Geriatric and Palliative Care

Guidelines Are Not Enough: The Added Impact of a Multidisciplinary Intervention on Palliative Care Delivery for Critically Ill Trauma Patients Lauren E McGuire, MD, Cari E Low, MD, Silvia M Soule, BS, Alizah J Folau, BS, Kylie McGhee, BS, Marta McCrum, MD, MPH, FACS University of Utah, Salt Lake City, UT Introduction: The benefit of palliative care (PC) for critically ill patients is well established. In 2017, the American College of Surgeons TQIP published best-practice guidelines for delivering PC to trauma patients. Prior work suggests that without a dedicated implementation strategy, guidelines alone are insufficient to change clinician behavior. Two years after guideline publication, our Level I trauma center implemented a multidisciplinary PC intervention that included a decision-support tool, provider trainings, and new workflows based on the TQIP guidelines. We assessed changes in PC use and clinical outcomes after each intervention. Methods: A retrospective cohort study of adult trauma patients admitted to the ICU for ≥72 hours at a single academic Level I trauma center from 10/2015 to 8/2021 was conducted. Three cohorts were identified: Cohort 1 “Pre-Guideline”; Cohort 2 “TQIP Guideline Only”; Cohort 3 “Guidelines + Intervention”. Data collected included demographics, injury characteristics, PC use and clinical outcomes. We compared PC use and outcomes across the 3 cohorts. Results: A total of 667 patients were analyzed. There were no significant differences in age, sex, insurance status, injury mechanism and severity, or in-hospital mortality across the 3 cohorts. After each intervention, there was earlier and increased number of PC consultations, more PC consults before death, increased PC consultation before tracheostomy and fewer ventilator days (Table 1). Table 1. - Results Variable Cohort 1 (before guidelines)* (n = 206) Cohort 2 (guidelines only) (n = 220) Cohort 3 (guidelines + intervention) (n = 241) p Value (Cohort 1 vs 3) PC consult, n (%) 12 (5.8%) 29 (13.2%) + 57 (23.7%) # <0.001 Hospital day of PC consult, avg (range) 10.3 (3-22) 5.5 (1-14) + 5.5 (1-20) 0.002 In-hospital death, n (%) 12 (5.8%) 19 (8.6%) 23 (9.5%) 0.16 PC consult before death, n (%) 4 (33.3%) 14 (73.7%) 22 (95.7%) <0.001 Days between PC consult and death, avg (range) 0.5 (0-1) 5.0 (1-14) + 3.8 (0-21) 0.17 Tracheostomy during hospitalization, n (%) 48 (23.3%) 42 (19.1%) 40 (16.6%) 0.09 PC consult before tracheostomy, n (%) 2 (4.2%) 4 (9.5%) 14 (35%) # <0.001 Total ventilator days, avg (range) 4.4 (0-28.9) 4.4 (0-55.0) 3.0 (0-22.2) 0.003 *Cohort 1 = Admitted before TQIP guidelines released (10/2015 - 10/2017); Cohort 2 = Between TQIP guidelines and multidisciplinary intervention (10/2017 - 9/2019); Cohort 3 = Post-multidisciplinary intervention (10/2019 - 8/2021).+ Statistically significant change between Cohort 1 and Cohort 2.# Statistically significant change between Cohort 2 and Cohort 3. Conclusion: Multidisciplinary clinical intervention was more effective than guidelines alone in improving delivery of palliative care to critically ill trauma patients. Development of a dedicated implementation guide for TQIP-PC guidelines may improve scalability and delivery of PC in all trauma centers. How Are We Defining Palliative Surgery in Cancer Patients? A Systematic Review Xinyi Casuarine Low, MSc, Jolene Wong, MD, MPH, Orly Farber, MD, Jennifer W Mack, MD, MPH, Zara Cooper, MD, MSC, FACS, Elizabeth J Lilley, MD, MPH Duke University School of Medicine, Durham, NC; Center for Surgery and Public Health, Brigham and Women’s Hospital, Boston, MA; Dana-Farber Cancer Institute, Brookline, MA Introduction: Up to 30% of patients with advanced cancer have surgical procedures, which are often palliative in nature. However, a consistent definition of palliative surgery is lacking in the literature. While some investigators consider palliative surgery as alleviating symptoms and improving quality of life (QoL), others consider any non-curative