C. M. McGreevy1, S. Pentakota1, A. Kunac1, O. Mohamed1, K. Sigler1, A. C. Mosenthal1, A. Berlin1 1Rutgers-New Jersey Medical School,Surgery Department,Newark, NJ, USA
Introduction: General surgeons are frequently consulted for placement of a gastrostomy tube, and patients requiring feeding access are often seriously ill. Current guidelines for quality palliative care recommend that all patients with a potentially life-limiting illness receive a palliative care assessment when feeding tube placement is considered. We aimed to characterize the extent of unmet palliative care need in patients receiving gastrostomy tubes by examining palliative care processes and outcomes in this population.
Methods: This is a retrospective study of all adult non-trauma inpatients who underwent gastrostomy tube placement in the year 2013. Patients were identified based on procedure codes. We abstracted data regarding demographics, diagnosis, indications, palliative care processes, and outcomes via chart review. The primary outcome was receipt of palliative care assessment prior to tube placement. Secondary outcomes included functional status at discharge as measured by Glasgow Outcome Scale (GOS) or Modified Rankin Scale (MRS), as well as in-hospital and 6-month mortality. We used counts and proportions to describe study variables and multivariable logistic regression to identify factors associated with receipt of palliative care.
Results: One hundred twenty-eight patients met inclusion criteria. All but 3 had a serious or life-limiting illness. Of the remaining 125 patients, head and neck malignancy (37%) was the leading indication, followed by acute cerebrovascular accident (27%), prolonged respiratory failure (15%), and other neurologic disorders (14%). Only 14% of patients in whom a tube was placed had a palliative care assessment prior to the procedure. Only indication and race/ethnicity were statistically significantly associated with this care pattern. No head and neck malignancy patients received a palliative care assessment, and non-black patients were much less likely to receive palliative care assessment prior to gastrostomy placement (OR: 0.28 (0.11-0.69)). 14% of patients required tube change due to a complication within 1 year of placement. In-hospital and 6-month mortality were 6% and 16%, respectively. 62% of survivors to discharge suffered from significant functional disability defined as a GOS of ≤3 or a MRS of ≥4: unable to walk or attend to bodily needs without assistance.
Conclusion: Despite expert consensus guidelines, the majority of patients with serious or life-limiting illness did not receive palliative care assessment prior to placement of a gastrostomy tube. While considered routine procedures, patients requiring feeding access have high mortality rates and poor functional outcomes. This suggests that consultation for feeding tube placement is an appropriate trigger for palliative care assessment and intervention to ensure treatment is aligned with patient preferences. Surgeons can promote high-quality, patient-centered care by taking an active role in this process.