care With Other Medical Options Available vs Controls
Demographic Characteristics of Patients Choosing Comfort Care With Other Medical Options Available vs Controls
Table 5.  Factors Relating to In-Hospital Care for Patients Choosing Comfort Care With Other Medical Options Available vs Controls
Factors Relating to In-Hospital Care for Patients Choosing Comfort Care With Other Medical Options Available vs Controls
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The SUPPORT Principal Investigators.  A controlled trial to improve care for seriously ill hospitalized patients: the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT).  JAMA. 1995;274(20):1591-1598.PubMedGoogle ScholarCrossref
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Pautex  S, Herrmann  FR, Zulian  GB.  Role of advance directives in palliative care units: a prospective study.  Palliat Med. 2008;22(7):835-841.PubMedGoogle ScholarCrossref
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Teno  JM, Gruneir  A, Schwartz  Z, Nanda  A, Wetle  T.  Association between advance directives and quality of end-of-life care: a national study.  J Am Geriatr Soc. 2007;55(2):189-194.PubMedGoogle ScholarCrossref
5.
Klingler  C, In der Schmitten  J, Marckmann  G.  Does facilitated advance care planning reduce the costs of care near the end of life? systematic review and ethical considerations.  Palliat Med. 2016;30(5):423-433.PubMedGoogle ScholarCrossref
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Centers for Disease Control and Prevention.  The State of Aging & Health in America 2013. Atlanta, GA: Centers for Disease Control and Prevention, US Dept of Health and Human Services; 2013.
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Arya  S, Kim  SI, Duwayri  Y,  et al.  Frailty increases the risk of 30-day mortality, morbidity, and failure to rescue after elective abdominal aortic aneurysm repair independent of age and comorbidities.  J Vasc Surg. 2015;61(2):324-331.PubMedGoogle ScholarCrossref
8.
Huber  M, Ozrazgat-Baslanti  T, Thottakkara  P, Scali  S, Bihorac  A, Hobson  C.  Cardiovascular-specific mortality and kidney disease in patients undergoing vascular surgery.  JAMA Surg. 2016;151(5):441-450.PubMedGoogle ScholarCrossref
9.
Pignaton  W, Braz  JR, Kusano  PS,  et al.  Perioperative and anesthesia-related mortality: an 8-year observational survey from a tertiary teaching hospital.  Medicine (Baltimore). 2016;95(2):e2208.PubMedGoogle ScholarCrossref
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Hosmer  DW, Lemeshow  S.  Applied Logistic Regression. New York, NY: Wiley; 2000.
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 National Palliative Care Registry Annual Survey Summary: Results of the 2012 National Palliative Care Registry Survey, as of July 2014. New York, NY: National Palliative Care Registry; 2014.
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George  N, Phillips  E, Zaurova  M, Song  C, Lamba  S, Grudzen  C.  Palliative care screening and assessment in the emergency department: a systematic review.  J Pain Symptom Manage. 2016;51(1):108-19.e2.PubMedGoogle ScholarCrossref
13.
May  P, Garrido  MM, Cassel  JB,  et al.  Prospective cohort study of hospital palliative care teams for inpatients with advanced cancer: earlier consultation is associated with larger cost-saving effect.  J Clin Oncol. 2015;33(25):2745-2752.PubMedGoogle ScholarCrossref
14.
Humphreys  J, Harman  S.  Late referral to palliative care consultation service: length of stay and in-hospital mortality outcomes.  J Community Support Oncol. 2014;12(4):129-136.PubMedGoogle ScholarCrossref
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Hui  D, Kim  SH, Roquemore  J, Dev  R, Chisholm  G, Bruera  E.  Impact of timing and setting of palliative care referral on quality of end-of-life care in cancer patients.  Cancer. 2014;120(11):1743-1749.PubMedGoogle ScholarCrossref
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Zhi  WI, Smith  TJ.  Early integration of palliative care into oncology: evidence, challenges and barriers.  Ann Palliat Med. 2015;4(3):122-131.PubMedGoogle Scholar
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Collins  LG, Parks  SM, Winter  L.  The state of advance care planning: one decade after SUPPORT.  Am J Hosp Palliat Care. 2006;23(5):378-384.PubMedGoogle ScholarCrossref
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Silveira  MJ, Kim  SY, Langa  KM.  Advance directives and outcomes of surrogate decision making before death.  N Engl J Med. 2010;362(13):1211-1218.PubMedGoogle ScholarCrossref
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Malyar  NM, Freisinger  E, Meyborg  M,  et al.  Low rates of revascularization and high in-hospital mortality in patients with ischemic lower limb amputation: morbidity and mortality of ischemic amputation.  Angiology. 2016;(Jan):13.PubMedGoogle Scholar
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Original Investigation
Pacific Coast Surgical Association
February 2017

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. 2017;152(2):183-190. 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.