surgery to be palliative. This affects our ability to draw strong conclusions from current research. Therefore, we aim to summarize definitions of palliative surgery in advanced cancer patients undergoing thoraco-abdominal procedures as a first step toward creating a unifying taxonomy. Methods: We conducted a systematic review querying PubMed, Embase, and CINAHL from August 2005 through December 2023. We included English-language studies reporting any definitions for palliative surgery at thoraco-abdominal sites in cancer patients. Three reviewers independently screened retrieved studies and identified themes based on how studies have defined palliative surgery. Results: Of 1905 unique records identified, 92 studies with more than 27000 patients were included. A total of 66% of studies did not define palliative surgery in methodology. Among 31 studies where a definition was provided, we identified 3 overarching themes for definitions of palliative surgery (Table 1): (1) based on preoperative intent and goals of the procedure; (2) based on procedure type; and (3) based on completeness of oncologic resection. Table 1. - Themes Identified for Definition of Palliative Surgery Themes for definition Timing Example Intent and goals of operation Preoperative Relieve symptoms or improve QoL Type of procedure Preoperative Gastrointestinal bypass for malignant bowel obstruction was considered palliative without further explanation Completeness of oncologic resection Intra- or postoperative Extensive disease resected with grossly positive margins Conclusion: Palliative surgery is not well defined, and heterogeneity exists in its definition. This impacts our capacity to derive definitive conclusions based on evidence presented by existing studies, highlighting a need to clearly define palliative surgery for future research and clinical care. One-Year Postoperative Outcomes for Seriously Ill Older Adults with Pain, Depression, Functional Dependence, and Informal Caregiving Needs after Major Elective Surgery Jolene Wong, MD, MPH, Yihan Wang, PhD, Evan Bollens-Lund, MA, Amanda J Reich, PhD, Hiba Dhanani, MD, Christine Ritchie, MD, MSPH, Tamryn F Gray, PhD, MPH, Dae Hyun Kim, MD, MPH, ScD, Amy Kelley, MD, MSHS, Zara Cooper, MD, FACS Centre of Surgery & Public Health, Boston, MA; Icahn School of Medicine at Mount Sinai, Brooklyn, NY; Centre of Surgery & Public Health, Brookline, MA; Massachusetts General Hospital, Boston, MA; Harvard Medical School, Jamaica Plain, MA; Brigham & Women’s Hospital, Boston, MA; National Institutes of Health, Bethesda, MD Introduction: Seriously ill (SI) older adults are at risk for poor outcomes after surgery. While the American College of Surgeons endorsed palliative care (PC) alongside operative care for SI adults, factors that can be improved by PC are understudied in surgical patients. We hypothesize that SI older adults with pain, depression, functional dependence, and informal caregiving needs have increased mortality, healthcare use and cost compared with other older surgical patients. Methods: We used data from the Health and Retirement Study-linked Medicare claims (2008-2018) to identify SI older (≥66 years) adults who had major elective surgery (Healthcare Cost and Utilization Project definition) vs others. Multivariable regression models were used to determine whether pain, depression, functional dependence, and informal caregiving (PDFC) in SI adults were independently associated with increased mortality, healthcare use, and cost at 1 year after operation. Results: Of 2499 older adults who underwent major elective surgery, 63% were SI and 50% had SI with PDFC. When compared with non-SI and SI adults without PDFC, SI adults with any PDFC had higher odds of mortality (odds ratio [OR] 4.9, 95% CI 2.4-10), higher rate of total hospital days (incidence rate ratio [IRR] 2, 95% CI 1.5-2.6), hospital readmission (IRR 2, 95% CI 1.6-2.4), and emergency department visits (IRR 1.9, 95% CI 1.6-2.3). They also incurred the