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

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.

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.

Surgery is common near the end of life. Among 1.8 million individuals who received Medicare and died in 2008, 20% had a surgical procedure requiring an operating room in the final year before death.¹ While the definition of high-risk surgery varies, a recent study identified 227 procedures that had a 1% or greater inpatient mortality rate among patients older than 65 years.² Surgical mortality reflects both the intrinsic risk of the procedure and the underlying morbidity of the patient. Prevalence of frailty and serious illness in old age challenge clinicians to improve the patient’s perioperative experience.

Evidence supports the benefit of palliative care for patients who are seriously ill and their families in medical settings,³ but less is known about its outcome in surgical settings. In multiple medical populations, palliative care is associated with improved symptomatic and psychosocial support, communication about goals of care, and ultimately the family’s rating of the decedent’s experience at the end of life.^3,4 If delivered earlier rather than later in the course of illness, palliative care can guide clinical interventions in alignment with patient’s preferences, often resulting in reduced health care use.^4-7

Surgeons and health systems are calling for the integration of palliative approaches.^8,9 Recent quality-improvement efforts have significantly reduced postoperative mortality by combining frailty screening with collaborative care planning by surgery, anesthesia, critical care, and palliative care clinicians.¹⁰ Involvement of palliative care in surgical planning, postoperative surveillance, and management may be an important contributor to these promising results. Yet, prior studies found that only 4% to 38% of patients who underwent surgery received palliative care at some point before death.^11-13 Stronger evidence for improved outcomes may advance palliative care integration in surgical settings.

This study aimed to characterize the use of palliative care in a national cohort of patients undergoing 227 previously identified, high-risk surgical procedures and evaluate its association with the quality of end-of-life care reported by families of patients who died. The cohort included US military veterans receiving care in the Department of Veterans Affairs (VA) Healthcare System, which has facilitated access to palliative care for well over a decade.^14,15 We hypothesized that (1) patients undergoing high-risk surgery would have considerable mortality compared with general surgery, (2) exposure to palliative care would be associated with higher quality of care at the end-of-life, and yet, (3) it would be relatively underused among individuals who died after surgery.

We conducted a retrospective cross-sectional analysis of patients who underwent high-risk surgical procedures in VA medical centers (VAMC) between January 1, 2012, and December 31, 2015. The study was approved by the joint VA Palo Alto Healthcare System and Stanford University institutional review board. The need for patient consent was waived because there was no direct patient contact and the study analyzed deidentified secondary data.

We used data from the VA Corporate Data Warehouse and the Veteran Experience Center. The Corporate Data Warehouse stores all clinical and administrative information about patients receiving care in VAMC.¹⁶ It assigns each patient a unique national identifier to reliably link various VA data sets.¹⁷ The Veteran Experience Center is the steward of data on veterans’ end-of-life care. It contacts families of all patients who have died to carry out the Bereaved Family Survey (BFS) to ascertain their perceptions of care received in the inpatient facility in the last month of life.¹⁸ Exclusion criteria include patients without a next of kin listed in the medical record and those who died within 24 hours of admission, unless they had a length of stay longer than 24 hours in a VAMC in the preceding month. The BFS is a valid, reliable, 19-item instrument to measure quality of end-of-life care that is endorsed by the National Quality Forum.¹⁹ Previous studies have shown that 45% of all contacted families reply to the BFS, with minimal response bias.¹⁸

The cohort included patients that underwent high-risk surgical procedures in VAMC between January 1, 2012, and December 31, 2015, and were continuously enrolled in the 12 months prior to the index operation. We used previously established definition of high-risk surgery, based on International Classification of Diseases, Ninth Revision codes of 227 operations with an inpatient mortality rate of 1% or greater among adults older than 65 years and up to 6% mortality rate for urgent or unplanned surgical admissions.² For patients who had more than 1 operation within the time frame, we designated the first procedure as the incident event, viewing it as the earliest opportunity to improve surgical care. We grouped operations into 8 a priori groups based on surgical subspecialty: cardiothoracic, vascular, intestinal, urologic, abdominal foregut (hepato-pancreato-biliary-gastric-duodenal), neurologic, esophageal, and other (gynecologic, orthopedic, and otolaryngologic) procedures.