Introduction

Each year in the United States, more than 700 000 people die while hospitalized.1 Many patients who die during hospitalization will have life-sustaining care either withheld or withdrawn shortly preceding their death. By the early 1990s, there was an increasing realization of the need for improved end-of-life care. The SUPPORT trial confirmed substantial shortcomings in the care for seriously ill hospitalized patients and concluded that greater individual and societal commitments and more proactive and forceful measures were needed to improve the experience of the seriously ill at the end of life.2 Since then, several changes have been enacted to address patient autonomy in times of incapacitation near the end of life. These include the advance directive, as well as physician orders for life-sustaining treatment (POLST) forms. Advance directives and POLST forms help define a patient’s wishes at end of life, alleviate patient fears, and improve patient-physician communication.3,4 They may also reduce overall costs at the end of life.5

According to the Centers for Disease Control and Prevention, by 2030, individuals 65 years and older will account for roughly 20% of the US population.6 More than a quarter of all Americans and 2 of every 3 older Americans have multiple chronic conditions.6 Caring for patients with advanced vascular disease is challenging given the complex nature of the surgical procedures performed, many of which, particularly in higher-risk patients, potentially are associated with substantial morbidity and mortality.7-9 There is a paucity of literature discussing end-of-life issues in the surgical patient despite the fact that palliative care is an Accreditation Council for Graduate Medical Education–accredited fellowship that offers board certification via the American Board of Surgery. We hypothesize that many patients who die on the vascular surgery service do so by choosing to receive comfort care only and that many patients who choose comfort care do so when additional treatment options are available. Additionally, we hypothesize that both advance directives and palliative care services are underused on the vascular surgery service at our tertiary care center.

Methods
Population

Quiz Ref IDThe study was reviewed and approved by the institutional review board of Oregon Health and Science University. Informed consent was waived due to the retrospective nature of the study. We conducted a retrospective electronic medical record review of patients aged 18 to 99 years who died while hospitalized on the vascular surgery service at Oregon Health and Science University Hospital from 2005 through 2014. Patients were identified and recorded by the decedent affairs department, which is responsible for identifying and recording all patients who die during their hospitalization at our facility. The medical record review was conducted by a single physician who was unblinded to the study objective, and no interrater reliability assessment was conducted. Patients included had a wide spectrum of vascular diseases. Patients younger than 18 years were excluded. Patients who died in the operating room were not transitioned to comfort care nor did they have the opportunity to get palliative care consultation prior to death and were therefore excluded from the final statistical analysis. Demographic data including medical, surgical, and social history, presence of advance directive, use of palliative care services, time of death, cause of death, and circumstances surrounding end-of-life care such as presence of family, days in the hospital, operative procedure, days in the intensive care unit (ICU), need for dialysis, mechanical ventilation, tracheostomy, cardiopulmonary resuscitation (CPR), reason for withdrawal or withholding of life-sustaining measures, prehospital home status (home vs care facility), and the patient’s prehospital functional status as defined by American College of Surgeons National Surgical Quality Improvement Program criteria were recorded on an Excel spreadsheet. Hospital, ICU, and ventilator days were clustered taking into account a reasonable expected stay in the hospital, or ICU, and time requiring mechanical ventilation for a heterogeneous group of vascular surgical patients. The groupings for all variables were determined prior to data collection.

Withdrawal or Withholding of Care Despite Available Medical Options

A subpopulation of patients who had life-sustaining care withheld or withdrawn despite available medical therapy was also analyzed. These were patients who were believed likely to have survived hospitalization had care not been withheld or withdrawn. Available medical therapy for those patients included further operative intervention, initiation of dialysis, tracheostomy, long-term ventilator care, and further diagnostic studies to investigate hemodynamic instability. Because they were believed likely to survive, this patient population was different from the population of patients who died secondary to cardiac arrest or had care withdrawn or withheld due to further care being unlikely to result in the patient’s survival. Such patients included those with large amounts of necrotic bowel and/or patients receiving maximal multiorgan system support yet continuing to decline. These patients were also included in the entire cohort of deceased patients (Table 1). This subpopulation was compared with a cohort of surviving patients matched by admitting diagnosis identified by Current Procedural Terminology and International Classification of Diseases, Ninth Revision, codes, who were admitted to the vascular surgery service from 2005 through 2014 and who had undergone a surgical intervention.

