Palliative Care in the Trauma and Surgical Critical Care Settings: A Narrative Review

Abstract

Background

We aimed to conduct a narrative review of available literature to understand the use of palliative care in the trauma and surgical critical care setting.

Methods

PubMed, EMBASE, and Google Scholar databases were searched for studies investigating the use of palliative care in the trauma and surgical critical care setting. The search included all studies published through January 9th, 2022. The risk of bias of included studies was assessed using the Joanna Briggs Institute Critical Appraisal Checklist tools. Outcomes were summarized in tables and synthesized qualitatively.

Results

A total of 22 studies were included in this review. Key elements of successful palliative care include communication, shared decision-making, family involvement, pain control, establishing a patient’s prognosis, and end-of-life management. Approaches to implementation based upon these key elements include best-case/worst-case scenarios, consultation trigger systems, and integrated institutional palliative care programs. Palliative care may reduce hospital length of stay, improve symptom management, and increase patient satisfaction, but the impact on mortality is unclear.

Conclusion

The core elements of palliative care have been identified and palliative care has been shown to improve outcomes in trauma and surgical critical care. However, the approaches for implementation still require development. The underutilization of palliative care for trauma patients reveals the need for refining criteria for use of palliative care and improvement in the education of surgical critical care teams to provide primary palliative care services.

Keywords

palliative care goals of care surgical critical care trauma surgery improved outcomes

Background

Between 2000 and 2019, the number of palliative care consultation programs in United States hospitals with over 50 beds has increased from 658 to 1,709, demonstrating a 260% increase.¹ The rise in the use of palliative care services has been supported by evidence demonstrating improved quality of care,^2,3 reduced health care utilization,⁴ and reduction in length of stays.^2,5,6 However, there have been concerns that the supply of specialist palliative care cannot meet the demand of consultations, emphasizing the need for all members of the surgical critical care team to take a more active role in providing primary palliative care to patients.⁷

In 2016, an international consensus on the definition of advanced care planning for adults was established, advocating those patients receive medical care that is consistent with their values, goals, and preferences during serious and chronic illness.⁸ Advance care planning focuses on future health care goals and preferences, but not all surgeons are aware of how these plans may apply or be utilized in acute care settings when the patient is critically ill. Defining outcome goals and assessing how they align with the patient’s own values and preferences has yet to be clearly demonstrated in the acute care setting. A literature gap analysis performed by the American Association for the Surgery of Trauma (AAST) Critical Care Committee identified several areas of research requiring further exploration and addressing goals of care in the acute care setting was proposed as a high priority topic.⁹ There are numerous studies evaluating individual palliative care consultation approaches,^10-12 how goals of care are documented in the surgical critical care environment,¹³ and how these goals are communicated within health care teams;^14,15 yet metrics for measuring care consistent with patient’s values and defining patient-centered outcomes have not been established.

There are a few studies assessing the impact of palliative care in the acute care setting, which are limited with respect to the population specificity and size.^2,3,6,11,13 There is also extensive heterogeneity among the goals and outcomes measured in palliative care studies. Currently, no published reviews assess the differing definitions of patient-centered outcomes and there are no reviews examining the different approaches in the acute care setting. Achieving clarification in the definition, approach, critical elements, and desired outcomes for palliative care in this setting will be fundamental to the development of guidelines and standardization.

To address these gaps, we conducted a narrative review of the current literature to analyze the use of palliative care in the trauma and surgical critical care setting. Identifying existing approaches to address palliative care in this setting may be valuable to surgeons and practitioners aiming to optimize care for the critically ill. Furthermore, evaluating the alignment of care received by the patient with their values and outcome goals will benefit health services researchers by generating clear, quantifiable metrics for subsequent investigations.

Objectives

The objective of this study is to evaluate the current literature investigating palliative care practices in the setting of adult trauma and surgical critical care to (1) identify definitions, critical elements, desired patient-centered outcomes, and approaches for addressing palliative care and (2) evaluate the impact of palliative care on adult trauma and surgical critical care patient outcomes including length of stay, mortality, symptom management, and patient satisfaction.

