534514 research-article2014
PMJ0010.1177/0269216314534514Palliative MedicineKarlekar et al.
Original Article
Utilization and determinants of palliative care in the trauma intensive care unit: Results of a national survey
Palliative Medicine 2014, Vol. 28(8) 1062–1068 © The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0269216314534514 pmj.sagepub.com
Mohana Karlekar1, Bryan Collier2, Abby Parish3, Lori Olson4 and Tom Elasy1
Abstract Background: There is a paucity of data evaluating utilization of palliative care in trauma intensive care units. Aim: We sought to determine current indications and determinants of palliative care consultation in the trauma intensive care units. Design: Using a cross-sectional assessment, we surveyed trauma surgeons to understand indications, benefits, and barriers trauma surgeons perceive when consulting palliative care. Setting/participants: A total of 1232 surveys were emailed to all members of the Eastern Association for the Surgery of Trauma. Results: A total of 362 providers responded (29% response rate). Majority of respondents were male (n = 287, 80.2%) and practiced in Level 1 (n = 278, 77.7%) trauma centers. Most common indicators for referral to palliative care were expected survival 1 week to 1 month, multisystem organ dysfunction >3 weeks, minimal neurologic responsiveness >1 week, and referral to hospice. In post hoc analysis, there was a significant difference in frequency of utilization of palliative care when respondents had access to boardcertified palliative care physicians (χ2 = 56.4, p < 0.001). Although half of the respondents (n = 199, 55.6%) reported palliative care consults beneficial all or most of the time, nearly still half (n = 174, 48.6%) felt palliative care was underutilized. Most frequent barriers to consultation included resistance from families (n = 144, 40.2%), concerns that physicians were “giving up” (n = 109, 30.4%), and miscommunication of prognosis (n = 98, 27.4%) or diagnosis (n = 58, 16.2%) by the palliative care physician. Conclusion: Although a plurality of trauma surgeons reported palliative care beneficial, those surveyed indicate that palliative care is underutilized. Barriers identified provide important opportunities to further appropriate utilization of palliative care services. Keywords Utilization, trauma, palliative care, end of life, intensive care unit
What is already known about the topic? •• Utilization of palliative care (PC) for the care of the trauma patient is inconsistent at best. Trauma surgeons are unaware of the benefits PC can offer patients, families, and trauma teams. Objective triggers to consult PC are needed. What this paper adds? •• This paper identifies specific deterrents to consult PC in the care of the trauma patients. About half of the trauma surgeons report PC consults beneficial all or most of the time, yet 48.6% respondents felt that PC was underutilized. Implications for practice, theory, or policy •• Trauma surgeons and PC teams need to partner more closely, so that trauma teams better understand the scope of PC services available and specific benefits to their patients with the goal of providing an objective framework where PC is routinely integrated into the care of the trauma patient.
1Vanderbilt
University, Nashville, TN, USA Roanoke Memorial Hospital, Roanoke, VA, USA 3School of Nursing, Vanderbilt University, Nashville, TN, USA 4University of Kansas Medical Center, Kansas City, KS, USA 2Carilion
Corresponding author: Mohana Karlekar, Vanderbilt University, Medical Center East, North Tower, Suite 4, Nashville, TN 37232, USA. Email: [email protected]
Downloaded from pmj.sagepub.com at The University of Edinburgh on June 18, 2015
1063
Karlekar et al.
Introduction Internationally, there is a growing body of evidence recognizing the need for more research and integration of palliative care (PC) into the various health-care systems.1 However, there remains a paucity of published data describing the intersection of palliative and trauma both in the United States and internationally. The American College of Surgeons published a landmark statement on end-of-life (EOL) care, “Principles Guiding Care at the End of Life” in 1998 that resulted in the creation of a PC Task Force whose aim was to improve the knowledge level of all surgeons in EOL care.2 More than 10 years after publication of this important document, baseline knowledge of PC among surgeons in residency training remains poor. Klaristenfeld et al.3 surveyed junior and senior surgical residents in a major academic center and found that 30 Not reported 8 (2.2) Practice location Urban 255 (71.2) 75 (20.9) Suburban 28 (7.8) Rural Not reported 0 (0) Trauma designation Level 1 278 (77.7) Level 2 66 (18.4) Level 3 7 (2.0) 7 (2.0) Other Not reported 0 (0) Institution 268 (74.9) Academic 88 (24.6) Non-academic Not reported 2 (0.6) Number of trauma patients admitted to institution in last 12 months 47 (13.1) 7000 Not reported 5 (1.4)
Expected survival was often cited as a determinant of PC consults with expected survival of 1 week to 1 month (n = 169, 47.2%), 2 days to 1 week (n = 161, 45.0%), and 1–4 months (n = 150, 41.9%) emerging as the most common determinants. Organ dysfunction, particularly multisystem dysfunction at days 8–21 (n = 146, 40.8%) or day 22 or more (n = 160, 41.2%), was also commonly cited as a determinant. Cognitive neurological injury including minimal responsiveness at hospital days 8–31 (n = 165, 46.1%) and hospital day 31 or more (n = 152, 42.5%) was also frequently noted as an indicator for PC consult. Difficult psychosocial situations were commonly considered indicators for PC with hospice referrals (n = 202, 56.4%), family conflict in decision making (n = 190, 53.1%), ethical conflict (n = 184, 51.4%), and lack of identifiable decision maker (n = 144, 40.2%) being the most common determinants. Indications for referral to PC are summarized in Table 4.
