J. K. Bhangu1,2, B. T. Young1,2, S. E. Posillico1,2, H. A. Ladhani1,2, S. J. Zolin1,2, C. W. Towe2,3, J. A. Claridge1,2, V. P. Ho1,2 1MetroHealth Medical Center,Division Of Trauma, Critical Care, Burns And Emergency General Surgery,Cleveland, OH, USA 2Case Western Reserve University School Of Medicine,Cleveland, OH, USA 3University Hospitals Cleveland Medical Center,Thoracic & Esophageal Surgery,Cleveland, OH, USA
Introduction:
American College of Surgeons guidelines suggest that a structured family meeting in trauma patients with high risk of mortality or permanent disability should be performed to align care with patient goals and avoid life-sustaining care inconsistent with patient values. Multidisciplinary family meetings (MDFM), rather than meetings with a single team, may facilitate decision making by allowing multiple specialists to provide concordant perspectives on prognosis. We hypothesized that use of MDFM would be associated with higher utilization of comfort measures for dying trauma patients.
Methods:
All trauma patients who died at an academic adult level I trauma center (December 2014 to December 2017) were reviewed. Patients who died within 24 hours of arrival or who were transferred to non-trauma services were excluded. Age, injury mechanism, length of stay (LOS), and use of tracheostomy or gastrostomy tube were collected. Code status was categorized as Full Code, Do Not Resuscitate (DNR) or Comfort Care (CC). DNR allowed escalation of care and aggressive measures until cardiac arrest. For CC, only interventions which would maximize the patient’s comfort were instituted. A family meeting was defined as any documented discussion with family addressing prognostication and/or goals of care. A MDFM required the presence of least 2 disciplines, including caregivers from different specialties (typically trauma, neurosurgery, or palliative care), social workers, or chaplains. Comparisons were made between patients with and without MDFM, via Wilcoxon rank sum or Fisher’s exact test.
Results:
177 patients met inclusion criteria. 68% of patients were male; median age was 70 (IQR 58-83). Most patients were admitted after blunt trauma (90%). The median hospital LOS was 6 days (IQR 4-12). 49 patients (28%) had at least one MDFM, 117 (66%) of patients had meetings with individual teams only, and 11 (6%) had no documented meetings. Patients with and without MDFM had similar age and LOS. At the time of death, 73% of patients were CC, 18% were DNR, and 9% were full code. Patients with MDFM were more likely to be CC at the time of death (88% vs 68%, p<0.05), and less likely to be DNR (8% vs 23%, p<0.05). (Table)
Conclusion:
In our center, families commonly discussed prognosis and goals of care with single teams. MDFM were less commonly performed but were associated with a higher use of comfort measures. We encourage the use of MDFM in the trauma setting and are adopting a protocol to identify patients appropriate for MDFM in our institution.