Methods

Data Sources and Search Strategy

We conducted a search of all studies investigating palliative care in the setting of adult trauma and surgical critical care utilizing three databases: PubMed, EMBASE, and Google Scholar. The search included all studies published through January 9th, 2022. The following search keywords were used: “Palliative Care” AND “Surgical Critical Care”; “Palliative Care” AND “Trauma Surgery”; “End of Life Care” AND “Surgical Critical Care”; and “End of Life Care” AND “Trauma Surgery.” The last search was conducted on January 9^th, 2022.

Study Selection and Eligibility Criteria

The inclusion criteria were

• Retrospective cohort studies, prospective cohort studies, randomized controlled trials (RCTs), cross-sectional studies, and observational studies.

• Studies investigating palliative care and/or goals of care in the setting of trauma/surgical critical care.

• Studies published in English.

• Population: Adults only (≥18yo).

Studies investigating long-term critical care patients or patients not in the acute care surgical setting were excluded. We also excluded studies that were not peer-reviewed or that were published in languages other than English.

Risk of Bias Assessment

The risk of bias of included studies was assessed using the Joanna Briggs Institute (JBI) Critical Appraisal Checklist tools.¹⁶ The checklist for cohort studies and cross-sectional studies was used according to the design of each included study.

Data Collection Process

Five authors (KN, MS, JS, TB, and AE) conducted the primary literature search, screened titles, and abstracts for eligibility criteria and extracted data from full-text studies. The reference lists in eligible studies were also evaluated for additional relevant studies. Six authors (KN, MS, JS, DA, TB, and AE) evaluated the risk of bias of each study, and any disagreements or discrepancies were resolved by all authors. The following data were extracted from included studies: study design, year of publication, study population, care setting, and location.

Data Synthesis

Results from the included studies were presented in tables and summarized in a qualitative narrative synthesis.

Outcome Measures

Regarding the impact of palliative care on patient outcomes, the primary outcome evaluated in this review was hospital length of stay (LOS) in days. The secondary outcome is in-hospital mortality, and the tertiary outcomes are symptom management and patient satisfaction.

Results

Study Selection and Demographics

A total of 22 studies were included in this review (eTable 1: Supplemental File, Figure 1).^{2,3,5,6,10,11,12,17-31} Five studies addressed the definitions and elements for palliative care in the trauma and surgical critical care setting,^17-21 Nine studies investigated approaches for palliative care,^10-12,22-27 and 8 studies evaluated the impact of palliative care on patient outcomes.^{2,3,5,6,28-31} These studies included 16 cross-sectional studies,^{2,5,6,10,11,17-23,25-27,31,} 3 retrospective cohort studies,^12,28,29 and 3 prospective cohort studies.^3,24,30

Risk of Bias

The risk of bias of four included studies was classified as moderate,^2,6,17,19 and all eighteen remaining studies were classified as low (eTable 2 and eTable 3: Supplemental File).^{3,5,10-12,18,20-31} Among cross-sectional studies classified as moderate risk of bias, common concerns included lack of identification of possible confounding factors and lack of strategies to account for confounders.

Definition and Critical Elements of Palliative Care

We identified several common critical elements of palliative care in the trauma and surgical critical care setting in the literature. One critical element of palliative care is ensuring ongoing appropriate medical and surgical management of the patient.¹⁷ Similarly, pain management and symptom management were identified as key elements.¹⁷ Additional elements include effective communication, involvement of the patient in decision-making, family discussions, psychological and spiritual care, the establishment of goals of care, and end-of-life management.^6,17-21 The importance of communication between members of the clinical team is highlighted by Kelley et al, who demonstrated that poor communication leads to increased uncertainty for patients and their surrogates.²⁰ A list of these essential elements of palliative care in the trauma and surgical critical care setting based on the common elements identified in the literature is reported in Table 1.

Table 1.

Essential Elements of Palliative Care.

Essential Elements of Palliative Care
• Communication	• End-of-life management
• Establishing prognosis	• Family engagement and involvement in decision-making
• Medical management	• Pain Control
• Psychosocial support	• Shared decision-making
• Surgical management	• Symptoms management

Approaches for Palliative Care

Several approaches to palliative care in trauma and surgical critical care have been reported in the literature (Table 2).

Table 2.

Approaches to Palliative Care Delivery in the Trauma and Surgical Critical Care Setting.

