A. Briggs1,2, V. Anto1, R. Handzel1, A. Peitzman1, R. Forsythe1 1University of Pittsburgh Medical Center,Pittsburgh, PA, USA 2Dartmouth Hitchcock Medical Center,Lebanon, NH, USA
Introduction:
Critically ill patients undergoing emergency general surgery procedures have significant risk of mortality. Perioperative patient and family conversations in this population can be difficult, as they can require not only discussion of the clinical situation, but also quality of life prior to the acute illness, assessment of patient goals for future quality of life and end of life care. The aim of this study was to analyze goals of care discussions in EGS patients in the intensive care unit (ICU).
Methods:
Emergency general surgery patients originating in or admitted to the medical and surgical intensive care units from 2010 to 2016 who underwent abdominal surgery were identified from a prospective, electronic record based registry. Postoperative deaths during admission were identified. Charts were reviewed to determine code status at the time of admission, changes in during the hospital stay, and at the time of death. Involvement of palliative care or ethics services was recorded.
Results:
During this time period, 799 patients underwent abdominal procedures. The unadjusted mortality rate was 24.2% (193/799). Of those patients who died, 97.4% (188/193) were full code at the time of admission, although in 33.7% of cases (65/193) there was no documentation of a detailed discussion of code status prior to the index procedure. At the time of death, 79.3% (153/193) had been transitioned to ‘comfort measures only’ (CMO). Palliative care or ethics services were involved in 14.5% of cases. During admission, 25.4% of patients had multiple changes in code status, with the majority transitioning from full code to ‘do not resuscitate’ (DNR) and then ultimately to CMO prior to death. In 6 patients, code status was decided at the time of arrest. Within the first 48 hours, 26.9% of deaths occurred, with 73.1% of these as patients transitioned to CMO, 11.5% as DNR and 15.4% with full code. In this early mortality population, 36.5% of patients did not have a documented preoperative discussion of code status.
Conclusions:
The majority of ICU patients who died after EGS procedures had been transitioned to CMO status prior to death. In patients who died within 48 hours, one-third had no documented preoperative discussion of code status. An understanding of patient goals of care is vital in the perioperative management of critically ill EGS patients. Further study is required to determine whether an increase in the preoperative discussion of code status would yield different decisions regarding pursuit of emergency procedures in this high-risk population.