Statistical Analysis

Statistical analysis was carried out using R, version 3.2.3 (R Core Team), and STATA 12.1 statistical software (StataCorp). Univariable tests were conducted using χ2 tests, Fisher exact test, t test, or Wilcoxon rank sum test, as appropriate. The purposeful-selection procedure of Hosmer and Lemeshow10 was used to identify a parsimonious multivariable logistic regression model. Predictor variables included in the multivariable analysis were as follows: more than 5 days in the ICU or receiving ventilator support, tracheostomy, dialysis, cardiopulmonary resuscitation, emergency (vs elective) admission, obesity, family presence, and operative time. The Hosmer and Lemeshow goodness-of-fit test was adequate. The Woolf method was used to determine odds ratios (ORs) and 95% confidence intervals where the cell had an observed frequency of zero. The Parzen median unbiased estimator of the OR was used when the modified Woolf confidence interval contradicted the test of significance in instances where observed frequencies were zero.

Results
Total Population

Quiz Ref IDA total of 111 patients died on the vascular surgery service at Oregon Health and Science University hospital from 2005 to 2014. Sixteen (14%) patients died in the operating room, all secondary to cardiac arrest. Sixty-seven (60%) patients were male, and the median age was 75 years (range, 24-94 years). Eighty-one (73%) patients presented to the hospital emergently and 30 (27%) were elective admissions. Ten of the 111 patients were in a care facility prior to admission. Twenty-five patients were considered partially dependent, while 9 were considered dependent. Forty-one (37%) patients had presented with a ruptured abdominal aortic aneurysm. Ninety-seven (87%) underwent a surgical intervention. Twenty-eight (25%) patients had a body mass index (calculated as weight in kilograms divided by height in meters squared) greater than 30, 92 (83%) had hypertension, and 29 (26%) had diabetes mellitus. Further demographic characteristics can be seen in Table 1. Eighty-one (73%) patients died with transition to comfort care. Of these 81 patients, 31 (38%) were transitioned to comfort care despite available treatment options such as continued ventilator support, dialysis, tracheostomy, further surgical intervention or further diagnostic studies. Quiz Ref IDOnly 15 of the 111 (14%) patients presented to the hospital with an advance directive. Quiz Ref IDTwenty-eight (25%) patients who were transitioned to comfort care had a palliative care consult. The median time from palliative care consult to death was 10 hours (interquartile range, 3.36-66 hours). When analyzing factors relating to in-hospital care of all patients who died on our vascular surgery service, we found that such patients tended to be in the hospital fewer than 11 days (n = 69 [62%]), while 37 (33%) required dialysis, 44 (40%) had an episode of CPR, and 10 (9%) required a tracheostomy for prolonged respiratory failure.

We analyzed our data to look for factors that influenced both the transition to comfort care and obtaining a palliative care consultation. We found that greater than 5 days requiring a ventilator (OR, 9.00; 95% CI, 1.87-43.32; P < .001), a palliative care consultation (OR, 21.53; 95% CI, 2.92-34.53; P = .02), and involvement of family at presentation (OR, 4.79; 95% CI, 1.45-15.81; P = .02) were all statistically significant in influencing the transition to comfort care (Table 2). Patients transitioned to comfort care also were older than those who were not transitioned to comfort care (median age, 75 years [interquartile range {IQR}], 66-83 years] vs 65 years [IQR, 56-72 years]; P ≤ .01). All 10 patients who presented from a care facility were transitioned to comfort measures, as were 27 of the 34 patients considered partially or fully dependent on assistance to complete activities of daily living. Similarly, greater than 5 days requiring a ventilator (OR, 5.67; 95% CI, 1.71-18.87; P = .01), and transitioning to comfort measures (OR, 21.53; 95% CI, 2.92-34.53; P = .02) were both significantly associated with an increased OR for getting a palliative care consultation (Table 3). Patients going to the operating room were less likely to get a palliative care consultation (OR, 0.11; 95% CI, 0.03-0.40; P ≤ .01). Patients getting a palliative consultation were less likely to be placed on mechanical ventilation (OR, 5.25; 95% CI, 1.40-19.73; P = .01) (Table 3). Patients having an episode of CPR during hospitalization were less likely to be placed on comfort care measures (OR, 13.80; 95% CI, 3.46-55.09; P ≤ .01), and less likely to have a palliative care consultation (OR, 8.24; 95% CI, 1.80-37.68; P < .001) (Table 2 and Table 3). Four of 10 patients who presented from a care facility and 11 of 34 patients considered partially or fully dependent on assistance for activities of daily living had a palliative care consultation prior to death.