Author	Approach	Key Findings
Kruser et al¹⁰	Best case/worst case	The approach helped to establish expectations, provide clarity, and facilitate deliberation
Bradley et al¹¹	Trigger system	Implementation of a trigger system did not increase palliative care consults in the surgical ICU.
Leonard et al¹³	Trigger system	A trigger system for early palliative care may benefit severely injured patients without TBI that underwent withdrawal of life-sustaining therapies
Hahne et al²²	Integrated palliative approach	Integrating a palliative care educational program within the surgical department results in the implementation of a shared palliative working method
Frey et al²³	Integrated palliative approach	Integrating a palliative care educational program resulted in increased staff confidence, which is believed to increase the quality of palliative care
Brown et al²⁴	Integrated palliative approach	Using an integrated palliative care approach resulted in statistically significant improvements in measures related to the implementation of primary palliative care, pain and symptom management, and end-of-life care
Schockett et al²⁵	Integrated palliative approach	Integrating a palliative care educational program into pre-existing didactic and rounding time for a trauma team can help residents develop palliative skills and foster culture change
Moran et al²⁶	Integrated palliative approach	The TQIP guidelines have applicability to trauma centers that manage geriatric trauma patients. The TQIP guidelines can facilitate the implementation of a palliative care program that meets institutional needs
Kirkland et al²⁷	Integrated palliative approach	Implementation of a surgical intensivist model results in increased palliative care consults for trauma patients in the ICU.

TQIP = Trauma Quality Improvement Program.

Best-Worst Case Scenario

The “best-case/worst-case” (BC/WC) intervention offers a structured framework to present patients with information. It can involve the use of graphics and descriptive terms to help convey the best-case clinical scenario and the worst-case clinical scenario. Kruser et al evaluated the effectiveness of this communication tool for high-risk surgical problems. Seventy-nine percent of surgeons reported that the BC/WC is better than their typical approach.¹⁰ Additionally, patients and families found that it helped to establish expectations, provide clarity, and enable deliberation.

Consultation Trigger System

Consultation triggers are criteria that may indicate the need for a specialty palliative care consultation. Several studies have evaluated the use of specific metrics and criteria that would serve to trigger palliative care consultation in the surgical critical care setting.^11,12 Bradley et al evaluated the use of a trigger system in the surgical ICU. In this retrospective study, trigger criteria were established and the impact on palliative care consults was evaluated. The trigger criteria most included in the patient groups were a multi-organ system failure, surgical ICU stay greater than 1 month, more than three surgical ICU visits in the same hospital stay, and death expected during the same surgical ICU stay. Overall, triggers rarely occurred and palliative care consults in the surgical ICU were infrequent.¹¹ Alternatively, a retrospective study by Leonard et al demonstrated that in-hospital complications as a trigger for palliative care for trauma patients may improve outcomes.¹²

Integrated Palliative Care Approach (Structural, Education, and Metrics)

We identified 6 studies that evaluated integrated palliative care approaches.^22-25,27,30 Several of these studies account for the implementation of American College of Surgeons (ACS) Trauma Quality Improvement Program (TQIP) guidelines at a particular institution. Key components of the ACS TQIP guidelines that were evaluated within these studies include developing an interdisciplinary care team, discussing goals of care, planning for end-of-life care, and establishing a framework to promote palliative care discussion.³³ For example, Brown et al demonstrated statistically significant improvement in palliative care metrics with the implementation of ACS TQIP recommendations.²⁴ Hahne et al, Frey et al, and Schockett et al found that integrating a palliative care educational program into the surgical department resulted in the development of palliative care skills and improved team confidence in providing palliative care.^22,23,25

Impact of Palliative Care on Patient Outcomes

Our review identified 8 studies investigating the impact of palliative care on outcomes in the setting of trauma/surgical critical care (Table 3).^{2,3,5,6,28-31} Bhangu et al and Hwang et al both found that palliative care consultation (PCC) was associated with decreased LOS compared to no PCC in traumatic brain injury patients and critical trauma patients, respectively.^6,31 Kupensky et al also found that geriatric trauma patients who received PCC had reduced LOS (7.92 days vs 13.11 days; P < .001).² In a subsequent analysis on the timing of PCC, Kupensky et al found that patients with early PCC (<72 hours after admission) had significantly reduced LOS compared to late PCC (>72 hours).²⁹

Table 3.

