Connecting Anesthesiology, Intensive and Emergency Care with Palliative Care – a novel outcome-based approach for a closer collaboration
Public Health, Healthcare Research, Social and Occupational Medicine
Final Report Abstract
As populations age globally, the rise in chronic and critical illnesses is reshaping healthcare systems. Simultaneously, the increase in invasive treatments and surgical procedures at the end-of-life and the rising number of deaths occurring in intensive care units (ICUs) may contradict peoples’ preferences for life-sustaining treatments and dying in non-hospital settings. This highlights a crucial challenge: balancing modern treatment options with patient-centered care involving dignity and autonomy. Further, this is where palliative care provided as primary palliative care by all clinicians and specialist palliative care, delivered by a trained multi-professional team, may play a key role in perioperative and critical care with a focus on improving quality of life rather than just prolonging survival. In this multi-center retrospective cohort study, we aimed to develop and validate a simple and accurate instrument (PC-ICU score) predicting involvement of specialist palliative care during ICU treatment with predictors routinely collected within 24 hours of ICU admission to enable early integration. Score development was performed in 60,061 patient cases, of which 5.5% received specialist palliative care. The area under the receiver operating characteristic (AU- ROC) curve was 0.81 indicating excellent discriminative ability. External validation of the comprehensive score indicated good accuracy. A non-commercial calculator is available. For patients undergoing surgery, we investigated the timing of perioperative palliative care involvement and postoperative patient-centered outcomes. The exposure was timing of initial perioperative specialist palliative care involvement; preoperative, defined as 30 days to one day prior to surgery, versus postoperative, defined as day of surgery until 90 days after. The primary outcome was postoperative hospital length of stay in days with non-home/hospice discharge and 30-day readmission as secondary outcomes. 5,960 patients were included of which 26.8% received the initial specialist palliative care consultation preoperatively. Compared to postoperative involvement, preoperative specialist palliative care integration was associated with a shorter postoperative hospitalization, particularly in patients without metastatic cancer. There were no differences in the risk of non-home/hospice discharge, but lower odds of 30-day hospital readmission. These data suggest that early involvement of specialist palliative care in patients undergoing surgery might be beneficial and different among patient population. To investigate and optimize perioperative care, we explored the association between time of workday and the risk of intraoperative and postoperative adverse events in patients undergoing non-cardiac elective surgeries. Higher risks of intraoperative complications were observed around the middle and toward the end of the workday. The identified high-risk hours were associated with higher postoperative adverse events. Additionally, we investigated the perioperative safety of sodium–glucose-cotransporter-2 (SGLT-2) inhibitors, antidiabetic drugs which are increasingly prescribed due to their beneficial effects on cardiovascular mortality. While surgical patients using SGLT-2 inhibitors (1,383/21,158) had a measurable but clinically irrelevant lower pH, comparable risks of major postoperative adverse events and perioperative acidosis were observed.