Respondents (N = 358), n (%)
Palliative team Palliative team compositiona Palliative care APN or PA 211 (58.9) 204 (57.0) Board-certified palliative care physician Social worker 162 (45.3) Chaplain 124 (34.6) Ethics consultant 104 (29.1) Hospice physician 96 (26.8) Utilization and perceptions of palliative care Number of times respondent consulted palliative care in last 12 months 0 patients 74 (20.7) 1–5 patients 114 (31.8) 6–10 patients 75 (20.9) 11–20 patients 58 (16.2) 21–30 patients 18 (5.0) >30 patients 13 (3.6) How often were palliative care consults beneficial in the past 12 months None of the time 54 (15.1) Some of the time 72 (20.1) Half of the time 7 (2.0) Most of the time 126 (35.2) All of the time 73 (20.4) Palliative medicine at my institution is Over utilized 8 (2.2) Appropriately utilized 108 (30.2) Underutilized 174 (48.6) Not utilized 8 (2.2) Not available 56 (15.6) APN: Advance Practice Nurses; PA: Physician’s Assistants. aParticipants could select more than one response.
Discussion Our findings represent the first systematic attempt to define utilization and determinants of PC by trauma providers. Our findings show that trauma surgeons surveyed are more likely to refer their patients to PC when there is an available PC Board-certified/eligible physician on the PC team, and when the overall prognosis is poor. However, our trauma surgeons surveyed worried that PC providers might miscommunicate information pertaining to prognosis and diagnosis. In addition, they reported a reluctance to refer to PC, concerned that patients and families will feel as if the trauma team was “giving up.” These findings are consistent with previously published studies exploring surgeons’ attitudes and beliefs on PC in the surgical population. Tilden et al.,15 in their open-ended interviews of trauma and burn surgeons, found that surgeons generally consulted PC in situations where they felt
Downloaded from pmj.sagepub.com at The University of Edinburgh on June 18, 2015
1066
Palliative Medicine 28(8)
Table 3. Benefits and barriers to use of palliative care in the trauma ICU.
Table 4. Indicators for palliative care consults in the trauma ICU.
Survey item
Indicator
Survey respondents (N = 358), n (%)
Benefits Benefits of palliative care consults for the trauma servicea Assistance with end-of-life 261 (72.9%) issues Decrease in futility 218 (60.9%) Communication of prognosis 177 (49.4%) Communication of diagnosis 97 (27.1%) Decrease in ICU stay 71 (19.8%) Decrease in LOS 59 (16.5%) Benefits of palliative care consults for patients and familiesa Assistance with end-of-life 279 (77.9%) issues Grief counseling 221 (61.7%) Improved communication of 207 (57.8%) prognosis Spiritual support 172 (48.0%) Improved communication of 130 (36.3%) diagnosis Barriers Barriers/disadvantages to consulting palliative medicine for the trauma servicea Concern patients and 103 (28.8%) families think I am “giving up” Lack of availability 93 (26.0%) Lack of timely access 79 (22.0%) Concern of loss of autonomy 28 (7.8%) in patient care Increase in length of ICU 8 (2.2%) stay Increase in length of hospital 6 (1.7%) stay Delay in surgical critical care 5 (1.4%) Barriers/disadvantages to consulting palliative medicine for patients and familiesa Family resistance 144 (40.2%) Concern that I am “giving 109 (30.4%) up” on the patient Miscommunication regarding 98 (27.4%) prognosis Miscommunication regarding 58 (16.2%) diagnosis Legal issues (e.g. fear of 26 (7.3%) lawsuit) ICU: intensive care unit; LOS: length of stay. aParticipants could select more than one response.
