From the Journals

Palliative care underutilized in dementia patients with acute abdomen

View on the News

Not routine, but I always do it

Few surgeons would argue that a patient with dementia and an acute abdomen would be less appropriate for a palliative care consultation than demented patients with a hip fracture or ICU admission who have been shown to benefit from triggered palliative care consults. However, the dynamic interaction between patient, family, and surgeon, described by Thomas Miner as the “palliative triangle,” will likely prevent universal acceptance of triggered consults (Ann Surg Oncol. 2002;9[7]:696-709). Despite the current trend of increasingly algorithmic care, there is still a need for surgeon autonomy for treatment decisions even when the recommended triggered intervention is highly appropriate. A mentor of mine put it, “I never do things routinely, but there are some things I do all the time.” As the benefits of palliative care become more evident, the referrals for palliative care for this latest indication will become “some things I do all the time” just as pharmacokinetics referrals have become for antibiotics, anticoagulation, and total parenteral nutrition.

Dr. Geoffrey Dunn

Geoffrey P. Dunn, MD, FACS, is the medical director of the palliative care consultation service at the University of Pittsburgh Medical Center Hamot in Erie, Pa., and vice chair of the ACS Committee on Surgical Palliative Care.



Despite high rates of in-hospital mortality and nonroutine discharge, palliative care is underutilized in patients with dementia and acute abdominal emergency, according to findings published in Surgery.

“Currently little is known about palliative care utilization among patients with dementia in possible need of surgical intervention. This raises the question of whether the acute surgical emergency represents an appropriate episode during which to introduce palliative care for patients with dementia,” wrote Ana Berlin, MD, FACS, of the department of surgery at New Jersey Medical School, Newark, N.J., and her coauthors (Surgery. 2017 Dec 4. doi: 10.1016/j.surg.2017.09.048).

Of 15,209 patients aged 50 years and older with dementia and acute abdomen, 7.5% received palliative care. Patients discharged nonroutinely and patients treated operatively were less likely to receive palliative care, the researchers reported.

Dr. Berlin and her colleagues used the National Inpatient Sample database to identify patients with dementia and acute abdomen who were admitted nonelectively between 2009 and 2013. They used ICD-9 primary and secondary codes to limit surgical diagnoses to gastrointestinal obstruction, ischemia, and perforation.

Overall, 50.9% of patients were admitted for gastrointestinal obstruction, 39.8% for perforation, 5.1% for bowel ischemia, and 4.3% for mixed pathology; 17.8% of patients were managed operatively.

Patients with intestinal ischemia had the highest rate of both operation and mortality, at 22.8% and 27.6%, respectively. These patients also had the lowest rate of routine discharge, at 15.9%, the authors said. In comparison, patients with obstruction had surgical intervention and in-hospital mortality rates of 17% and 10.1%, respectively, and a routine discharge rate of 20.9%. Patients with perforation had an operation rate of 13.8%, in-hospital mortality rate of 6.8%, and routine discharge rate of 26.9%.

The palliative care utilization rate overall was 7.5%. Patients with mixed pathology who did not have surgery were most likely to receive palliative care, at 21.1%, noted Dr. Berlin and her coauthors.

Patients who died postoperatively were less likely than were those who died without surgical intervention to have received palliative care (20.9% vs. 31.4%; odds ratio = 0.63, 95% confidence interval, 0.46-0.86; P = .0039), and those who were discharged nonroutinely after an operation were less likely than were patients who were discharged nonroutinely without an operation to receive palliative care (3.7% vs. 7.0%; OR = 0.44, 95% CI, 0.34-0.57; P less than .0001).

Lastly, patients who received palliative care had shorter median hospital stays than did those who did not receive palliative care (5 days vs. 6 days; P less than .0001). These patients also had lower median hospital charges ($29,500 vs. $31,600; P = .0403).

The results identify two subsets of patients with unmet palliative care needs: patients requiring operative intervention, and patients with a diagnosis of intestinal ischemia, the authors said. In addition, the findings suggest that “surgeons should consider initiating palliative care … early in the hospital course for patients with dementia presenting with acute surgical abdomen,” they wrote.

“Both hip fracture and intensive care unit admission in patients with dementia have been described as appropriate triggers for palliative care assessment. ... Acute abdominal emergency [may also represent] an appropriate episode during which to introduce palliative care for patients with dementia,” they concluded.

The study was funded by the Rutgers New Jersey Medical School department of surgery and the New Jersey Medical School Hispanic Center of Excellence, Health Resources, and Services Administration. No other disclosures were reported.

Next Article: