Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
. 2020 Feb 1;155(2):138-146.
doi: 10.1001/jamasurg.2019.5083.

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

Maria Yefimova  1   2 , Rebecca A Aslakson  3   4 , Lingyao Yang  5 , Ariadna Garcia  5 , Derek Boothroyd  5 , Randall C Gale  1 , Karleen Giannitrapani  1   6 , Arden M Morris  7 , Jason M Johanning  8   9 , Scott Shreve  10 , Melissa W Wachterman  11   12   13 , Karl A Lorenz  1   14
Affiliations

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

Maria Yefimova et al. JAMA Surg. .

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 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.

PubMed Disclaimer

Conflict of interest statement

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

Figures

Figure 1.
Figure 1.. Flowchart of the Study Cohort and the Analytic Sample
VAMC indicates Department of Veterans Affairs Medical Center.
Figure 2.
Figure 2.. Ninety-Day Mortality and Proportion of Palliative Care Consultations Across 8 Groups of High-risk Surgical Procedures
The Other category includes gynecologic, orthopedic, and otolaryngologic procedures. A total of 95 204 patients were included.
See this image and copyright information in PMC

Comment in

References

    1. Kwok AC, Semel ME, Lipsitz SR, et al. . The intensity and variation of surgical care at the end of life: a retrospective cohort study. Lancet. 2011;378(9800):1408-1413. doi:10.1016/S0140-6736(11)61268-3 - DOI - PubMed
    1. Schwarze ML, Barnato AE, Rathouz PJ, et al. . Development of a list of high-risk operations for patients 65 years and older. JAMA Surg. 2015;150(4):325-331. doi:10.1001/jamasurg.2014.1819 - DOI - PMC - PubMed
    1. Kelley AS, Morrison RS. Palliative care for the seriously ill. N Engl J Med. 2015;373(8):747-755. doi:10.1056/NEJMra1404684 - DOI - PMC - PubMed
    1. Bakitas MA, Tosteson TD, Li Z, et al. . Early versus delayed initiation of concurrent palliative oncology care: patient outcomes in the ENABLE III randomized controlled trial. J Clin Oncol. 2015;33(13):1438-1445. doi:10.1200/JCO.2014.58.6362 - DOI - PMC - PubMed
    1. El-Jawahri A, Traeger L, Greer JA, et al. . Effect of inpatient palliative care during hematopoietic stem-cell transplant on psychological distress 6 months after transplant: results of a randomized clinical trial. J Clin Oncol. 2017;35(32):3714-3721. doi:10.1200/JCO.2017.73.2800 - DOI - PMC - PubMed

Publication types

MeSH terms