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Geriatric Trauma and End-of-Life Decisions
By Karen L. Johnson PhD, RN, School of Nursing, University of Maryland, Baltimore, is Associate Editor for Critical Care Alert.
Dr. Johnson reports no financial relationship to this field of study.
The population of the United States is aging and by 2020, there will be 51 million Americans over the age of 65 years.1 As the population ages, a greater number of elderly patients will be injured and require hospitalization for traumatic injuries. Recent reports suggest that elderly patients are the fastest growing segment of patients admitted to trauma centers.2 Estimates predict that 40% of trauma admissions will be over the age of 65 by the year 2050.3
Geriatric trauma is usually defined as that occurring in individuals older than 65 years.4 While age appears to contribute to mortality in elderly trauma patients, age, by itself, does not predict in-hospital mortality in elderly trauma patients.5 Unfortunately, the effect of trauma on the elderly is more serious than that observed in younger patients.6
End-of-Life Experiences in Hospitalized Elders
Research at the end of life has been identified as a priority by professional organizations.7-9 There is a growing body of knowledge related to the end-of-life experience and care for hospitalized elderly patients with specific disease states such as heart disease,10 cancer11 and stroke.12 Unfortunately, little is known about end-of-life care for hospitalized elderly patients with traumatic injuries. These complex patients present their own unique challenges at the end of life. They face death from an unexpected acute event, unlike other elderly patients for whom death comes as a gradual decline from chronic illness or as an acute exacerbation in the context of significant disease. To these patients, trauma represents a sudden onset of an acute life-threatening condition for which they have not prepared.
Two large-scale studies on hospitalized elderly patients at end of life have recently been conducted: The Study to Understand Prognosis and Preferences for Outcomes and Risks of Treatment (SUPPORT)13 and the Hospitalized Elderly Longitudinal Project (HELP).14 SUPPORT was a large-scale two-phase study conducted over a five-year period in five academic medical centers in the U.S. More than 9100 patients, with an average age of 65 years, were enrolled in the SUPPORT studies. Unfortunately, both the SUPPORT and HELP studies excluded patients with traumatic injury.
The SUPPORT Study
SUPPORT Phase I was a two year (1989-1991) prospective observational study designed to assess communication patterns, the frequency of aggressive treatment and the characteristics of hospital death.13 SUPPORT Phase I confirmed shortfalls in patient-physician communication and barriers to optimal management. Shortfalls in communication were evidenced by the fact that less than half of the physicians knew when their patients preferred to avoid cardiopulmonary resuscitation. A high frequency of aggressive treatment was apparent, as 46% of do-not-resuscitate orders were written within two days of death. Unfortunately, 38% of patients who died spent at least ten days in an intensive care unit (ICU), and for 50% of conscious patients who died in the hospital, family members reported moderate to severe pain at least half the time.
SUPPORT Phase II was a two-year (1992-1994) cluster randomized controlled clinical trial designed to test an intervention to address the deficiencies identified in Phase I. The intervention aimed to make it easier to achieve better end-of-life decision-making. It provided physicians with accurate predictive information of future functional ability, survival probability for each day up to six months, and patient preferences for end-of-life care. A skilled nurse augmented the medical care team to elicit patient preferences, facilitate advance planning, provide prognoses, enhance understanding, and enable palliative care. The goals of the intervention program were to increase communication and understanding of prognoses in an effort to reduce the use of resources and time spent by patients in undesirable states before death and to facilitate earlier treatment decisions. Outcome variables included physician understanding of patient preferences, incidence and time of documentation of DNR orders, pain, time spent in the ICU, comatose, or receiving mechanical ventilation before death, and hospital resource use.
Unfortunately, the intervention proved to have no impact on any of the outcome variables. In fact, there were no secular trends toward improvement for intervention or control patients during the five years of SUPPORT data collection. SUPPORT II results demonstrate that additional resources to improve end-of-life processes of care will not work until we more fully understand the patient's experience within the context of the hospital environment.
The HELP Study
This was a random sample of persons over age 80 years who were hospitalized in one of the SUPPORT centers during 1994. It was intended only to create an additional database in an effort to describe the largely unexamined experience of the "very" elderly. Over 1100 patients were enrolled in the HELP studies.
Lynn and colleagues15 performed a secondary data analysis to examine the end-of-life experience for patients in SUPPORT and HELP who died in the hospital. More than half the patients remained conscious in the last three days of life and were able to communicate with their surrogates. The most prevalent symptom patients reported was fatigue (80%), over 50% reported dyspnea, 40% reported severe pain, and 25% had moderate anxiety. Less than 15% reported nausea. Over 70% of patients found it difficult to tolerate these physical symptoms. These results highlight an unacceptable situation: severely ill elderly patients die in acute care hospitals often with severe pain, shortness of breath, anxiety and other symptoms that are difficult to tolerate.
Quality Indicators for End-of-Life Care in Vulnerable Elders
Care for vulnerable elders has come under increased scrutiny in the past several years as studies demonstrate inadequate quality of care with regard to control of symptoms, matching of care with patient preferences, and optimal resource use at the end of life.13 With aging comes a shift in health goals along with health status as older adults conclude that minimizing compromised function or disability and maximizing quality of life are sometimes more important than postponing death.14 Providing quality care for hospitalized elderly patients requires a knowledgeable staff as well as health care system processes that support and recognize the unique needs of the elderly patient population. This vulnerable group of patients has been shown to benefit from coordinated programs of care.16
Wenger and Rosenfeld17 identified 14 quality indicators for end-of-life care in vulnerable elders that focus on institutional and medical provider interventions. They focus on patient preferences for care (through advance planning and decisions about aggressiveness of care) and palliation. These indicators aim to assess the provision of care to achieve a "good death," defined by the Institute of Medicine as "one that is free from avoidable distress and suffering for patients, families, and caregivers; in general accord with patients' and families' wishes; and reasonably consistent with clinical cultural and ethical standards.11 The indicators include advanced directives, documentation of care preferences, eliciting preferences concerning future health states, advance directive continuity, patient preferences of mechanical ventilation, patient participation in life-sustaining care decisions, care consistency with documented care preferences, management of ventilator withdrawal, treatment of dyspnea and pain, and attention to spiritual issues (see Table). These indicators should be included in our trauma system quality improvement processes to serve as a basis with which to compare the care provided by health care delivery systems and as a method to evaluate change over time or in response to an intervention.
Unfortunately there are multiple barriers to achieving these quality indicators in the care of elderly trauma patients. The lack of physician initiative in raising the issue of advanced directives is frequently perceived as a barrier by patients.18 Moreover, some advanced directives may be have been written many years prior to admission. Unlike heath care providers in primary care settings, trauma care providers in the acute care settings rarely have established relationships with patients to discuss these issues.
Consideration of these quality indicators is often met with skepticism and frustration that the indicators are unrealistic in the trauma patient population. Discussion of end of life care in these patients tends to occur late in the hospitalization because long-term functional outcomes of elderly patients who survive their injuries can be good.19 Discussions about limitation of care are frequently a source of conflict among health care team members. Perceived suffering of geriatric trauma patients is a frequent cause of emotional distress for critical care nurses.20 Nurses feel they are frequently the first members of the team to raise the question of limiting care because of futility and patient suffering. Unfortunately, the futility of care in elderly trauma patients is not obvious and opinions are greatly influenced by clinician skill and experience as well as personal and cultural values.21
Nonetheless, health care providers who interact with geriatric trauma patients and their families have the obligation to review these guidelines to determine what will work best in their respective ICUs. Some consider the absence of appropriate end-of-life care as medical error.22 The ACOVE quality indicators, as summarized in the Table on page 46, can be used as a checklist that might initiate the process of exploring end-of-life care in geriatric trauma patients and their families. The implementation and testing of these indicators provide a target to which we can benchmark the care we provide to these vulnerable patients and their families at such crucial times.