Patterns of Specialty Palliative Consultation for Patients Admitted to Surgical Services

Background: Historically, there have been perceptions that engagement with palliative care (PC) services may preclude potentially curative but high-risk operations. As such, we sought to investigate the relationship between specialty PC consultation and the care trajectory of surgical patients. We hypothesized that PC consultation would be associated with increased frequency of nonoperative treatments being chosen among surgical inpatients. Design: All general surgery and general surgery subspecialty patients receiving PC consultation at a single tertiary academic medical center from 2020 to 2021 were identified. Surgical operations were stratified as "elevated risk" in accordance with 2014 American Heart Association guidelines. Retrospective chart review was performed, and comparisons were made with univariable statistics. Results: We identified a total of 729 patients who received specialty PC consultation, 159 of whom were admitted to a surgical service. PC was actively involved in consultation for surgical decision making in 27% (43/159) of these encounters. PC assistance with surgical decision making was associated with a greater incidence of elevated-risk operative procedures during admission compared with patients without presurgical PC consultation (OR 3.29 [2.51, 7.16]). There was no association between PC involvement with surgical decision making and odds of discharge to hospice (OR 0.42 [0.18, 1.51]) nor death during admission (OR 0.66 [0.21, 2.10]). Conclusions: We found that specialty PC involvement in surgical decision making does not preclude the pursuit of disease-directed surgical treatment. Contrary to our hypothesis, our single institutional data demonstrate that early PC consultation can be synergistic with surgical disease management and does not preclude elevated-risk operative care.

Mortality Conversations Between Male Veterans and Their Providers Prior to Dysvascular Lower Extremity Amputation

BACKGROUND

Among patients facing lower extremity amputation due to dysvascular disease, the mortality risk is very high. Given this, as well as the importance of a patient-centered approach to medical care, informing patients about their possible risk of dying may be important during preoperative shared decision-making. The goal of this investigation was to gain an understanding of patient and provider experiences discussing mortality within the context of amputation within the Veterans Health Administration.

METHODS

Semistructured interviews were performed with Veterans with peripheral arterial disease and/or diabetes, vascular and podiatric surgeons, and physical medicine and rehabilitation physicians. Interviews were analyzed using team-based content analysis to identify themes related to amputation-level decisions.

RESULTS

We interviewed 22 patients and 21 surgeons and physicians and identified 3 themes related to conversations around mortality: (1) both patients and providers report that mortality conversations are not common prior to amputation; (2) while most providers find value in mortality conversations, some express concerns around engaging in these discussions with patients; and (3) some patients perceive mortality conversations as unnecessary, but many are open to engaging in the conversation.

CONCLUSIONS

Providers may benefit from introducing the topic with patients, including providing the context for why mortality conversations may be valuable, with the understanding that patients can always decline to participate should they not be interested or comfortable discussing this issue.

Palliative Care Interventions for Peripheral Artery Disease: A Systematic Review and Narrative Synthesis

Background: Peripheral artery disease (PAD) encompasses conditions with poor outcome and severe suffering, both mentally and physically, yet utilization and research into palliative care interventions remain sparse. Objective: The purpose of this study is to identify existing evidence on palliative care intervention for chronic limb threatening ischaemia (CLTI) and abdominal aortic aneurysm (AAA). Design: We conducted a PROSPERO-registered systematic review of studies published between 1991 and 2020 in which people with PAD received palliative care interventions and at least one patient outcome was recorded. For the purpose of this study, a palliative care intervention was defined as one which aims primarily to reduce negative impact of PAD on patients' and/or caregivers' physical, emotional, psychological, social, or spiritual condition. Results: A total of 8 studies involving 87,024 patients met the inclusion criteria (4 cohort studies and 4 cross-sectional studies). Methodological quality ranged from low to moderate. The small number of studies and study heterogeneity precluded meta-analysis. Regarding our primary outcomes, only two articles recorded patient-reported outcomes. Five articles found an association between palliative care and reduction in health care utilization, a secondary outcome of the study. Most of the studies reported that palliative care was likely underused. Only two of the studies included non-hospital patients. Conclusion: Despite high mortality and morbidity associated with PAD, evidence of the effectiveness of palliative care in this group of patients is lacking. There are only a handful of articles on palliative care for people with PAD, and the majority are small, methodologically flawed and lack meaningful patient-reported outcomes. High-quality research of palliative care interventions in patients with PAD is urgently needed to better understand the impact of palliative care on quality of end of life and to develop and evaluate service-level interventions.

Chronic limb-threatening ischaemia and reframing the meaning of 'end'

INTRODUCTION

The possibility of amputation and/or death from chronic limb-threatening ischaemia (CLTI) is real, and deeper understandings of the person and family's capacity and preparedness for limb loss and clinical interventions (active or palliative) are required.

BACKGROUND

The lead-in period to the surgeon's recommendation for amputation for CLTI may be sudden or protracted; the number/invasiveness of previous revascularisation interventions varies, and limb loss and end-of-life considerations frame the experience.

METHOD

This prospective, longitudinal, interpretative phenomenological study in three vascular surgical units involved 19 CLTI journeys. Participants were interviewed when making decisions about amputation (15 patients, 12 family members) and, where applicable, 6-months postamputation (8 patients, 7 family members). Hermeneutic interpretation using Heidegger's philosophical construct of Being-towards-death guided the analysis. The COREQ checklist ensured rigour in research reporting.

FINDINGS

Some participants were unable to face the possibility of death and metaphorically 'fled', either through productive optimism or through hoping for more time (Heidegger's inauthentic positioning towards death). For others, authentic positionings of Being-towards-death were understood as: the confrontation of the certainty of their death by making choices about how to die; the indefiniteness of death where treatment choices influenced timing, yet the time for death remained unknown; the nonrelational nature of death, as the journey could only be lived by the person; and death as not to be outstripped, where for some, there was a freeing of oneself for amputation and/or death.

DISCUSSION

The term 'end of limb' to denote the futility of the limb is a useful marker that emphasises the noncurative nature of CLTI. This may help to instigate and support discussions about end of life to support palliation care planning and the person and family's existential preparation for death.

CONCLUSION

Death frames the experience of CLTI. Using 'end-of-limb' and 'end-of-life' terminology may facilitate a family/patient-centred approach to possible amputation and other conservative or palliative strategies.

RELEVANCE TO CLINICAL PRACTICE

Understanding of CLTI illness experience. Decisions about revascularisation, amputation or conservative care. End-of-life care for CLTI.