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2019 HSR&D/QUERI National Conference Abstract

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4064 — Palliative Care and End of Life Outcomes Following High Risk Surgery

Lead/Presenter: Maria Yefimova,  COIN - Palo Alto
All Authors: Yefimova M (Center for Innovation to Implementation, Palo Alto), Yang, L (Center for Innovation to Implementation, Palo Alto), Garcia, A (Center for Innovation to Implementation, Palo Alto) Boothroyd, D (Center for Innovation to Implementation, Palo Alto) Giannitrapani, K (Center for Innovation to Implementation, Palo Alto) Morris, A (Stanford University) Johanning, J (Surgery, Nebraska-Western Iowa VA Medical Center, Nebraska) Shreve, S (Hospice and Palliative Care, Lebanon VA Health Care System, Lebanon) Watcherman, M (General Internal Medicine, VA Boston Health Care System, Boston) Lorenz, K (Center for Innovation to Implementation, Palo Alto)

Objectives:
Palliative care has potential to improve support that patients and families receive when undergoing high risk surgery. The objective of this study is to characterize perioperative palliative care and its influence on family reported end-of-life outcomes among Veterans who died within 90 days of a high-risk surgical operation.

Methods:
This is retrospective cross-sectional cohort study of Veterans who underwent one of 227 high-risk operations between 2012 and 2015. We examined the effect of palliative care consultation (PCC) 30 days before or 90 days after surgery on family-reported ratings of end-of-life care. VA that surveys all families of inpatient decedents using the validated Bereaved Family Survey. We used a single item for overall end-of-life care, and composite scores for communication and support.

Results:
95,204 Veterans underwent high risk operations in 129 inpatient VA medical centers. Most patients were ?65 years and had cardiothoracic or vascular procedures. Ninety-day mortality was 6.0% but varied by surgical sub-specialty. In the entire cohort, 3.5% had a PCC, and 0.8% received one before surgery. Among the 5,740 Veterans who died within 90 days, 28.4% had any PCC with 5.6% receiving it before surgery. Families of decedents who received PCC were 47% more likely to rate overall end-of-life care as "excellent" (OR = 1.47; 95% CI = 1.14-1.88, P = 0.007) than those who did not. Similarly, families of decedents who received PCC were more likely than their counterparts to rate end-of-life communication (OR = 1.43, 95% CI = 1.09-1.87, p = 0.004) and support (OR = 1.31, 95% CI = 1.01-1.71, p = 0.05) as "excellent".

Implications:
A cohort of Veterans undergoing high-risk surgical operations had substantial postoperative mortality, yet only one-quarter of those who died within 90 days of the procedure used palliative care. Receipt of a palliative consultation was associated with better rating of overall end-of-life care, communication, and support, as reported by the bereaved families of inpatient decedents.

Impacts:
Among surgical decedents, palliative care is associated with higher quality end-of-life care. These findings advocate for clinical practices and policies that support integrating palliative services and approaches in the perioperative period, such as preoperative frailty screening and shared decision-making regarding surgery.