highest mean Medicare costs (USD $26554 vs $26418 vs $17370) at 1 year after operation. Conclusion: PDFC is common among SI older adults and associated with poor outcomes. Palliative care during surgical admission could decrease mortality and reduce downstream healthcare use and cost for these individuals. Patient and Surgical Factors Associated with New-Onset Postoperative Depression Lejla Pepic, BS, Irena Cenzer, PhD, Krista Reich, MD, Amy L Byers, PhD, MPH, John Boscardin, PhD, Matthew Miller, DPT, PhD, Victoria Tang, MD University of California, San Francisco, San Francisco, CA; University of Calgary, Calgary, AB, Canada Introduction: Among older adults undergoing operation, depressive symptoms are associated with increased likelihood of poor postoperative outcomes. However, little is known about the risk of developing postoperative depression, a key patient-centered outcome. Our study aimed to identify risk factors associated with new-onset depression in older adults after major operation. Methods: Using nationally representative longitudinal data from the Health and Retirement Study, we conducted a retrospective analysis examining older adults (≥65 years of age) without preoperative depression who underwent moderate to high-stress operation, defined by the Operative Stress Score (OSS). Our primary outcome was new-onset depression within 1 year of operation, binarily defined as ≥3 on the 8-item Center for Epidemiologic Studies Depression scale. Data were analyzed using multivariable logistic regression with predictor variables including demographic information, health status, cognitive impairment, functional status, marital status, and health-related behaviors. Results: Our cohort included 1471 participants, mean age 74.0 ± 8.7 years, 57.1% were women, 89.2% underwent moderate-stress procedures. Overall, 19.4% of participants met study criteria for new-onset depression within 1 year. Multimorbidity, activities of daily living (ADL) disability, and lower self-rated health were positively associated with depression. Higher education and higher wealth status were negatively associated with depression (Table 1). Table 1. - Risk Factors Associated with 1-Year Postoperative New-Onset Depression Preoperative characteristic New-Onset Depression (%) Odds Ratio (95% CI) p Value Age, years 65-7575-85>85 17.5 (14.6, 20.5)18.3 (15.1, 21.5)21.2 (14.1, 28.3) 11.1 (0.8, 1.4)1.3 (0.8, 2.0) 0.7320.328 Gender MenWomen 16.5 (13.4, 19.6)19.5 (16.7, 22.3) 11.2 (0.9, 1.6) 0.164 Race/Ethnicity(W = White, AA = African American) WAAOther 18.1 (15.9, 20.3)15.5 (9.2, 21.9)26.5 (14.9, 38.2) 10.8 (0.5, 1.4)1.6 (0.9, 3.1) 0.4790.118 Education(≥High school) NoYes 23.0 (18.2, 27.8)16.7 (14.4, 19.0) 10.7 (05, 0.9) 0.015* Wealth Quartile 1st2nd-3rd4th 20.9 (15.3, 26.5)19.7 (16.7, 22.7)14.4 (11.0, 17.8) 10.9 (0.6, 1.4)0.6 (0.4, 1.0) 0.701<0.001* Self-Rated Health(Fair or Poor) NoYes 16.3 (14.0, 18.7)23.5 (18.9, 28.2) 11.6 (1.2, 2.2) 0.004* Multimorbidity(≥3 conditions) NoYes 16.1 (13.5, 18.7)21.3 (17.7, 24.8) 11.4 (1.1, 1.9) 0.020* ADL Disability NoYes 17.6 (15.5, 19.7)28.3 (17.6, 39.0) 11.9 (1.1, 3.2) 0.028* Operative Stress Score (OSS) ModerateHigh 17.9 (15.7, 20.0)21.5 (14.4, 28.6) 11.3 (0.8, 2.0) 0.318 Conclusion: This study found that nearly 20% of surgical patients ≥65 years of age may experience new-onset depression soon after operation. Education level, wealth, self-rated health, multimorbidity, and ADL disability were associated with new-onset depression. Preoperatively, these factors can help identify at-risk older adults who may benefit from early postoperative psychosocial intervention aimed at reducing risk of incident depression. Survival and Functional Status after Unanticipated Operation in Long-Term Nursing Home Residents Tej D Azad, MD, MS, Jason M Johanning, MD, FACS, Shipra Arya, MD, Daniel E Hall, MD, FACS, Jeremy Walston, MD, Shari Ling, MD, Andrew Hersh, BA Johns Hopkins University, Baltimore, MD; University of Nebraska Medical Center, Omaha, NE; Stanford