Withdrawal or Withholding of Care Despite Available Medical Options

There were 31 patients who had care withheld or withdrawn despite the possibility of additional available therapy. These patients were matched with 83 randomly selected controls matched by admitting diagnoses. The control patients were hospitalized from 2004 to 2014, and all underwent surgical intervention. Both groups were similar with respect to sex, abdominal aortic aneurysm rupture rate, tobacco use, and medical comorbidities (Table 4). This subpopulation was older, with a median age of 77 years compared with the control age of 68 years (mean difference, 10.37 years; 95% CI, 6.55-14.21 years; P < .001), and were more likely to have an advance directive (OR, 3.78; 95% CI, 1.23-11.53; P = .03). In terms of admission status, the withdrawal or withheld care group was more likely to have presented emergently to the hospital, although this was not statistically significant (Table 4).

When examining factors relating to in-hospital care, comfort care recipients were more likely to have received a palliative care consultation during their hospitalization (10 [32%] vs 1 [1%]; OR, 39.05; 95% CI, 4.73-322; P < .001). On univariable analysis we found that more than 5 days receipt of ventilator support (OR, 9.45; 95% CI, 3.41-26.18; P < .001), more than 5 days in the ICU (OR, 4.11; 95% CI, 1.59-10.68; P ≤ .01), new respiratory failure necessitating tracheostomy (OR, 23.92; 95% CI, 2.80-204; P < .001), and new renal failure necessitating dialysis (OR, 14.48; 95% CI, 3.69-56.86; P < .001) (Table 5) were significant. On multivariate analysis we found that a combined end point of requiring dialysis, tracheostomy, or CPR (OR, 14.20; 95% CI, 3.16-63.71; P < .001) was a significant predictor for patients transitioning to comfort care despite available therapy. More than 5 days in the ICU or longer than 5 days receipt of ventilator support was a nonsignificant predictor of transitioning to comfort care (OR, 3.26; 95% CI, 0.72-14.70; P = .12).

Discussion

Many teams from various specialties care for patients at end of life; however, we still do not know what prompts end-of-life discussions. There is no consensus on when to involve palliative care services in the care of critically ill patients. The number of palliative care services in hospitals has increased, as has their patient interaction, which was roughly 4% of annual hospital admissions in 2012.11 The involvement of palliative care teams is variable and physician dependent. George et al12 published a systematic review looking at methods, tools, and outcomes of palliative care consultations in the emergency department. They concluded that emergency department screening of patients for palliative care referrals was feasible and may offer benefits. The target population for their proposed screening tool included patients older than 65 years and/or identification of chronic life-limiting illnesses. Both of these factors are applicable to many vascular surgery patients. Earlier palliative care consultation during hospitalization in patients with advanced cancer may be associated with a lower cost of stay.13 Meanwhile, others have suggested that late referrals to palliative care may have a negative effect on health outcomes.14 Hui et al15 suggested that outpatient palliative care referral may improve end-of-life care compared with inpatient palliative care consultation. In our review, all palliative care consultations were inpatient, and the timing of the palliative care consultation was variable. We found that patients who received palliative care consultation were less likely to receive mechanical ventilation. This is possibly due to the surgical team and family electing to limit care prior to palliative care consultation or is a reflection of the palliative care team working with family, the patient, and the surgical team to limit care. None of the patients in our review had an ethics consultation prior to withdrawal of care.

There is strong evidence favoring earlier palliative care consultation in patients with advanced cancer and/or debilitating chronic medical illnesses.16,17 Many of our vascular surgical patients who die during their hospitalization present to the hospital emergently and require prolonged ventilator support and/or ICU stays, dialysis, and/or tracheostomy, leaving limited time for end-of-life discussions or palliative care consultation. Given the benefits of early palliative care consultation in other disciplines and the demographic characteristics and comorbidities of vascular surgical patients, consideration for preoperative palliative care involvement in patients undergoing high-risk vascular surgery is reasonable when such consultation is feasible.

