Leeds Vascular Institute, Leeds Teaching Hospitals NHS Trust, Leeds, UK.
School of Medicine, University of Leeds, Leeds, UK.
Ann Vasc Surg. 2024 Feb;99:280-289. doi: 10.1016/j.avsg.2023.08.024. Epub 2023 Oct 16.
Unplanned vascular admissions have a high mortality. Previous studies have indicated that end of life care (EoLC) among this group of patients is low but there exist limited data on EoLC in the United Kingdom. The aim of this study was to evaluate the quality and predictors of EoLC for unplanned vascular admissions to a tertiary center in the United Kingdom.
This was a retrospective single-center cohort study of unplanned vascular surgery admissions from August 1, 2019 to January 22, 2020. Data on patient demographics, markers of quality of palliative care, mortality, and cause of death of unplanned admission to the vascular surgery department were collected from hospital and general practitioner records and evaluated against EoLC to evaluate predictors and efficacy of EoLC. Quality of palliative care markers included documentation of preferred place of death and care priorities, time spent in hospital and the intensive care unit toward the end of life, and realization of documented care objectives. EoLC input was defined as a dedicated palliative care consultation (PCC) by a palliative care professional, medical doctor, surgeon, or advanced care practitioner. We also conducted a subgroup analysis of patients within this group with chronic limb-threatening ischemia (CLTI), diabetic foot, and ruptured aortic aneurysms, as all patients in this group should be offered EoLC according to international guidelines.
One-hundred and fifty patients were included. Median age at presentation was 70.5 years, and the cohort consisted of mostly men (72%). CLTI (31%) was the most common reason for admission. Surgical intervention was carried out in 60% of patients. Two-year mortality was 36%, and pneumonia (22%) was the most common cause of death. Seven percent of patients received PCC, which occurred a median of 10 days before death. Only a minority of patients had preferred place of care/death (14%), care priorities (37%), and family involvement during advance care planning (17%) documented in their notes; 29% of patients had Recommended Summary Plan for Emergency Care and Treatment forms in place. A diagnosis of left ventricular systolic dysfunction, chronic kidney disease, and increasing age predicted Recommended Summary Plan for Emergency Care and Treatment form completion. Patients with PCC were more likely to have advance care planning, but this did not translate into improvements in the other markers of quality of palliative and, consequently, EoLC.
EoLC was insufficient and of low quality despite a high mortality in this group. Clinical guidelines and pathways are needed to ensure these patients are considered for EoLC and those with CLTI, diabetic foot sepsis or ruptured abdominal aortic aneurysms are offered it by default. Further research is needed to help identify vascular patients who would benefit from EoLC earlier to improve quality at end of life.
计划外的血管入院患者死亡率较高。先前的研究表明，这组患者的临终关怀（EoLC）水平较低，但英国关于 EoLC 的数据有限。本研究的目的是评估英国一家三级中心计划外血管手术入院患者的 EoLC 质量和预测因素。
这是一项回顾性单中心队列研究，纳入 2019 年 8 月 1 日至 2020 年 1 月 22 日期间计划外血管外科入院患者。从医院和全科医生记录中收集患者人口统计学数据、姑息治疗质量标志物、计划外血管外科入院患者的死亡率和死亡原因，并将其与 EoLC 进行评估，以评估 EoLC 的预测因素和疗效。姑息治疗质量标志物包括记录首选死亡地点和护理优先级、临终前在医院和重症监护病房的时间，以及记录的护理目标的实现情况。EoLC 输入被定义为姑息治疗专业人员、内科医生、外科医生或高级护理从业者进行的专门姑息治疗咨询（PCC）。我们还对该组中患有慢性肢体缺血性疾病（CLTI）、糖尿病足和破裂性腹主动脉瘤的患者进行了亚组分析，因为根据国际指南，所有这些患者都应接受 EoLC。
共纳入 150 例患者。中位年龄为 70.5 岁，队列主要由男性（72%）组成。CLTI（31%）是最常见的入院原因。60%的患者接受了手术干预。两年死亡率为 36%，肺炎（22%）是最常见的死亡原因。7%的患者接受了 PCC，中位时间为死亡前 10 天。只有少数患者在病历中记录了首选护理/死亡地点（14%）、护理优先级（37%）和家庭参与预先护理计划（17%）；29%的患者有推荐的紧急护理治疗计划表格。左心室收缩功能障碍、慢性肾脏病和年龄增长预测了推荐的紧急护理治疗计划表格的完成。接受 PCC 的患者更有可能进行预先护理计划，但这并没有转化为姑息治疗和临终关怀质量的其他标志物的改善。
尽管该组患者死亡率较高，但 EoLC 仍然不足且质量较低。需要临床指南和途径来确保这些患者被考虑接受 EoLC，并且默认情况下为 CLTI、糖尿病足败血症或破裂性腹主动脉瘤患者提供 EoLC。需要进一步的研究来帮助确定更早受益于 EoLC 的血管患者，以提高生命末期的生活质量。
