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

Maria Yefimova, Rebecca A. Aslakson, Lingyao Yang, Ariadna Garcia, Derek Boothroyd, Randall C. Gale, Karleen Giannitrapani, Arden M. Morris, Jason M. Johanning, Scott Shreve, Melissa W. Wachterman, Karl A. Lorenz

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Abstract

Importance: Palliative care has the potential to improve care for patients and families undergoing high-risk surgery. Objective: To characterize the use of perioperative palliative care and its association with family-reported end-of-life experiences of patients who died within 90 days of a high-risk surgical operation. Design, Setting, and Participants: This secondary analysis of administrative data from a retrospective cross-sectional patient cohort was conducted in the Department of Veterans Affairs (VA) Healthcare System. Patients who underwent any of 227 high-risk operations between January 1, 2012, and December 31, 2015, were included. Exposures: Palliative-care consultation within 30 days before or 90 days after surgery. Main Outcomes and Measures: The outcomes were family-reported ratings of overall care, communication, and support in the patient's last month of life. The VA surveyed all families of inpatient decedents using the Bereaved Family Survey, a valid and reliable tool that measures patient and family-centered end-of-life outcomes. Results: A total of 95204 patients underwent high-risk operations in 129 inpatient VA Medical Centers. Most patients were 65 years or older (69278 [72.8%]), and the most common procedures were cardiothoracic (31157 [32.7%]) or vascular (23517 [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.

Original languageEnglish (US)
Pages (from-to)138-146
Number of pages9
JournalJAMA Surgery
Volume155
Issue number2
DOIs
StatePublished - Feb 2020

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ASJC Scopus subject areas

  • Surgery

Cite this

Yefimova, M., Aslakson, R. A., Yang, L., Garcia, A., Boothroyd, D., Gale, R. C., Giannitrapani, K., Morris, A. M., Johanning, J. M., Shreve, S., Wachterman, M. W., & Lorenz, K. A. (2020). Palliative Care and End-of-Life Outcomes Following High-risk Surgery. JAMA Surgery, 155(2), 138-146. https://doi.org/10.1001/jamasurg.2019.5083