Advance directives are one component of advance care planning, but we found that most of our patients who died while hospitalized had not completed an advance directive. In phase 2 of the SUPPORT trial, investigators implemented interventions to improve end-of-life care. Among others, interventions included physician updates regarding likelihood of 6-month survival, and increased interaction of a specialty-trained nurse with patient, family, and physician to help elicit preferences; however, few improved end-of-life care. Interventions did, however, lead to an increase in the use of advance directives.18 In a review of 3746 adults aged 51 years or older who died between 2000 and 2006, it was found that patients who had prepared advance directives received care that was strongly associated with their preferences.19 Our study, however, showed that few vascular surgical patients present with an advance directive. Increasing the use of advance directives is therefore an opportunity to improve overall and end-of-life care in the vascular surgical patient.

There are numerous reports examining predictors of morbidity and mortality in vascular surgical patients covering a variety of vascular ailments.7-9,20 However, to our knowledge this report is the first to look at predictors for patients and/or families choosing comfort care and the use of palliative care in vascular surgery patients. This, of course, is not a problem unique to vascular surgery. There is an overall paucity of literature regarding end-of-life issues in surgical patients, and a recent systematic review highlighted the difficulties and shortcomings of palliative care research in surgical patients.21 We found that patients who elected comfort care were more likely to receive ventilator support for more than 5 days and to need dialysis. Also, patients who received a palliative care consultation tended to require a ventilator for more than 5 days and present to the hospital emergently. Patients who received CPR during their hospitalization were less likely to be placed on comfort care or receive a palliative care consultation, likely due to the patient dying before either could be achieved. These observations speak to the need and importance of early recognition of critically ill vascular surgical patients who would potentially benefit from early palliative care consultation and advance care planning. Indeed, because the events associated with withdrawal of care are often not anticipated, we argue that all vascular surgical patients should have an advance directive and perhaps those at particular high risk should have a preoperative palliative care consultation. Involvement of palliative care services is not abdication of responsibility by the surgeon in end-of-life care of their patients. Like many other elements in patient care, the support of experts to help guide both the surgeon and the patient in providing the best care can optimize overall care.

Limitations

Our study has limitations. First, it is limited by the retrospective study design. A single physician who was unblinded to the study objective performed the data abstraction, and therefore no interrater reliability assessment was conducted. Determining cause of death and reason for transition to comfort care was gathered from patient records retrospectively, which involves some subjective interpretation. Also, our patient list was developed from a decedent affairs record of hospital deaths recorded monthly. Each patient death was categorized by the inpatient service on which the patient died, which may lead to misclassification of patients. Therefore, we may have missed patients who died following vascular surgery but were cared for by a different primary team. Our study was small and at a single center. Certain variables in the multivariate analysis were limited due to quasi-complete separation, making the multivariate analysis exploratory. Therefore, univariable associations were used for primary analysis. Examination of a larger population of patients across many surgical specialties would be more representative of all surgical patients. A prospective study looking at reasons for withdrawal or withholding of care in a surgical population would be ideal. This is an exploratory, hypothesis-seeking study, and further prospective studies looking at outcomes related to early palliative care intervention and preoperative advance care planning are needed.

Conclusions

This exploratory study examined clinically relevant factors that may affect patient and family decisions to transition to comfort measures. We found that few patients who die while hospitalized on the vascular surgery service receive a palliative consultation, and few present with advance directives. More emphasis needs to be placed on early advance care planning in patients who are undergoing surgical procedures given the increased age and frequently poorer health of the surgical patient. Quiz Ref IDIn critically ill surgical patients treated both emergently and electively, early palliative care consultation, together with discussions with the patients and their families regarding end-of-life care, has the potential to improve overall care.

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Article Information

Accepted for Publication: July 2, 2016.

Corresponding Author: Dale G. Wilson, MD, Division of Vascular Surgery, Knight Cardiovascular Institute, Department of Surgery, Mail code OP11, 3181 SW Sam Jackson Park Rd, Portland, OR 97239-3098 (wilsodal@ohsu.edu).