the patient would eventually die from injuries or if the patient’s condition was more likely to be chronic with little chance of improvement. They were reluctant to consult PC when prognosis was uncertain, as they worried that families might feel as if they were “giving up on the patient.”15 The perceived family resistance to PC may reflect the
Expected survivala 4 months In-house mortality > 50% Not a determinant Organ dysfunctiona Single organ, days 1–7 Single organ, days 8–21 Single organ, day 22 or more Two organs, day 1–7 Two organs, day 8–21 Two organs, day 22 or more Multisystem, days 1–7 Multisystem, days 8–21 Multisystem, day 22 or more Not a determinant Cognitive neurological injurya Minimally responsive, days 1–7 Minimally responsive, days 8–30 Minimally responsive, day 31 or more One-step commands, day 14 Not a determinant Difficult psychosocial situationsa Ethical conflict Family conflict in decision making Lack of identifiable decision maker Hospice referrals Current/previous history of suicide attempt Not a determinant
Respondents (N = 358), n (%) 114 (31.8) 161 (45.0) 169 (47.2) 150 (41.9) 50 (14.0) 106 (29.6) 83 (23.2) 9 (2.5) 17 (4.7) 26 (7.3) 22 (6.1) 45 (12.6) 59 (16.5) 93 (26.0) 146 (40.8) 160 (41.2) 143 (39.9) 66 (18.4) 165 (46.1) 152 (42.5) 32 (8.9) 123 (34.4) 184 (51.4) 190 (53.1) 144 (40.2) 202 (56.4) 37 (10.3) 91 (25.4)
ICU: intensive care unit. aParticipants could select more than one response.
misconception that PC is not delivered simultaneously with an aggressive plan of care that focuses on prolonging life. It may also suggest that trauma surgeons are unaware of the true scope of services provided by PC teams. Finally, this perception may indicate a general discomfort surgeons have in conducting goals of care discussions or introducing the concept of PC to patients and families. Based on published literature, it seems that different clinicians vary in their opinions of how different clinicians communicate prognosis to patients and families in the ICU setting. Aslakson et al.16 surveyed greater than 100 clinicians in three different SICUs and found clinicians surveyed (ICU nurses, intensive care physicians and surgeons) all had very different perceptions of how one another
Downloaded from pmj.sagepub.com at The University of Edinburgh on June 18, 2015
1067
Karlekar et al. communicated prognosis. Intensivists and critical care nurses, though satisfied with the adequacy of their own communication, seemed dissatisfied with the adequacy of communication by surgeons early on in a patients’ course with respect to prognosis.16 Trauma surgeons’ perceptions of PC communication based on our survey results appear contradictory. Although nearly half of the respondents (n = 177, 49.4%) surveyed indicated that there was improved communication of prognosis with PC consultation, with 27% (n = 97) reporting improved communication of diagnosis, respondents surveyed, however, also indicated that PC teams may miscommunicate information to patients and families citing this as a barrier to consult PC. Specifically, 27.4% (n = 98) of the respondents indicated that PC teams may miscommunicate prognostic information to patients and families, and 16.2% (n = 58) of the respondents indicated that PC teams will miscommunicate diagnostic information to patients and families. These dissonant views may be explained by individual surgeons’ perceptions and overall unfamiliarity with PC. Our survey results indicate that 20% of the trauma surgeons reported no availability of PC services in their institution and only 55% reported PC consults as being beneficial all or most of the time. This is not surprising as there is a relative shortage of nationwide PC service in the United States.17 Trauma surgeons therefore may be unaware of the scope of PC services and benefits to patients, families, and trauma teams. Interestingly, our respondents seemed unaware of the potential impact of PC on ICU LOS based on survey responses. Only 16.5% (n = 59) respondents felt PC use decreased ICU LOS, though Mosenthal et al. have published data documenting a decrease in median LOS in trauma ICUs by 2 days when PC is consulted without any significant change in mortality.4,18 Our study has several limitations. First, our response rate (29%) was suboptimal, as only 358 of 1232 of members completed the survey.19 Second, there was likely response bias. Trauma providers more knowledgeable and interested in PC may have been more likely to respond as compared to providers less familiar with PC. Surveys were emailed using the EAST database. It is possible that this database did not have accurate emails for all of their members potentially resulting in a non-response bias. Next, our survey relied on providers’ recollection of their past practices, leading to possible recall bias. Because our survey results reflect determinants of PC by trauma providers across the Eastern United States only, results are potentially not generalizable to trauma providers across the United States or across the world. While there was a concerted effort to allow open-ended questions in each section, there was a lower response rate for these questions limiting the ability to either summarize or infer from responses. Finally, we surveyed trauma surgeons’ referral practices based on patient outcomes, injury patterns, and
associated psychosocial factors. We did not take into consideration other factors that can impact referral practices such as institutional support, PC team characteristics such as affability, proficiency, and availability of services. Our results highlight the need for PC and trauma providers to partner in establishing a clinical model to incorporate PC into the trauma ICU taking into account the availability and needs of both teams. We believe that integration of PC teams into the care of the trauma patients will provide an extra layer of support to patients, families, and providers regarding goals of care and communication.
Conclusion It is notable that the majority of trauma providers do find consultation with a PC provider beneficial in the care of their patients. However, significant potential barriers to consultation exist, which provide future opportunities to improve the appropriate utilization of PC. Declaration of conflicting interests The authors declare that there is no conflict of interest.
Funding This research received no specific grants or funding from any public, commercial, or not-for-profit sectors.
References 1. Centeno C. International research: comparison and collaboration to understand and promote palliative care. Palliat Med 2014; 28(2): 99–100. 2. Statement on principles guiding care at the end of life. American College of Surgeons’ Committee on Ethics. Bull Am Coll Surg 1998; 83(4): 46. 3. Klaristenfeld DD, Harrington DT and Miner TJ. Teaching palliative care and end of life issues: a core curriculum for surgical residents. Ann Surg Oncol 2007; 14: 1801–1806. 4. Mosenthal AC, Murphy PA, Barker LK, et al. Changing the culture around end of life care in the trauma intensive care unit. J Trauma 2008; 64: 1587–1593. 5. Lamba S, Murphy P, McVicker S, et al. Changing end of life care practice for liver transplant service patients: structured palliative care intervention in the surgical intensive care unit. J Pain Symptom Manage 2012; 44: 508–519. 6. Mosenthal AC and Murphy PA. Interdisciplinary model for palliative care in the trauma and surgical intensive care unit: Robert Wood Johnson Foundation demonstration project for improving palliative care in the intensive care unit. Crit Care Med 2006; 34: S399–S403. 7. Mosenthal AC, Weissman DE, Curtis JR, et al. Integrating palliative care in the surgical and trauma intensive care unit: a report from the Improving Palliative Care in the Intensive Care Unit (IPAL-ICU) Project Advisory Board and the Center to Advance Palliative Care. Crit Care Med 2012; 40(4): 1199–1206.
Downloaded from pmj.sagepub.com at The University of Edinburgh on June 18, 2015
1068
Palliative Medicine 28(8)
8. McCahill LE, Dunn GP, Mosenthal AC, et al. Palliation as a core surgical principle: part 1. J Am Coll Surg 2004; 199: 149–160. 9. Baggs JG, Norton SA, Schmitt MH, et al. Intensive care unit cultures and end of life decision making. J Crit Care 2007; 22: 159–168. 10. Dunn GP. Surgical palliative care: recent trends and developments. Surg Clin North Am 2011; 91: 277–292. 11. The 2nd Trauma Program. The art of communicating with families of trauma victims, http://www.adventuresincaring. org/education/2nd-trauma-program/ (accessed 16 April 2012). 12. Bradley CT and Brasel KJ. Developing guidelines that identify patients who would benefit from palliative care services in the surgical intensive care unit. Crit Care Med 2009; 37: 1147–1148. 13. Buchman TG, Cassell J, Ray S, et al. Who should manage the dying patient? Rescue, shame, and the surgical dilemma. J Am Coll Surg 2002; 194(5): 665–673. 14. Cassell J, Buchman TG, Streat S, et al. Surgeons, intensivists and the covenant of care: administrative models and
values affecting care at the end of life—updated. Crit Care Med 2003; 31: 1551–1557. 15. Tilden LB, Williams BR, Tucker RO, et al. Surgeon’s attitudes and practices in utilization of palliative and supportive care services for patients with a sudden advanced illness. J Palliat Med 2009; 12(11): 1039–1040. 16. Aslakson RA, Wyskiel R, Shaeffer D, et al. Surgical intensive care unit clinician estimates of the adequacy of communication regarding prognosis. Crit Care 2010; 14: R218. 17. Lupu D. Estimation of palliative medicine and hospice physician workforce shortage. J Pain Symptom Manage 2010; 40(6): 899–911. 18. Aslakson RA, Cheng J, Vollenweider D, et al. Evidencebased palliative care in the intensive care unit: a systematic review of interventions. J Palliat Med 2014; 17: 219–236. 19. Kusano AS, Kenworthy-Heinige T and Thomas CR Jr. Survey of bereavement practices of cancer care and palliative care physicians in the Pacific Northwest United States. J Oncol Pract 2012; 8(5): 275–281.
Downloaded from pmj.sagepub.com at The University of Edinburgh on June 18, 2015
PMJ0010.1177/0269216314534514Palliative MedicineKarlekar et al.
Original Article
Utilization and determinants of palliative care in the trauma intensive care unit: Results of a national survey
Palliative Medicine 2014, Vol. 28(8) 1062–1068 © The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0269216314534514 pmj.sagepub.com
Mohana Karlekar1, Bryan Collier2, Abby Parish3, Lori Olson4 and Tom Elasy1
Abstract Background: There is a paucity of data evaluating utilization of palliative care in trauma intensive care units. Aim: We sought to determine current indications and determinants of palliative care consultation in the trauma intensive care units. Design: Using a cross-sectional assessment, we surveyed trauma surgeons to understand indications, benefits, and barriers trauma surgeons perceive when consulting palliative care. Setting/participants: A total of 1232 surveys were emailed to all members of the Eastern Association for the Surgery of Trauma. Results: A total of 362 providers responded (29% response rate). Majority of respondents were male (n = 287, 80.2%) and practiced in Level 1 (n = 278, 77.7%) trauma centers. Most common indicators for referral to palliative care were expected survival 1 week to 1 month, multisystem organ dysfunction >3 weeks, minimal neurologic responsiveness >1 week, and referral to hospice. In post hoc analysis, there was a significant difference in frequency of utilization of palliative care when respondents had access to boardcertified palliative care physicians (χ2 = 56.4, p < 0.001). Although half of the respondents (n = 199, 55.6%) reported palliative care consults beneficial all or most of the time, nearly still half (n = 174, 48.6%) felt palliative care was underutilized. Most frequent barriers to consultation included resistance from families (n = 144, 40.2%), concerns that physicians were “giving up” (n = 109, 30.4%), and miscommunication of prognosis (n = 98, 27.4%) or diagnosis (n = 58, 16.2%) by the palliative care physician. Conclusion: Although a plurality of trauma surgeons reported palliative care beneficial, those surveyed indicate that palliative care is underutilized. Barriers identified provide important opportunities to further appropriate utilization of palliative care services. Keywords Utilization, trauma, palliative care, end of life, intensive care unit
What is already known about the topic? •• Utilization of palliative care (PC) for the care of the trauma patient is inconsistent at best. Trauma surgeons are unaware of the benefits PC can offer patients, families, and trauma teams. Objective triggers to consult PC are needed. What this paper adds? •• This paper identifies specific deterrents to consult PC in the care of the trauma patients. About half of the trauma surgeons report PC consults beneficial all or most of the time, yet 48.6% respondents felt that PC was underutilized. Implications for practice, theory, or policy •• Trauma surgeons and PC teams need to partner more closely, so that trauma teams better understand the scope of PC services available and specific benefits to their patients with the goal of providing an objective framework where PC is routinely integrated into the care of the trauma patient.
1Vanderbilt
University, Nashville, TN, USA Roanoke Memorial Hospital, Roanoke, VA, USA 3School of Nursing, Vanderbilt University, Nashville, TN, USA 4University of Kansas Medical Center, Kansas City, KS, USA 2Carilion
Corresponding author: Mohana Karlekar, Vanderbilt University, Medical Center East, North Tower, Suite 4, Nashville, TN 37232, USA. Email: [email protected]
Downloaded from pmj.sagepub.com at The University of Edinburgh on June 18, 2015
1063
Karlekar et al.
Introduction Internationally, there is a growing body of evidence recognizing the need for more research and integration of palliative care (PC) into the various health-care systems.1 However, there remains a paucity of published data describing the intersection of palliative and trauma both in the United States and internationally. The American College of Surgeons published a landmark statement on end-of-life (EOL) care, “Principles Guiding Care at the End of Life” in 1998 that resulted in the creation of a PC Task Force whose aim was to improve the knowledge level of all surgeons in EOL care.2 More than 10 years after publication of this important document, baseline knowledge of PC among surgeons in residency training remains poor. Klaristenfeld et al.3 surveyed junior and senior surgical residents in a major academic center and found that 30 Not reported 8 (2.2) Practice location Urban 255 (71.2) 75 (20.9) Suburban 28 (7.8) Rural Not reported 0 (0) Trauma designation Level 1 278 (77.7) Level 2 66 (18.4) Level 3 7 (2.0) 7 (2.0) Other Not reported 0 (0) Institution 268 (74.9) Academic 88 (24.6) Non-academic Not reported 2 (0.6) Number of trauma patients admitted to institution in last 12 months 47 (13.1) 7000 Not reported 5 (1.4)
Expected survival was often cited as a determinant of PC consults with expected survival of 1 week to 1 month (n = 169, 47.2%), 2 days to 1 week (n = 161, 45.0%), and 1–4 months (n = 150, 41.9%) emerging as the most common determinants. Organ dysfunction, particularly multisystem dysfunction at days 8–21 (n = 146, 40.8%) or day 22 or more (n = 160, 41.2%), was also commonly cited as a determinant. Cognitive neurological injury including minimal responsiveness at hospital days 8–31 (n = 165, 46.1%) and hospital day 31 or more (n = 152, 42.5%) was also frequently noted as an indicator for PC consult. Difficult psychosocial situations were commonly considered indicators for PC with hospice referrals (n = 202, 56.4%), family conflict in decision making (n = 190, 53.1%), ethical conflict (n = 184, 51.4%), and lack of identifiable decision maker (n = 144, 40.2%) being the most common determinants. Indications for referral to PC are summarized in Table 4.