University, Stanford, CA; University of Pittsburgh, Pittsburgh, PA; Centers for Medicare and Medicaid Services, Baltimore, MD Introduction: Geriatric surgery efforts have focused largely on community-dwelling patients. Little is known about long-term nursing home care (LTC) residents who undergo unplanned operation. Methods: We linked Medicare claims to the Minimum Data Set (MDS) to identify LTC residents who underwent unplanned inpatient operation in 2018. The primary outcomes were 1-year functional status and mortality. Multivariable models (mortality, Cox Proportional Hazard; functional decline, logistic regression) underwent standard risk-adjustment, including for baseline cognitive and functional status, frailty, and Operative Stress Score (OSS). Results: A total of 18,018 LTC residents underwent unanticipated inpatient operation (OSS 3, 52%). One-year mortality was 42.3%. Demographic (older age, White race, male sex) and baseline factors (functional status, cognitive impairment, and frailty) were significantly associated with mortality. Of patients surviving beyond 1-year, only 16% experienced functional improvement. Higher baseline functional status (odds ratio [OR] 0.88, 95% CI 0.87-0.89, p < 0.0001) was protective against functional decline, while older age (OR 1.0, 95% CI 1.01-1.03, p < 0.0001), female sex (OR 1.2, 95% CI 1.1-1.3, p = 0.004), higher OSS (OR 1.2, 95% CI 1.1-1.2, p < 0.0001), and baseline cognitive impairment (moderate: OR 1.4, 95% CI 1.2-1.7, p < 0.0001; severe: OR 2.0, 95% CI 1.7-2.3, p < 0.0001) were associated with increased risk of functional decline. Conclusion: LTC residents undergoing unanticipated operation experience a high rate of mortality. Those who survive are unlikely to experience improved functional status. These data should inform shared decision-making regarding operative intervention in this high-risk population, particularly among those with diminished baseline functional or cognitive impairment. ePosters Analyzing the Impact of Palliative Decompressive Gastrostomy on Patient Wellbeing: A Mixed Methods Study Jeffrey Roberson, MD, Julia Gasior, BS, Sara Ginzberg, MD, Emna Bakillah, MD, Lauren Shreve, MD, MBA, Jesse Passman, MD, Catherine E Sharoky, MD, MSCE, Gregory Nadolski, MD, Kate R Courtright, MD, Elinore J Kaufman, MD, FACS The Hospital of the University of Pennsylvania, Philadelphia, PA Introduction: Palliative decompressive gastrostomy is intended to relieve the severe physical symptoms of malignant small bowel obstruction (SBO) near the end of life, but its overall impact on patients and caregivers is unknown. The objective of this study was to assess the impact of palliative decompressive gastrostomy on patient wellbeing. Methods: We prospectively enrolled patients with a malignant SBO and their caregivers in a mixed-methods study at the time of informed consent for decompressive gastrostomy. We collected the Edmonton Symptom Assessment Scale (ESAS) and the Functional Assessment of Chronic Illness Therapy-Palliative (FACIT-Pal-14) surveys from patients at baseline and 2-weeks, and the Caregiver Burden Scale survey from caregivers at baseline. Survey scores were compared using paired T tests. We also conducted semi-structured interviews with patients and their caregivers at follow-up until thematic saturation was reached. Content analysis was used to identify themes with two independent coders. Results: We enrolled 15 patient-caregiver dyads. The median caregiver burden scale score was 33 (high burden ≥17). Eight patients (53%) survived to 2 weeks, and of these, median ESAS scores (54 vs. 44, p = 0.009) and median FACIT-Pal-14 scores (22 vs. 31, p = 0.015) were significantly improved. Interviews revealed three major themes: improved symptom management, new stressors, and opportunities for improvement. Conclusion: Decompressive gastrostomy effectively alleviated symptoms near the end-of-life for patients with a malignant SBO. This palliative intervention may provide greater benefit