Advertisement

Palliative Care Consultation is Associated with Decreased Rates of In-Hospital Mortality Among Patients Undergoing Major Amputation

      Highlights

      • Palliative care was consulted for 12% of patients during admission for first major amputation.
      • Undergoing through knee amputation and receiving an amputation for acute limb ischemia were associated with increased rates of palliative care consultation.
      • Palliative care consultation was associated with decreased rates of in-hospital mortality.

      Background

      Despite advancements in medical care and surgical techniques, major amputation continues to be associated with risks for morbidity and mortality. Palliative care programs may help alleviate symptoms and align patients’ goals and the care they receive with their treatment plan. Access to specialty palliative medicine among vascular surgery patients is limited. Here, we aim to describe utilization and impact of formal palliative care consultation for patients receiving major amputations.

      Methods

      This is a retrospective, secondary data analysis project examining the records of patients who received major amputations by the vascular surgery team between 2016 and 2021. Demographics, operative, and postoperative outcomes were recorded. The primary outcome variable was palliative care consultation during index admission (the admission in which the patient received their first major amputation). Secondary outcomes were in-hospital mortality and code status at the time of death, if death occurred during the index admission, location of death, and discharge destination.

      Results

      The cohort comprised of 292 patients (39% female, 53% Black, mean age 63), who received a lower extremity major amputation. Most patients (65%) underwent amputation for limb ischemia. One-year mortality after first major amputation was 29%. Average length of stay was 20 days. Thirty-five (12%) patients received a palliative care consultation during the hospitalization in which they received their first major amputation. On multivariable analysis, patients were more likely to receive a palliative care consult during their index admission if they had undergone a thorough knee amputation (OR = 2.89, P = 0.039) or acute limb ischemia (OR = 4.25, P = 0.005). A formal palliative care consult was associated with lower likelihood of in-hospital death and increased likelihood of discharge to hospice (OR = 0.248, P = 0.0167, OR = 1.283, P < 0.001).There were no statistically significant differences in the code status of patients who received a palliative care consultation.