Respondents (N = 358), n (%)
Palliative team Palliative team compositiona Palliative care APN or PA 211 (58.9) 204 (57.0) Board-certified palliative care physician Social worker 162 (45.3) Chaplain 124 (34.6) Ethics consultant 104 (29.1) Hospice physician 96 (26.8) Utilization and perceptions of palliative care Number of times respondent consulted palliative care in last 12 months 0 patients 74 (20.7) 1–5 patients 114 (31.8) 6–10 patients 75 (20.9) 11–20 patients 58 (16.2) 21–30 patients 18 (5.0) >30 patients 13 (3.6) How often were palliative care consults beneficial in the past 12 months None of the time 54 (15.1) Some of the time 72 (20.1) Half of the time 7 (2.0) Most of the time 126 (35.2) All of the time 73 (20.4) Palliative medicine at my institution is Over utilized 8 (2.2) Appropriately utilized 108 (30.2) Underutilized 174 (48.6) Not utilized 8 (2.2) Not available 56 (15.6) APN: Advance Practice Nurses; PA: Physician’s Assistants. aParticipants could select more than one response.
Discussion Our findings represent the first systematic attempt to define utilization and determinants of PC by trauma providers. Our findings show that trauma surgeons surveyed are more likely to refer their patients to PC when there is an available PC Board-certified/eligible physician on the PC team, and when the overall prognosis is poor. However, our trauma surgeons surveyed worried that PC providers might miscommunicate information pertaining to prognosis and diagnosis. In addition, they reported a reluctance to refer to PC, concerned that patients and families will feel as if the trauma team was “giving up.” These findings are consistent with previously published studies exploring surgeons’ attitudes and beliefs on PC in the surgical population. Tilden et al.,15 in their open-ended interviews of trauma and burn surgeons, found that surgeons generally consulted PC in situations where they felt
Downloaded from pmj.sagepub.com at The University of Edinburgh on June 18, 2015
1066
Palliative Medicine 28(8)
Table 3. Benefits and barriers to use of palliative care in the trauma ICU.
Table 4. Indicators for palliative care consults in the trauma ICU.
Survey item
Indicator
Survey respondents (N = 358), n (%)
Benefits Benefits of palliative care consults for the trauma servicea Assistance with end-of-life 261 (72.9%) issues Decrease in futility 218 (60.9%) Communication of prognosis 177 (49.4%) Communication of diagnosis 97 (27.1%) Decrease in ICU stay 71 (19.8%) Decrease in LOS 59 (16.5%) Benefits of palliative care consults for patients and familiesa Assistance with end-of-life 279 (77.9%) issues Grief counseling 221 (61.7%) Improved communication of 207 (57.8%) prognosis Spiritual support 172 (48.0%) Improved communication of 130 (36.3%) diagnosis Barriers Barriers/disadvantages to consulting palliative medicine for the trauma servicea Concern patients and 103 (28.8%) families think I am “giving up” Lack of availability 93 (26.0%) Lack of timely access 79 (22.0%) Concern of loss of autonomy 28 (7.8%) in patient care Increase in length of ICU 8 (2.2%) stay Increase in length of hospital 6 (1.7%) stay Delay in surgical critical care 5 (1.4%) Barriers/disadvantages to consulting palliative medicine for patients and familiesa Family resistance 144 (40.2%) Concern that I am “giving 109 (30.4%) up” on the patient Miscommunication regarding 98 (27.4%) prognosis Miscommunication regarding 58 (16.2%) diagnosis Legal issues (e.g. fear of 26 (7.3%) lawsuit) ICU: intensive care unit; LOS: length of stay. aParticipants could select more than one response.
