N.S. Dagen1, A.H. Stephen1, D.S. Heffernan1 1Brown University School Of Medicine, Division Of Trauma Critical Care, Department Of Surgery, Providence, RI, USA
Introduction: The intersection of surgery and palliative care (PC) is well-studied as it relates to oncology. However, little is known about care processes and medical decision making when patients present with novel surgical emergencies that are unrelated to the diagnoses that initiated their palliative care. Perforated peptic ulcer disease (PUD) is a potentially life-threatening surgical presentation and operative intervention remains the optimal care of patients with perforated PUD. We reviewed how PC status among patients with acutely perforated PUD affects operative interventions and outcome status.s.
Methods: A 4-year retrospective review of National Inpatient Sample (NIS) patients presenting with acute perforated PUD. Charts were reviewed for preadmission palliative care diagnoses, as well as DNR/DNI status. Charts were reviewed for all interventions including undergoing operation for the perforated PUD and timing of operative intervention. Outcomes included length of stay, mortality, and days to in-hospital death.
Results:Among the total of 7,881 patients with perforated PUD, patients with PC (N=810), were older (77.4+/-0.3 versus 59.9+/-0.19 years; p<0.001), more likely female (65.4% versus 49.1%; p<0.001), more likely Caucasian (80.1% versus 68.4%; p<0.001), and markedly less likely to have private insurance (24.5% versus 71.4%; p<0.001). For associated comorbidities, palliative care patients had higher rates of CHF (11.7% versus 2.4%; p=0.002), dementia (9.6% versus 1.7%; p <0.001), hypertension (73.4% versus 45.4%; p<0.001), or a history of a malignancy (17.7% versus 6.1%; p<0.001). Overall, PC patients were less likely to undergo operation for the perforated PUD (71.4% versus 83.5%; p<0.0001). Notably, among patients who underwent operation, PC patients were less likely to undergo operation within 24 hours of presentation (83.1% versus 94.7%; p=0.002). Overall, PC patients with perforated PUD had markedly higher overall rates of death (39.2% versus 1.1%; p<0.001). Interestingly, among PC patients, there was no difference on mortality rate whether managed operatively or non-operatively (39.4% versus 38.8%; p=0.95). Adjusting for demographics and significant comorbidities, PC patients still had a markedly increased risk of death following operation for perforated PUD (OR=14.7; 95% CI=11.7-31.5). Further, among patients who died, those who were managed non-operatively had shorter time to death (3.2+/-0.4 versus 10.2+/-0.5 days; p<0.001).
Conclusion: Palliative care patients have very high mortality when presenting with perforated peptic ulcer disease and mortality is unaffected by whether patients undergo operative intervention or are managed non-operatively. This data should carefully inform decision making in palliative care status patients.