From the Department of Surgery, Rutgers-New Jersey Medical School (M.F., F.H., S.R.P., D.H.L., A.C.M.), Newark, New Jersey.
J Trauma Acute Care Surg. 2019 Nov;87(5):1156-1163. doi: 10.1097/TA.0000000000002440.
Palliative Care (PC) is indicated in patients with functional dependency and advanced care needs in addition to those with life-threatening conditions. Older trauma patients have PC needs due to increased risk of mortality and poor long-term outcomes. We hypothesized that older trauma patients discharged alive with poor outcomes are not easily identified nor receive PC interventions.
Prospective observational study of trauma patients 55 years or older. Patients with poor functional outcomes defined by discharge Glasgow Outcome Scale Extended (GOSE) 1-4 or death at 6-month follow-up were analyzed for rate and timing of PC interventions including goals of care conversation (GOCC), do-not-resuscitate (DNR) order, do not intubate (DNI) order, and withdrawal of life supporting measures. Logistic regression was performed for having and timing of GOCC.
Three hundred fifteen (54%) of 585 patients had poor outcomes. Of patients who died, 94% had GOCC compared with 31% of patients who were discharged with GOSE 3 or 4. In patients who died, 85% had DNR order, 18% had DNI order, and 56% had withdrawal of ventilator. Only 24% and 9% of patients with GOSE of 3 or 4, respectively, had DNR orders. Fifty percent of the patients who were dead at 6-month follow-up had GOCC during initial hospitalization. The median time to DNR in patients that died was 2 days compared with 5 days and 1 day in GOSE 3 and 4 (p = 0.046). Age, injury severity scale, and preexisting limited physiological reserve were predictive of having a GOCC.
The PC utilization was very high for older trauma patients who died in hospital. In contrast, the majority of those who were discharged alive, but with poor outcomes, did not have PC. Development of triggers to identify older trauma patients, who would benefit from PC, could close this gap and improve quality of care and outcomes.
姑息治疗（PC）适用于功能依赖和有先进医疗需求的患者，以及有生命危险的患者。由于较高的死亡率和较差的长期预后，老年创伤患者有 PC 的需求。我们假设，生存但预后不良的老年创伤患者不易被识别，也无法获得 PC 干预。
对 55 岁或以上的创伤患者进行前瞻性观察性研究。通过出院格拉斯哥预后评分扩展（GOSE）为 1-4 分或 6 个月随访时死亡来定义功能结局不良的患者，分析 PC 干预措施（包括治疗目标对话（GOCC）、不复苏（DNR）医嘱、不插管（DNI）医嘱和停止生命支持措施）的发生率和时机。采用逻辑回归分析进行 GOCC 的时机。
585 例患者中有 315 例（54%）预后不良。在死亡患者中，94%进行了 GOCC，而在出院时 GOSE 为 3 或 4 的患者中，有 31%进行了 GOCC。在死亡患者中，85%有 DNR 医嘱，18%有 DNI 医嘱，56%有呼吸机撤机。分别只有 24%和 9%的 GOSE 为 3 或 4 的患者有 DNR 医嘱。在 6 个月随访时死亡的患者中，有 50%在住院期间进行了 GOCC。死亡患者的 DNR 中位数时间为 2 天，而 GOSE 为 3 或 4 的患者分别为 5 天和 1 天（p=0.046）。年龄、损伤严重度评分和预先存在的有限生理储备是进行 GOCC 的预测因素。
在院内死亡的老年创伤患者中，PC 的使用率非常高。相比之下，大多数出院但预后不良的患者没有接受 PC。开发识别老年创伤患者的触发因素，使他们受益于 PC，可能会缩小这一差距，提高护理质量和预后。