the patient would eventually die from injuries or if the patient’s condition was more likely to be chronic with little chance of improvement. They were reluctant to consult PC when prognosis was uncertain, as they worried that families might feel as if they were “giving up on the patient.”15 The perceived family resistance to PC may reflect the
Expected survivala 4 months In-house mortality > 50% Not a determinant Organ dysfunctiona Single organ, days 1–7 Single organ, days 8–21 Single organ, day 22 or more Two organs, day 1–7 Two organs, day 8–21 Two organs, day 22 or more Multisystem, days 1–7 Multisystem, days 8–21 Multisystem, day 22 or more Not a determinant Cognitive neurological injurya Minimally responsive, days 1–7 Minimally responsive, days 8–30 Minimally responsive, day 31 or more One-step commands, day 14 Not a determinant Difficult psychosocial situationsa Ethical conflict Family conflict in decision making Lack of identifiable decision maker Hospice referrals Current/previous history of suicide attempt Not a determinant
Respondents (N = 358), n (%) 114 (31.8) 161 (45.0) 169 (47.2) 150 (41.9) 50 (14.0) 106 (29.6) 83 (23.2) 9 (2.5) 17 (4.7) 26 (7.3) 22 (6.1) 45 (12.6) 59 (16.5) 93 (26.0) 146 (40.8) 160 (41.2) 143 (39.9) 66 (18.4) 165 (46.1) 152 (42.5) 32 (8.9) 123 (34.4) 184 (51.4) 190 (53.1) 144 (40.2) 202 (56.4) 37 (10.3) 91 (25.4)
ICU: intensive care unit. aParticipants could select more than one response.
misconception that PC is not delivered simultaneously with an aggressive plan of care that focuses on prolonging life. It may also suggest that trauma surgeons are unaware of the true scope of services provided by PC teams. Finally, this perception may indicate a general discomfort surgeons have in conducting goals of care discussions or introducing the concept of PC to patients and families. Based on published literature, it seems that different clinicians vary in their opinions of how different clinicians communicate prognosis to patients and families in the ICU setting. Aslakson et al.16 surveyed greater than 100 clinicians in three different SICUs and found clinicians surveyed (ICU nurses, intensive care physicians and surgeons) all had very different perceptions of how one another
Downloaded from pmj.sagepub.com at The University of Edinburgh on June 18, 2015
1067
Karlekar et al. communicated prognosis. Intensivists and critical care nurses, though satisfied with the adequacy of their own communication, seemed dissatisfied with the adequacy of communication by surgeons early on in a patients’ course with respect to prognosis.16 Trauma surgeons’ perceptions of PC communication based on our survey results appear contradictory. Although nearly half of the respondents (n = 177, 49.4%) surveyed indicated that there was improved communication of prognosis with PC consultation, with 27% (n = 97) reporting improved communication of diagnosis, respondents surveyed, however, also indicated that PC teams may miscommunicate information to patients and families citing this as a barrier to consult PC. Specifically, 27.4% (n = 98) of the respondents indicated that PC teams may miscommunicate prognostic information to patients and families, and 16.2% (n = 58) of the respondents indicated that PC teams will miscommunicate diagnostic information to patients and families. These dissonant views may be explained by individual surgeons’ perceptions and overall unfamiliarity with PC. Our survey results indicate that 20% of the trauma surgeons reported no availability of PC services in their institution and only 55% reported PC consults as being beneficial all or most of the time. This is not surprising as there is a relative shortage of nationwide PC service in the United States.17 Trauma surgeons therefore may be unaware of the scope of PC services and benefits to patients, families, and trauma teams. Interestingly, our respondents seemed unaware of the potential impact of PC on ICU LOS based on survey responses. Only 16.5% (n = 59) respondents felt PC use decreased ICU LOS, though Mosenthal et al. have published data documenting a decrease in median LOS in trauma ICUs by 2 days when PC is consulted without any significant change in mortality.4,18 Our study has several limitations. First, our response rate (29%) was suboptimal, as only 358 of 1232 of members completed the survey.19 Second, there was likely response bias. Trauma providers more knowledgeable and interested in PC may have been more likely to respond as compared to providers less familiar with PC. Surveys were emailed using the EAST database. It is possible that this database did not have accurate emails for all of their members potentially resulting in a non-response bias. Next, our survey relied on providers’ recollection of their past practices, leading to possible recall bias. Because our survey results reflect determinants of PC by trauma providers across the Eastern United States only, results are potentially not generalizable to trauma providers across the United States or across the world. While there was a concerted effort to allow open-ended questions in each section, there was a lower response rate for these questions limiting the ability to either summarize or infer from responses. Finally, we surveyed trauma surgeons’ referral practices based on patient outcomes, injury patterns, and
associated psychosocial factors. We did not take into consideration other factors that can impact referral practices such as institutional support, PC team characteristics such as affability, proficiency, and availability of services. Our results highlight the need for PC and trauma providers to partner in establishing a clinical model to incorporate PC into the trauma ICU taking into account the availability and needs of both teams. We believe that integration of PC teams into the care of the trauma patients will provide an extra layer of support to patients, families, and providers regarding goals of care and communication.