      Conclusions

      In a large academic medical center, palliative medicine consultation was associated with lower in-hospital mortality among patients with advanced vascular disease and major limb amputation. These data will hopefully stimulate much needed prospective research to develop and test tools to identify patients in need and derive evidence about the impact of palliative care services.
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Annals of Vascular Surgery
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Jones W.S.
        • Patel M.R.
        • Dai D.
        • et al.
        High mortality risks after major lower extremity amputation in Medicare patients with peripheral artery disease.
        Am Heart J. 2013; 165 (815.e1): 809-815
        • Duff S.
        • Mafilios M.S.
        • Bhounsule P.
        • et al.
        The burden of critical limb ischemia: a review of recent literature.
        Vasc Health Risk Manag. 2019; 15: 187-208
        • Wilson D.G.
        • Harris S.K.
        • Peck H.
        • et al.
        Patterns of care in hospitalized vascular surgery patients at end of life.
        JAMA Surg. 2017; 152: 183-190
        • de Mestral C.
        • Hsu A.T.
        • Talarico R.
        • et al.
        End-of-life care following leg amputation in patients with peripheral artery disease or diabetes.
        J Br Surg. 2020; 107: 64-72
        • Kwong M.
        • Curtis E.E.
        • Mell M.W.
        Underutilization of palliative care for patients with advanced peripheral arterial disease.
        Ann Vasc Surg. 2021; 76: 211-217
        • Liu S.
        • Heller D.R.
        • Jean R.A.
        • et al.
        Palliative care is underutilized and affects healthcare costs in ruptured abdominal aortic aneurysms.
        Surgery. 2020; 168: 234-236
        • Broman K.K.
        • Phillips S.E.
        • Ehrenfeld J.M.
        • et al.
        Identifying futile interfacility surgical transfers.
        Am Surg. 2017; 83: 866-870
        • Lilley E.J.
        • Cooper Z.
        • Schwarze M.L.
        • et al.
        Palliative care in surgery: defining the research priorities.
        J Palliat Med. 2017; 20: 702-709
        • Kelley A.S.
        • Meier D.E.
        Palliative care--a shifting paradigm.
        N Engl J Med. 2010; 363: 781-782
        • Ferguson L.
        • Barham D.
        Palliative care pandemic pack: a specialist palliative care service response to planning the COVID-19 pandemic.
        J Pain Symptom Manage. 2020; 60: e18-e20
        • Aslakson R.
        • Cheng J.
        • Vollenweider D.
        • et al.
        Evidence-based palliative care in the intensive care unit: a systematic review of interventions.
        J Palliat Med. 2014; 17: 219-235
        • Maciver J.
        • Ross H.J.
        A palliative approach for heart failure end-of-life care.
        Curr Opin Cardiol. 2018; 33: 202-207
        • Quinn K.L.
        • Stukel T.
        • Huang A.
        • et al.
        Association between attending physicians' rates of referral to palliative care and location of death in hospitalized adults with serious illness: a population-based cohort study.
        Med Care. 2021; 59: 604-611
        • Brumley R.
        • Enguidanos S.
        • Jamison P.
        • et al.
        Increased satisfaction with care and lower costs: results of a randomized trial of in-home palliative care.
        J Am Geriatr Soc. 2007; 55: 993-1000
        • RStudio Team
        RStudio: Integrated Development for R.
        RStudio, PBC, Boston, MA2020
        • Gaertner J.
        • Siemens W.
        • Meerpohl J.J.
        • et al.
        Effect of specialist palliative care services on quality of life in adults with advanced incurable illness in hospital, hospice, or community settings: systematic review and meta-analysis.
        BMJ. 2017; 357: j2925
        • Olmsted C.L.
        • Johnson A.M.
        • Kaboli P.
        • et al.
        Use of palliative care and hospice among surgical and medical specialties in the Veterans Health Administration.
        JAMA Surg. 2014; 149: 1169-1175
        • Scally C.P.
        • Robinson K.
        • Blumenthaler A.N.
        • et al.
        Identifying core principles of palliative care consultation in surgical patients and potential knowledge gaps for surgeons.
        J Am Coll Surg. 2020; 231: 179-185
        • Gandesbery B.
        • Dobbie K.
        • Joyce E.
        • et al.
        Surgical versus medical team assignment and secondary palliative care services for patients dying in a cardiac hospital.
        Am J Hosp Palliat Care. 2019; 36: 316-320
        • Rodriguez R.
        • Marr L.
        • Rajput A.
        • et al.
        Utilization of palliative care consultation service by surgical services.
        Ann Palliat Med. 2015; 4: 194-199
        • Campbell W.B.
        • Verfaillie P.
        • Ridler B.M.
        • et al.
        Non-operative treatment of advanced limb ischaemia: the decision for palliative care.
        Eur J Vasc Endovasc Surg. 2000; 19: 246-249
        • Ernst K.F.
        • Hall D.E.
        • Schmid K.K.
        • et al.
        Surgical palliative care consultations over time in relationship to systemwide frailty screening.
        JAMA Surg. 2014; 149: 1121-1126
        • Hicks C.W.
        Commentary: palliative care consults should be considered standard of care for patients presenting with ruptured abdominal aortic aneurysms.
        Surgery. 2020; 168: 237
        • Lilley E.J.
        • Khan K.T.
        • Johnston F.M.
        • et al.
        Palliative care interventions for surgical patients: a systematic review.
        JAMA Surg. 2016; 151: 172-183
        • Northouse L.L.
        • Mood D.W.
        • Schafenacker A.
        • et al.
        Randomized clinical trial of a family intervention for prostate cancer patients and their spouses.
        Cancer. 2007; 110: 2809-2818
        • Higginson I.J.
        • Bausewein C.
        • Reilly C.C.
        • et al.
        An integrated palliative and respiratory care service for patients with advanced disease and refractory breathlessness: a randomised controlled trial.
        Lancet Respir Med. 2014; 2: 979-987
        • Zimmermann C.
        • Swami N.
        • Krzyzanowska M.
        • et al.
        Early palliative care for patients with advanced cancer: a cluster-randomised controlled trial.
        Lancet. 2014; 383: 1721-1730
        • Bakitas M.
        • Lyons K.D.
        • Hegel M.T.
        • et al.
        Effects of a palliative care intervention on clinical outcomes in patients with advanced cancer: the Project ENABLE II randomized controlled trial.
        JAMA. 2009; 302: 741-749
        • May P.
        • Normand C.
        • Cassel J.B.
        • et al.
        Economics of palliative care for hospitalized adults with serious illness: a meta-analysis.
        JAMA Intern Med. 2018; 178: 820-829
        • Earle C.C.
        • Park E.R.
        • Lai B.
        • et al.
        Identifying potential indicators of the quality of end-of-life cancer care from administrative data.
        J Clin Oncol. 2003; 21: 1133-1138