Impact of Palliative Care on Patient Outcomes.

Study	Length of Stay	Mortality	Symptom Management	Patient Satisfaction
Kupensky et al²	Patients with PCC had reduced LOS compared to without (7.92 days vs 13.11 days; P < .001)	NR	Patients with PCC had improved symptom management (3.65 out of 4 symptoms vs 3.47 out of 4 symptoms; P = .023)	NR
McGraw et al³	NR	NR	NR	PCC increased patient satisfaction (aOR 1.82; 95% CI 1.12-2.95; P = .02)
Baimas-george et al⁵	NR	PCC associated with 80% increased odds of transition to hospice care instead of in-hospital mortality (OR 1.78; 95% CI 1.71-1.86; P < .01)	NR	NR
Bhangu et al⁶	PCC associated with reduced LOS (5 d vs 11 d; P < .001)	NR	NR	NR
Lilley et al²⁸	NR	PCC associated with decreased odds of death in an institutional setting (OR .34; 95% CI 0.30-.39; P < .05)	NR	NR
Kupensky et al²⁹	Decreased LOS for patients receiving early PCC compared to late (7.92 days vs 13.11 days; P = .007)	No significant difference in mortality between early and late PCC (29 vs 23; P = .371)	NR	NR
Vogel et al³⁰	NR	NR	NR	PCC implementation significantly increased patient satisfaction (82.0 vs 86.0; P = .001)
Hwang et al³¹	Patients receiving PCC had significantly shorter LOS than those without PCC (6 d vs 15 d; P < .001)	NR	NR	NR

PCC = palliative care consultation; LOS = length of stay.

Palliative care consultation was not associated with any significant differences in mortality for geriatric trauma patients in a study by Kupensky et al² However, Baimas-George et al and Lilley et al found that PCC was associated with decreased inpatient mortality in studies of adult trauma patients and emergency general surgery patients, respectively.^5,28

Geriatric trauma patients who received PCC had displayed significantly improved symptom management compared to those who did not (3.65 out of 4 symptoms vs 3.47 out of 4 symptoms, P = .023) in a retrospective cohort study.² McGraw et al and Vogel et al found that patient satisfaction was significantly improved in trauma patients who received PCC compared to those who did not.^3,30

Discussion

While there has not been a consistent definition of palliative care in the trauma and surgical critical care setting, palliative care has typically been defined as a multidisciplinary team focusing on improving the quality of life for patients and their families, reducing suffering, and engaging key stakeholders in the decision-making process.^4,23,25,32 Key elements of successful palliative care in the trauma or surgical critical care setting include communication, shared decision-making, family involvement, pain control, symptom control, medical management, surgical management, psychosocial support, establishing a patient’s prognosis, and end-of-life management.^17-21

Based on these key elements, several approaches have been proposed to implement the principles of palliative care in the trauma and surgical critical care setting. These approaches include best-case/worst-case scenarios, consultation trigger systems, and integrated institutional palliative care programs.^10-12,22-27 Many of these approaches are in their infancy and require further studies to elucidate the impact they may have on patient outcomes. While the outcomes of several of these interventions are unknown, the positive impact of palliative care on patient outcomes has been studied in surgical and critical care settings. Specialist palliative care services have been shown to reduce LOS, improve symptom management, and increase patient satisfaction. There have been mixed results on the impact of palliative care on in-hospital mortality for trauma and surgical critical care patients.^{2,3,5,6,28-31}

The ACS TQIP Best Practices Guidelines delineate two types of palliative care: primary palliative care and specialist palliative care.³³ Primary palliative care is typically delivered by an interdisciplinary team with expertise in the prognosis and needs of patients with sudden injury. For example, identification of health care proxy, advanced care planning, communication of prognosis and goals of care, pain and symptom management, emotional support for families, and educational support for families. Specialist palliative care involves supplementation with board-certified specialists for more complex patients.³³