Conclusion It is notable that the majority of trauma providers do find consultation with a PC provider beneficial in the care of their patients. However, significant potential barriers to consultation exist, which provide future opportunities to improve the appropriate utilization of PC. Declaration of conflicting interests The authors declare that there is no conflict of interest.
Funding This research received no specific grants or funding from any public, commercial, or not-for-profit sectors.
References 1. Centeno C. International research: comparison and collaboration to understand and promote palliative care. Palliat Med 2014; 28(2): 99–100. 2. Statement on principles guiding care at the end of life. American College of Surgeons’ Committee on Ethics. Bull Am Coll Surg 1998; 83(4): 46. 3. Klaristenfeld DD, Harrington DT and Miner TJ. Teaching palliative care and end of life issues: a core curriculum for surgical residents. Ann Surg Oncol 2007; 14: 1801–1806. 4. Mosenthal AC, Murphy PA, Barker LK, et al. Changing the culture around end of life care in the trauma intensive care unit. J Trauma 2008; 64: 1587–1593. 5. Lamba S, Murphy P, McVicker S, et al. Changing end of life care practice for liver transplant service patients: structured palliative care intervention in the surgical intensive care unit. J Pain Symptom Manage 2012; 44: 508–519. 6. Mosenthal AC and Murphy PA. Interdisciplinary model for palliative care in the trauma and surgical intensive care unit: Robert Wood Johnson Foundation demonstration project for improving palliative care in the intensive care unit. Crit Care Med 2006; 34: S399–S403. 7. Mosenthal AC, Weissman DE, Curtis JR, et al. Integrating palliative care in the surgical and trauma intensive care unit: a report from the Improving Palliative Care in the Intensive Care Unit (IPAL-ICU) Project Advisory Board and the Center to Advance Palliative Care. Crit Care Med 2012; 40(4): 1199–1206.
Downloaded from pmj.sagepub.com at The University of Edinburgh on June 18, 2015
1068
Palliative Medicine 28(8)
8. McCahill LE, Dunn GP, Mosenthal AC, et al. Palliation as a core surgical principle: part 1. J Am Coll Surg 2004; 199: 149–160. 9. Baggs JG, Norton SA, Schmitt MH, et al. Intensive care unit cultures and end of life decision making. J Crit Care 2007; 22: 159–168. 10. Dunn GP. Surgical palliative care: recent trends and developments. Surg Clin North Am 2011; 91: 277–292. 11. The 2nd Trauma Program. The art of communicating with families of trauma victims, http://www.adventuresincaring. org/education/2nd-trauma-program/ (accessed 16 April 2012). 12. Bradley CT and Brasel KJ. Developing guidelines that identify patients who would benefit from palliative care services in the surgical intensive care unit. Crit Care Med 2009; 37: 1147–1148. 13. Buchman TG, Cassell J, Ray S, et al. Who should manage the dying patient? Rescue, shame, and the surgical dilemma. J Am Coll Surg 2002; 194(5): 665–673. 14. Cassell J, Buchman TG, Streat S, et al. Surgeons, intensivists and the covenant of care: administrative models and
values affecting care at the end of life—updated. Crit Care Med 2003; 31: 1551–1557. 15. Tilden LB, Williams BR, Tucker RO, et al. Surgeon’s attitudes and practices in utilization of palliative and supportive care services for patients with a sudden advanced illness. J Palliat Med 2009; 12(11): 1039–1040. 16. Aslakson RA, Wyskiel R, Shaeffer D, et al. Surgical intensive care unit clinician estimates of the adequacy of communication regarding prognosis. Crit Care 2010; 14: R218. 17. Lupu D. Estimation of palliative medicine and hospice physician workforce shortage. J Pain Symptom Manage 2010; 40(6): 899–911. 18. Aslakson RA, Cheng J, Vollenweider D, et al. Evidencebased palliative care in the intensive care unit: a systematic review of interventions. J Palliat Med 2014; 17: 219–236. 19. Kusano AS, Kenworthy-Heinige T and Thomas CR Jr. Survey of bereavement practices of cancer care and palliative care physicians in the Pacific Northwest United States. J Oncol Pract 2012; 8(5): 275–281.
Downloaded from pmj.sagepub.com at The University of Edinburgh on June 18, 2015