We examined mortality at 30 days, 90 days, and 1 year after surgery. Mortality is traditionally tracked for 30 days in surgical quality-improvement registries.²⁰ It is still attributable to surgical intervention within 90 days.²¹ We examined mortality at 1 year to expose the long-term illness burden within our cohort and be consistent with the prognostic timeframe for palliative care.³ Death was ascertained from the Corporate Data Warehouse’s VA Vital Status File, which is derived from VA Beneficiary Death File, Medicare Vital Status File, and Social Security Administration Death Master File.²²

The primary outcome was the BFS overall care score, which reflects the global rating of end-of-life care by the family of the decedent on a 5-point Likert scale. We dichotomized the variable as excellent vs all other categories, in accordance with VA’s national top-box scoring.²³ We also examined validated BFS subscales for quality of end-of-life communication and support.¹⁸ Communication factor is the sum of 5 items: that staff (1) listened to concerns; (2) provided wanted medical treatment; (3) were kind, caring, and respectful; (4) kept family members informed about the patient’s condition and treatment; and (5) attended to personal care. It ranges from 0 to 15 points, with 15 being the best possible score. The support factor is the sum of 3 items: that staff provided enough (1) support before death, (2) emotional support after death, and (3) spiritual support. It ranges from 0 to 9 points, with 9 being the best possible score. Both subscales were dichotomized using validated cutoffs, based on the associations with the BFS Overall Care score.²⁴ We classified a communication score of 13 or more as excellent and a support score of 7 or more as excellent.

We examined exposure to palliative care consultation within the perioperative window of 30 days prior to 90 days after index surgery. Thirty days before surgery are in alignment with Veteran’s Health Administration policy for preoperative appointments, an encounter that provides an opportunity for palliative care referral. Consultations were identified by encounter stop codes 351 (indicating a hospice consultation) or 353 (indicating a palliative consultation) and Current Procedural Terminology codes 99241 through 99245 or 99251 through 99255.²⁵

We controlled for known or hypothesized covariates, including the surgical subspecialty; the patient’s age, sex, race/ethnicity, and illness burden; and the respondent’s relationship to the patient. Age is strongly associated with surgical mortality²⁶ and end-of-life outcomes.^17,23 End-of-life care experiences are known to vary by race/ethnicity.¹⁷ We calculated Charlson Comorbidity Index (CCI) scores²⁷ in the 12 months before surgery as proxy for illness burden, a known factor associated with surgical mortality.²⁸ We characterized the patient’s area of residence; marital status; and the presence of serious illness, such as cancer, dementia, cardiopulmonary failure, and end-stage renal disease. These diagnoses were identified from inpatient admissions that occurred up to 12 months before surgery and categorized using a previously developed hierarchy.²³

We estimated 1-year survival after high-risk surgery using Kaplan-Meier methods. We calculated proportions for mortality and palliative care use by surgical subspecialty. We present group comparisons using standardized mean differences, which are less sensitive to large sample sizes than tests of significance.²⁹

To examine the association between palliative care and end-of-life outcomes, we used a multivariable generalized linear model, assuming a facility-level random intercept to account for correlation of care practices within VAMC. We fitted separate models for each BFS outcome: overall care, communication, and support. Missing BFS data (<2% of the total) was imputed following the Veteran Experience Center hot-deck imputation approach.³⁰ Covariates included the patient’s age (<65 years and ≥65 years), race/ethnicity (white, black, or other), the BFS respondent’s relationship to the patient (spouse, child, parent, sibling, or other), CCI score (0, 1-3, or ≥4 points, with higher scores indicating higher illness burdens), and the surgical subspecialty. We imputed missing data for covariates (<5%) with 10 multiple imputations,³¹ with chain equations using all covariates.³² Regression parameters estimates and SDs for the 10 imputed data sets were combined using the Rubin rules.³⁰ We adjusted for survey nonresponse using inverse probability weights from a logistic regression that anticipates BFS response from covariates.¹⁸ After assessing collinearity and potential interactions, we evaluated the significance of the model with covariates as fixed effects and assessed goodness of fit. Analyses were performed using R version 3.3.2 (R Foundation for Statistical Computing), and any P value less than .05 was considered statistically significant.