In addition to the two types of palliative care outlined by TQIP, studies within the trauma and surgical critical care setting have used definitions of palliative care that have either been modified for the field or utilized standard definitions from other organizations. In studies such as those by Lilley et al, Miller et al, and Owens, the definitions of palliative care are broader and less specific to trauma and surgical critical care.^4,34,35 For instance, Miller et al applied definitions of palliative care set forth by the Centers for Medicare & Medicaid Services (CMS) and the National Coalition for Hospice & Palliative Care (NCHPC).³⁴

In addition to the standard essential aspects of palliative care, such as pain management, symptom management, medical management, prognosis, and end-of-life care, there are also other important components. One of these critical elements of palliative care is communication. Communication and the role it plays in palliative care in surgery were selected as a research priority in 2003 by the American College of Surgeons Palliative Care Workgroup.³⁶ Cook et al explored the importance of communication in the surgical critical care setting by developing a communication framework to assist surgeons in delivering goal-concordant care for high-risk patients.³⁷ Udelsman et al noted that limitations in communication secondary to aspects, such as inaccessible records, absence of protocols, and difficulty documenting complex conversations can lead to conflict in establishing goals of care.³⁸ Myers et al identified that there is a lack of outcome evidence surrounding the use of various clinical tools in advanced care planning and establishing goals of care.³⁹ They identify developing communication skills, standardizing documentation, implementing quality improvement initiatives, and improving coordination as critical areas to address moving forward.³⁹

An important aspect of communication is ensuring that the patient’s family is involved in the communication process when appropriate. Truog et al in a consensus statement by the American College of Critical Care Medicine noted the importance of the social structure that supports critically ill patients, which includes the family. They even noted improved patient outcomes when the family was involved in the communication process.¹³ Although family communications can be conducted via numerous approaches, Bhangu et al noted successful outcomes through a formalized family meeting.⁶ At the intersection of communication between the patient, the patient’s family, and the surgical critical care team is shared decision-making. Shared or inclusive decision-making ensures that all key stakeholders are involved in shared decision-making about the treatment plan and their role in the treatment plan. Surgical Palliative Care: A Resident’s Guide: outlines key principles of palliative care and approaches to many of the critical elements listed above.⁴⁰

Overall, the literature demonstrates that palliative care in the trauma and surgical critical care setting reduces LOS, improves symptom management, and increases patient satisfaction. However, the impact on mortality is mixed, a study finding no significant difference,² and others demonstrating significantly reduced mortality.^5,28 Additional benefits of palliative care in the acute care setting such as a reduction in potentially inappropriate interventions and decreased non-beneficial resource use have also been proposed.^41,42 These findings overwhelmingly support palliative care in the trauma and surgical critical care setting as an intervention for improving patient outcomes, improving patient satisfaction, and reducing unneeded or non-beneficial resource use.

Despite these clear benefits, the incorporation of palliative care in the trauma and surgical critical care setting is less utilized in certain populations with rates of PCC reported as low as .3% and as high as 35%.^5,31 The wide variation in PCC utilization reported by the literature is likely multivariate in nature, including such variables as differences in data analysis and differences in the age of the patient populations studied as the highest reported PCC rates were from studies investigating geriatric trauma populations. A study by Fiorentino et al found that geriatric trauma patients were significantly more likely to receive PCC than younger patients with similar injuries, supporting this assessment.⁴³ Furthermore, a study by Wycech et al found that despite receiving the same injury severity, younger trauma patients had triple the time to PCC, five times the Hospital Length of Stay (HLOS), a higher rate of futile interventions, and received more aggressive treatment.⁴² These findings demonstrate the distinct roles of specialist palliative care and primary palliative care in the surgical critical care setting. More complex populations such as geriatric trauma patients who tend to have significant comorbid conditions likely benefit most from specialist palliative care consultation. On the other hand, primary palliative care provided by surgeons may be more appropriate for younger trauma patients with less complicated presentations. Surgeons must therefore be equipped to provide primary palliative care and identify when it is appropriate to consult palliative care specialists depending on the needs of the patient.^41,42,44

A potential approach for improving primary palliative care use may be implementing educational programs for surgical critical care teams to increase awareness of resources and communication skills for speaking with patients and families. Amen et al implemented courses to educate resident surgeons on palliative care for trauma critical care patients and found that implementation was associated with an increase in advanced care planning documentation, a decrease in LOS, and improvements in patient outcomes.⁴⁴ Considering the wide variation in palliative care utilization across institutions, hospitals should investigate the use of primary palliative care in their trauma and surgical critical care departments and consider implementing similar interventions to improve appropriate consultation and potentially improve patient outcomes.