Published Online: November 2, 2016. doi:10.1001/jamasurg.2016.3970

Author Contributions: Dr Wilson had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Wilson, Azarbal, Mitchell, Landry, Moneta.
Acquisition, analysis, or interpretation of data: Wilson, Harris, Peck, Hart, Jung.
Drafting of the manuscript: Wilson, Moneta.
Critical revision of the manuscript for important intellectual content: Wilson, Harris, Peck, Hart, Jung, Mitchell, Landry, Moneta.
Statistical analysis: Wilson, Hart.
Administrative, technical, or material support: Harris, Peck, Jung.
Study supervision: Jung, Azarbal, Mitchell, Landry, Moneta.

Conflict of Interest Disclosures: None reported.

Previous Presentation: This paper was presented at the 87th Annual Meeting of the Pacific Coast Surgical Association; February 14, 2016; Kohala Coast, Hawaii.

References
1.
Hall  MJ, Levant  S, DeFrances  CJ.  Trends in inpatient hospital deaths: National Hospital Discharge Survey, 2000-2010.  NCHS Data Brief. 2013;(118):1-8.PubMedGoogle Scholar
2.
The SUPPORT Principal Investigators.  A controlled trial to improve care for seriously ill hospitalized patients: the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT).  JAMA. 1995;274(20):1591-1598.PubMedGoogle ScholarCrossref
3.
Pautex  S, Herrmann  FR, Zulian  GB.  Role of advance directives in palliative care units: a prospective study.  Palliat Med. 2008;22(7):835-841.PubMedGoogle ScholarCrossref
4.
Teno  JM, Gruneir  A, Schwartz  Z, Nanda  A, Wetle  T.  Association between advance directives and quality of end-of-life care: a national study.  J Am Geriatr Soc. 2007;55(2):189-194.PubMedGoogle ScholarCrossref
5.
Klingler  C, In der Schmitten  J, Marckmann  G.  Does facilitated advance care planning reduce the costs of care near the end of life? systematic review and ethical considerations.  Palliat Med. 2016;30(5):423-433.PubMedGoogle ScholarCrossref
6.
Centers for Disease Control and Prevention.  The State of Aging & Health in America 2013. Atlanta, GA: Centers for Disease Control and Prevention, US Dept of Health and Human Services; 2013.
7.
Arya  S, Kim  SI, Duwayri  Y,  et al.  Frailty increases the risk of 30-day mortality, morbidity, and failure to rescue after elective abdominal aortic aneurysm repair independent of age and comorbidities.  J Vasc Surg. 2015;61(2):324-331.PubMedGoogle ScholarCrossref
8.
Huber  M, Ozrazgat-Baslanti  T, Thottakkara  P, Scali  S, Bihorac  A, Hobson  C.  Cardiovascular-specific mortality and kidney disease in patients undergoing vascular surgery.  JAMA Surg. 2016;151(5):441-450.PubMedGoogle ScholarCrossref
9.
Pignaton  W, Braz  JR, Kusano  PS,  et al.  Perioperative and anesthesia-related mortality: an 8-year observational survey from a tertiary teaching hospital.  Medicine (Baltimore). 2016;95(2):e2208.PubMedGoogle ScholarCrossref
10.
Hosmer  DW, Lemeshow  S.  Applied Logistic Regression. New York, NY: Wiley; 2000.
11.
 National Palliative Care Registry Annual Survey Summary: Results of the 2012 National Palliative Care Registry Survey, as of July 2014. New York, NY: National Palliative Care Registry; 2014.
12.
George  N, Phillips  E, Zaurova  M, Song  C, Lamba  S, Grudzen  C.  Palliative care screening and assessment in the emergency department: a systematic review.  J Pain Symptom Manage. 2016;51(1):108-19.e2.PubMedGoogle ScholarCrossref
13.
May  P, Garrido  MM, Cassel  JB,  et al.  Prospective cohort study of hospital palliative care teams for inpatients with advanced cancer: earlier consultation is associated with larger cost-saving effect.  J Clin Oncol. 2015;33(25):2745-2752.PubMedGoogle ScholarCrossref
14.
Humphreys  J, Harman  S.  Late referral to palliative care consultation service: length of stay and in-hospital mortality outcomes.  J Community Support Oncol. 2014;12(4):129-136.PubMedGoogle ScholarCrossref
15.
Hui  D, Kim  SH, Roquemore  J, Dev  R, Chisholm  G, Bruera  E.  Impact of timing and setting of palliative care referral on quality of end-of-life care in cancer patients.  Cancer. 2014;120(11):1743-1749.PubMedGoogle ScholarCrossref
16.
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