We identified 95 204 patients who underwent high-risk surgical procedures at 129 VAMCs between January 1, 2012, and December 31, 2015. Typically, patients who underwent high-risk operations were male (91 950 [96.6%]), non-Hispanic white individuals (72 554 [76.2%]), and older than 65 years (69 278 [72.8%]). Postoperative mortality was 3.6% (3402 of 95 204 patients) at 30 days, 6.0% (5740 of 95 204 patients) at 90 days, and 12.3% (11 669 of 95 204 patients) at 1 year. Of 5740 individuals who had died by 90 days after surgery, 2676 (46.6%) died as inpatients in a VAMC. Families of 1124 decedents (42.0%) responded to the BFS (eTable 3 in the Supplement describes BFS respondent and nonrespondent characteristics). Figure 1 illustrates the flowchart of the analytic sample.

Table 1 includes characteristics for the overall cohort, decedents who died by 90 days, and decedents whose families contributed BFS scores. Compared with the overall cohort, individuals who died by 90 days had more comorbidities and CCI scores of 4 or more (2967 [51.7%] vs 27 821 [29.2%]) and higher prevalence of cancer (2624 [45.7%] vs 28 230 [29.7%]), cardiopulmonary failure (1581 [27.5%] vs 16 748 [17.6%]), end-stage renal disease (17 431 [8.3%] vs 3869 [4.1%]), and dementia (305 [5.3%] vs 1852 [1.9%]).

Cardiothoracic procedures (in 31 157 patients [32.7%]) and vascular procedures (23 517 [24.7%]) were the most frequently performed procedures in the overall cohort. Among individuals who died within 90 days, the most common type of procedure was intestinal (1376 [24.0%]). We observed considerable differences in mortality rates across surgical subspecialties. Patients who underwent neurosurgical operations had the highest 90-day mortality rate (875 of 6223 patients [14.1%] vs 5740 of 95204 patients [6.0%] across all types), while patients who underwent urologic operations had the lowest rate (278 of 7226 [3.8%]).

Unadjusted proportions for BFS overall care score (excellent vs less than excellent) and communication and support factors are presented in Table 2. A total of 589 BFS respondents (52.4%) rated overall end-of-life care as excellent. Two-thirds scored communication (780 of 1124 [69.4%]) and support (742 of 1124 [66.1%]) as excellent. There were no differences by surgical subspecialty, illness burden, or the respondent’s relationship to the patient. A lower proportion of the families of black patients rated end-of-life care as excellent (65 of 161 [40.4%] vs 448 of 830 [54.0%] for white patients). A higher proportion of families of patients older than 65 years rated overall end-of-life care as excellent (467 of 852 [54.8%] vs 122 of 272 [44.9%]). More families of patients that received palliative care (304 of 535 [56.8%]) rated end-of-life care as excellent than those who did not receive palliative care (285 of 589 [47.3%]). The proportion of excellent ratings were similar when examining palliative care before (54 of 100 [54.0%]) vs after surgery (250 of 435 [57.5%]).

Our mixed-model analysis, which adjusted for both patient-level and facility-level variations, supported associations between palliative consultations and better end-of-life outcomes. Table 3 presents the odds ratios for excellent rating vs all others for each of the 3 BFS outcomes. Controlling for age, race/ethnicity, illness burden, the respondent’s relationship to patient, and the surgical subspecialty, families of decedents who received a palliative consultation were 47% more likely to rate overall end-of-life care as excellent (odds ratio [OR], 1.47 [95% CI, 1.14-1.88]; P = .007) compared with those who did not. The association held true for the communication factor (OR, 1.43 [95% CI, 1.09-1.87]; P = .002) and support factor (OR, 1.31 [95% CI, 1.01-1.79]; P = .045).

In the overall cohort of patients undergoing high-risk surgery, only 3374 patients (3.5%) had a palliative care consultation within the perioperative window; 770 patients (0.8%) received it preoperatively. The median (interquartile range) time to consultation was 12 (1-39) days postoperatively (mean [SD], 13 [28.1] days). Exposure to palliative care was higher among decedents who died within 90 days (1632 patients [29.9%]); however, few had it before surgery (319 [5.6%]). Most palliative consultations (1436 of 1632 [88.0%]) were on the inpatient wards rather than in the outpatient setting.

The frequency of palliative consultations varied by the type of surgery. Figure 2 illustrates 90-day mortality and proportion of palliative care consultations for 8 subspecialties. Patients receiving cardiothoracic surgery had the least exposure to palliative care; 485 of 31 157 (1.6%) received a palliative consultation compared with 3374 of 95 204 (3.5%) for the overall cohort. Of the individuals who died within 90 days who had received cardiothoracic surgery, 18.5% had a palliative consultation (eTable 1 in the Supplement). Neurosurgical procedures were most common. They had the highest 90-day mortality (875 of 6223 [14.1%]) and the highest proportion of palliative care use (569 [9.1%]). Of the individuals who died within 90 days of receiving neurosurgery, 288 of 875 (32.9%) had had a palliative consultation.

We sought to examine the few patients who received preoperative palliative care. After stratifying the overall cohort by the level of illness burden based on CCI, we found that among 770 patients with preoperative palliative consultations, 477 (61.9%) had an illness burden with a CCI of 4 or more, and 4 patients (0.05%) had no comorbidities (defined as a CCI score of 0). These proportions were similar for individuals who died within 90 days. Of 259 patients with preoperative palliative care, 175 had 4 or more comorbidities (67.6%) vs 1 patient who had none (0.04%). These descriptive comparisons suggest that preoperative palliative care targeted patients who were sicker (additional data in eTable 2 in the Supplement).

This study is among the first to examine the influence of palliative care on end-of-life outcomes in a large, national cohort of patients undergoing surgery. We focused on 90-day outcomes as the time horizon for maximal benefit of palliative interventions and postoperative complications.^21,33 Mortality in high-risk surgery ranged from 3.8% to 14.1%, with neurological procedures having the greatest risk among the 8 subspecialties. This may be explained by a larger proportion of emergency rather than elective cranial procedures that confer a greater risk of death.³⁴ Mortality reflected both procedural risk and patients’ clinical status, because decedents, compared with survivors, were older and had higher illness burdens.

We found that end-of-life outcomes among individuals who died after surgery and their association with palliative care were comparable with those dying from serious medical illness.¹⁸ Across all bereaved family respondents in the cohort, 52.4% rated overall end-of-life care as excellent. This proportion is similar to 53% to 59% of families reporting excellent end-of-life care for deceased veterans with cancer, dementia, end-stage renal disease, or cardiopulmonary failure.²³ Consistent with other studies,³⁵ the patient’s older age and white race were associated with better BFS outcomes, reflecting possible cultural and generational differences in the perceptions of end-of-life care.³⁶ Ultimately, our hypothesis that exposure to palliative care is associated with better end-of-life experience held true for all 3 outcomes: overall care, communication, and support provided to individuals who died after surgery in the last month of life.

While the benefits of palliative care were similar to those described in medical literature,^23,25,37 it was relatively underused in the surgical setting. In the cohort with noteworthy perioperative mortality, only 3.5% of patients had a palliative consultation in the perioperative window. Among individuals who died within 90 days, 29.9% had palliative care, contrasted with 52.7% of decedents who died of cancer contemporaneously in VAMCs.³⁸ The VA has mandated national access to palliative care services,¹⁵ and most decedents in medical contexts eventually receive palliative care.^6,39 While we could not ascertain which service line referred the patient, the fact that a palliative consultation occurred a mean of about 2 weeks after the operation suggests that medical as well as surgical teams may be involved in initiating palliative care.

Expanding on current efforts to align surgical decision-making with patient goals, especially for older patients with greater frailty,^9,40 we examined exposure to preoperative palliative care. While less than 1% of the overall cohort had a palliative consultation within 30 days before surgery, a higher proportion of patients in poor health were referred. These findings may reflect surgeons’ recognition of comorbidity^7,10 in line with emerging interventions. Systematic preoperative frailty screening by the surgical team has been found to increase earlier referral to palliative care and reduce surgical mortality.⁷ Patient decision-making may also explain low levels of preoperative palliative care in this cohort. By focusing on patients who already underwent surgical procedures, we potentially missed those who received palliative care consultation and declined surgery.