Through greater utilization of palliative care services, critical care surgeons have the capacity to improve the planning of care for critically injured patients to align with their immediate and long-term goals while maintaining patient dignity.⁴⁵ Palliative care facilitates necessary conversations allowing patients to express their goals of care and selection of treatments that align with these goals or discontinuation of interventions that are no longer desired. In addition to improving patient outcomes, these conversations may decrease the utilization of unwanted or unnecessary treatments and reduce unnecessary health care costs.⁴⁶

Future Recommendations

We offer several recommendations moving forward. First, considering the wide variation in palliative care utilization across institutions, hospitals should investigate the use of palliative care in their trauma and surgical critical care departments and consider implementing educational programs to improve appropriate consultation and efforts to augment the ability of surgeons to provide primary palliative care. Second, national trauma associations should publish standardized guidelines regarding palliative care in the setting of trauma and surgical critical care to improve utilization and consistency in PCC across institutions. Third, based on the discrepancies in the definitions and elements of palliative care, surgeons may not be aware of the benefits offered by the use of palliative care. A national survey of cardiothoracic surgeons found that 40% of respondents reported the perception that palliative care is “giving up,” demonstrating that many surgeons may not be familiar with the beneficial aspects of palliative care.⁴⁷ It is therefore imperative that trauma associations establish a common definition of palliative care and the role it plays in the critically ill so surgeons are more likely to appropriately provide primary palliative care and consult palliative services. Fourth, surgeons should take a more active role in leading the multidisciplinary approach to palliative care because it is a valuable aspect of patient management. State and national legislations are critical for increasing the awareness, utilization, access, and reimbursement for palliative care services.⁴⁸ As leaders within the surgical community, surgeons should therefore also take an active role in palliative care legislation conversations with policymakers. There is substantial heterogeneity in what outcomes were reported and how they were reported by studies investigating PCC in the setting of critical care surgery. Future studies may consider evaluating additional palliation focused outcomes such as discharge disposition, reduction in non-beneficial treatment, and changes in code status.

Limitations

A limitation on the analysis of the information gathered was the heterogeneity in both the methodology of the results analysis as well as the patient populations included. The effectiveness of including each of the elements of care individually on the outcomes was difficult to characterize due to the frequent implementation of multiple elements at a single time and the theoretical ethical challenges of withholding key elements in the delivery of end-of-life care. By identifying the commonalities and delineating them in this review, further investigations can be focused on measuring outcomes that specifically involve these elements and provide evidence for their continued implementation in this setting. Analysis of the primary results supports the use of the individual and integrated approaches to goal setting. Evidence also shows benefits of specific methods for determining when palliative interventions are necessary such as the trigger consultation system, yet the frequency of its implementation has been limited due to the criteria required for the initiation of palliative care. Further investigations of the approaches can elucidate the reasoning for their shortcomings and allow for refining of the initiation criteria to benefit a larger population of patients.

Conclusion

The core elements of palliative care have been identified and the evidence clearly supports the benefits of palliative care in achieving improved outcomes in the trauma and surgical critical care settings, however, the approaches for implementation still require development. Palliative care has not demonstrated a clear positive effect on mortality, but the literature supports its role in increasing patient satisfaction and reducing the use of unnecessary medical interventions. The underutilization of palliative care for trauma patients reveals the need for refining the timing of consultation, the education of care teams regarding its implementation in the surgical critical care setting, and the importance of primary palliative care in the surgical critical care setting.

Supplemental Material

Supplemental Material - Palliative Care in the Trauma and Surgical Critical Care Settings: A Narrative Review

Supplemental Material for Palliative Care in the Trauma and Surgical Critical Care Settings: A Narrative Review by Kevin Newsome, Matthew Sauder, Jeffrey Spardy, Lisa Kodadek, Darwin Ang, Christopher P. Michetti, Tracy Bilski, and Adel Elkbuli in The American Surgeon

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Supplemental Material

Supplemental material for this article is available online.

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