E. W. Tindal1, C. A. Adams1, S. F. Monaghan1, D. S. Heffernan1, A. H. Stephen1, W. G. Cioffi1, S. N. Lueckel1 1Rhode Island Hospital,General Surgery,Providence, RI, USA
Introduction: As the population ages, there has been a change in focus from curing disease to improving end of life care. Patients who receive early palliative care report increased quality of life, less depression and had longer survival compared to patients with more aggressive care. Additionally, Do-Not-Resuscitate (DNR) orders have been associated with higher quality of life. In the setting of trauma, devastating injuries and an aging population with a reduced capacity to recover make the incorporation of these practices increasingly important. Here we aim to determine predictors of having an advanced directive (AD) at the time of presentation in trauma patients.
Methods: This is a retrospective analysis of our trauma registry from 2015 to 2017. We queried our registry for adult (≥ 18 years) patients with “Advanced directive limiting care” listed as a comorbidity on admission. We performed a multivariate logistic regression including a case-matching analysis to control for age to identify significant predictors of a pre-existing AD following univariate analysis.
Results: We identified 7561 patients, 822 with an AD on admission. Those with an AD were older (80 vs 55 years, p<.001), more likely to be female (64.8 vs 39.5%, p<.001) and white (93.3 vs 82.2%, p<.001). Patients with an AD were more likely to arrive from a nursing home (NH) (23.8 vs 0.1%, p<.001), and have multiple co-morbidities including a functionally-dependent health status (FDHS) (63.0 vs 35.7%, p<.001). Regression analysis demonstrated that a pre-existing AD was independently associated with age over 65 (odds ratio (OR) 3.8, p<.001), female gender (OR 1.5, p<.001), arrival from NH (OR 178, p<.001) as well as comorbidities which include dementia (OR 2, p<.001), congestive heart failure (CHF) (OR 1.6, p<.05), hypertension (HTN) (OR 2.7, p<.001), FDHS (OR 1.2, p<.05) and chronic obstructive pulmonary disorder (COPD) (OR 2.6, p<.001). Case-control matching for age was performed given the large age discrepancy between the two groups and showed that these factors remained significant with the exception of CHF and FDHS.
Conclusion: Our findings demonstrate that, in addition to age and comorbidities, gender plays a significant role in end-of-life planning even prior to arrival at the hospital. As a result of this, those without an AD in place may experience more physical and emotional discomfort following a traumatic injury than those who present with an AD at the time of admission. Additional analysis is warranted to determine what personal and systemic factors may be driving this relationship.