These results emphasize the possibility that interventions for patients who underwent surgery may be similar to the ones for patients with serious medical illness. Communication and psychosocial support are among the most evidence-based palliative practices to improve end-of-life care.^40,41 A small palliative specialist workforce precludes offering a specialist consultation for all patients who might benefit. Thus, there is an increasing focus on equipping all frontline clinicians with skills to provide primary palliative care, leaving the most complex cases for subspecialist referral. As an example, surgeons or surgical advance practice clinicians may adopt communication tools, such as the Best Case/Worst Case framework⁴² to address palliative needs of patients who are at high risk (eg, those who are frail).⁴³

The Veterans’ Health Administration is taking steps to address some of the barriers to integrating perioperative palliative care, such as clinician training, goals-of-care communication, and access to specialist-palliative care.⁴⁴ Nationally, the Education in Palliative and End-of-Life Care for Veterans curriculum improves primary palliative knowledge and skills,⁴⁵ which can be adopted by surgeons. The VA National Center for Ethics in Healthcare’s Life Sustaining Treatment Decisions Initiative⁴⁵ aims to elicit and document patient preferences, especially prior to high-risk treatments, such as high-risk surgery. Additionally, recent quality-improvement efforts across the Veteran’s Health Administration, such as colocated preoperative and palliative services, may aid in screening patients undergoing high-risk surgery and engaging them in shared decision-making prior to surgery. Although research is needed, these efforts to increase perioperative palliative care support hold potential to improve outcomes.

This study has limitations. Because veterans have worse morbidity than the general population,⁴⁶ these findings are generalizable to patients who are more seriously ill. We captured palliative care through subspecialty consultations but may have missed primary palliative approaches by surgeons. Such care would likely bias results to the null, if both primary and specialist palliative care improves outcomes.⁴⁷ Moreover, we do not account for correlations of clinician care practices nor are able to distinguish whether surgical medical service initiated the palliative consultation. Lastly, the outcomes are limited to respondents of the BFS, which constitutes a small proportion of individuals who died after surgery. Little is known about outcomes for patients who died at home or in other settings. Nonetheless, the study illuminates an important opportunity to improve surgical care.

Consistent with other medical settings, palliative care consultations among patients undergoing high-risk surgery were associated with better patient-focused and family-focused end-of-life outcomes. Yet, palliative care was used in a minority of cases both before and after the operation. These data advocate for clinical practices and policies that support integrating palliative care services and approaches in the perioperative period, such as preoperative frailty screening and shared decision-making regarding surgery. Integrating palliative care into surgical practice offers a promising avenue to benefit patients and families.

Accepted for Publication: October 22, 2019.

Corresponding Author: Maria Yefimova, PhD, RN, Center for Innovation to Implementation, VA Palo Alto Health Care System, 795 Willow Rd, Ste 152-MPD, Menlo Park, CA 94025 (maria.yefimova@va.gov).

Published Online: January 2, 2020. doi:10.1001/jamasurg.2019.5083

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

Concept and design: Yefimova, Aslakson, Gale, Johanning, Shreve, Lorenz.

Acquisition, analysis, or interpretation of data: Yefimova, Yang, Garcia, Boothroyd, Gale, Giannitrapani, Morris, Johanning, Wachterman, Lorenz.

Drafting of the manuscript: Yefimova, Yang, Garcia, Boothroyd, Gale, Lorenz.

Critical revision of the manuscript for important intellectual content: Yefimova, Aslakson, Garcia, Gale, Giannitrapani, Morris, Johanning, Shreve, Wachterman, Lorenz.

Statistical analysis: Yefimova, Yang, Garcia, Boothroyd, Lorenz.

Obtained funding: Lorenz.

Administrative, technical, or material support: Yefimova, Aslakson, Garcia, Gale, Johanning, Shreve, Lorenz.

Supervision: Aslakson, Giannitrapani, Johanning, Wachterman, Lorenz.

Conflict of Interest Disclosures: Dr Johanning reported a patent to FutureAssure LLC pending and licensed. No other disclosures were reported.

Funding/Support: This study was supported by the Department of Veterans Affairs Office of Geriatrics and Extended Care and Operational Palliative Care Quality Improvement Resource Center.

Role of the Funder/Sponsor: The funder had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Disclaimer: The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the US government.

Meeting Presentation: This paper was presented at the Association of VA Surgeons 2019 Annual Meeting; April 27, 2019; Seattle, Washington.

Additional Information: Randall C. Gale, DrPH, is deceased.