if performed earlier, and caregivers and patients need improved resources and education for tube management to minimize added stressors. Decreased Patient Mortality Following Implementation of Geriatric Surgery Verification Standards Ileana Horattas, MD, Blake Westling, DO, Kelly Bahr, RN, Christin Boozer, APP, Adina Brett-Morris, PhD, Mark C Horattas, MD, FACS Cleveland Clinic Akron General, Akron, OH Introduction: The American College of Surgeons (ACS) proposed 32 standards to designate hospitals prepared to care for geriatric surgery patients. Our hospital obtained geriatric surgery verification designation. The present goal was to examine the effect of geriatric surgery verification (GSV) on patient outcomes, primarily mortality. Methods: Patients over age 75 who underwent surgery performed by general surgery during their admission to our hospital from July of 2021 through January of 2024 were included. Data were collected prospectively during this time. The GSV criteria were implemented in July 2022. Patients were separated into the pre-implementation group and post-implementation group. The 30-day mortality rate and hospital were Results were analyzed using with a = Results: The GSV standards were by a multidisciplinary group during In patients were included in the present Of these, were admitted to GSV the post-implementation group included patients the year to there were 23 30-day in patients In the years, there were 30-day among patients This was a significant = There were hospital among pre-implementation patients and among post-implementation patients This was not significant = Conclusion: of care across and in and of the GSV Implementation of the GSV standards may improve 30-day mortality in the at-risk geriatric surgery Geriatric Surgery Verification of Care and Status Blake Westling, DO, MBA, Ileana Horattas, MD, Christin Boozer, RN, Kelly Bahr, RN, Adina Brett-Morris, PhD, Mark C Horattas, MD, FACS Cleveland Clinic Akron General, Akron, OH Introduction: patients a in The of patients years or older is to from to by Our hospital the Geriatric Surgery Verification (GSV) by the American College of Surgeons (ACS) to care for patients 75 years and Our goal was to improve advanced care and status for geriatric patients. Methods: our implementation July were on advanced care at Methods for goals of care were and was for for the and for inpatient Results: In to education regarding the geriatric surgery status for general surgery patients over 75 years of age was Following education and of status on admission increased to in After multidisciplinary efforts to improve care for geriatric status further improved to Conclusion: care and of status is to the care of patients. goals of care with geriatric are to the of surgery and their care. This to a in inpatient geriatric status and improved care for patients. Using a to Palliative Care Needs among Trauma Patients MD, MS, MD, J MD, Christine MD, FACS University of California, Introduction: Delivery of palliative care alongside trauma care is a of the palliative care guidelines by the American College of Surgeons Trauma as be if this patient in the have proposed to identify patients that benefit from palliative care. However, and implementation of this have not Methods: This retrospective study patients admitted to academic care hospital after injury during who had a at time of hospital Patient outcomes were assessed including ICU and inpatient mortality. Palliative care included of care palliative care and inpatient Results: Of trauma patients admitted from 31, screened at time of patients had significantly hospital greater likelihood of ICU and higher inpatient mortality patients were more to have or palliative care consultation and in Conclusion: The used at time of is a to identify trauma patients with and higher mortality risk who are to benefit from palliative care work palliative care intervention to needs and goals with hospital

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