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Less Aggressive Post-TBI Care in Elders Doesn’t Boost Mortality

September 26, 2017

By Anne Harding

NEW YORK (Reuters Health) – Providing high-quality palliative and end-of-life care, rather than aggressive treatment, to older patients with traumatic brain injury (TBI) does not increase mortality, new data show.

Resistance, by surgeons and other care providers, to emphasizing palliative and end-of-life care in a hospital setting is largely based on concerns that it will increase mortality, Dr. Elizabeth J. Lilley of The Center for Surgery and Public Health in Boston, the study’s first author, told Reuters Health in a telephone interview. “What we found was that actually was not true. The hospitals that had the lowest mortality actually had the best end-of-life care,” she said.

People age 65 or older account for nearly a quarter of all trauma admissions, Dr. Lilley and her team noted in a report online September 20 in JAMA Surgery. Prognosis for older patients after severe TBI is poor, they add, with one-year mortality rates above 80%. “As a result, trauma surgeons are increasingly tasked with delivering end-of-life care to older patients,” they add.

In-hospital mortality is the quality benchmark for trauma centers, the authors write, but this does not take into account patient preferences for receiving palliative care, avoiding high-intensity treatment and enrolling in hospice.

Dr. Lilley and her colleagues looked at 34,691 Medicare patients (median age, 79) hospitalized with TBI in 2005-2011 at 363 hospitals. Primary outcomes were intensity of treatment - the use of aggressive interventions such as tracheostomy and gastrostomy - and processes of care, or the percentage of patients who consulted with a palliative care specialist or enrolled in hospice before death.

At the 91 hospitals classified as low-mortality, 39.8% of TBI patients died before discharge, versus 52.7% at the other hospitals.

Among patients who survived to discharge, 30-day mortality after discharge was 26.6% for the low-mortality hospitals and 20.8% for the other hospitals. But cumulative mortality - in-hospital and 30-day postdischarge mortality combined - was 55.8% for the low-mortality hospitals and 62.5% for the others. Both differences were statistically significant.

Among patients who died in the hospital, 4.0% had gastrostomy placement, 6.1% tracheostomy placement, 17.6% received palliative care consultations, and 2% enrolled in hospice. Among patients who died after discharge, 20.8% had gastrostomy placement, 22.2% tracheostomy placement, 14.0% palliative care consultations, and 58.0% enrolled in hospice.

The patients who died after discharge from the low-mortality hospitals had a shorter length of stay and spent less time in the intensive care unit. They were also significantly less likely to have gastrostomy (adjusted odds ratio, 0.61) or tracheostomy (aOR, 0.71), and significantly more likely to enroll in hospice (aOR, 1.72). They were less likely to receive a palliative care consultation.

“There are a growing number of trauma and acute care surgeons who recognize the value of high-quality end-of-life care,” Dr. Lilley said. “Part of what we need to learn and what we need to do as a community of professionals is to figure out how do we determine prognosis and how do we share that prognosis with family members.” While some will prefer a more aggressive, life-sustaining approach to treatment, she added, many will likely opt for more supportive treatment if given the choice.

She added: “We need to have validated measures for end-of-life care in surgery, and it’s the only way we ever will improve end-of-life care.”

Dr. Emily Finlayson of the University of California, San Francisco, who co-authored an accompanying editorial, spoke with Reuters Health by telephone. She noted that the fact that patients at low-mortality hospitals who did end up dying underwent less “poking and prodding” suggests “these hospitals are really better at figuring out what kind of care is appropriate” and at triaging patients with a worse prognosis toward more supportive care. “I think it really sets up a model where you can be more supportive and less aggressive with care and achieve better outcomes with patients.”

The open question is why some hospitals have cultures that foster more aggressive care, and others less, she added. “There’s that culture piece, which is really so heterogeneous in this country. That really drives the variation in end-of-life care. That’s really the next mountain to climb with this kind of research.”

Dr. Finlayson noted that the Coalition for Quality in Geriatric Surgery, supported by the American College of Surgeons and the Hartford Foundation, is developing methods for measuring the quality of end-of-life care that will be released in 2019. “One critical piece of this initiative is to create more-robust metrics of measuring patient preferences for end-of-life care and making sure that these preferences are known to the entire care team,” she said.


JAMA Surg 2017.

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