Frail Older Patients Receiving Higher-Intensity End-of-Life Care
Frail older adults undergoing emergency general surgery receive more aggressive end-of-life care than older adults without frailty, according to the authors of a recent study.1
“Older emergency surgery patients have very high rates of mortality in the six months after surgery,” notes Zara Cooper, MD, MSc, FACS, one of the study’s authors and Kessler Director of the Center for Surgery and Public Health at Brigham and Women’s Hospital in Boston. “The end-of-life care that these patients receive is of interest to surgical clinicians and policymakers who seek to improve patient and family outcomes and experience.”
There were little data describing end-of-life care in older patients who die after emergency general surgery. “We sought to describe end-of-life trajectories for older emergency general surgery patients and, specifically, to compare patients with frailty to those who are not frail,” Cooper reports.
Cooper and colleagues retrospectively analyzed data of 138,916 adults older than age 66 years who underwent partial colectomy, small bowel resection, laparotomy, adhesiolysis, or peptic ulcer disease repair between 2008 and 2014 who died within one year. Of this group, patients with any degree of frailty went to hospice less often, spent fewer days at home, and needed higher-intensity care at the end of life. “We were surprised to see that frail patients received higher-intensity end-of-life care, and had higher healthcare utilization,” Cooper offers.
Frailty is well-recognized as a harbinger of adverse outcomes after surgery. Patients with more accurate prognostic understanding are less likely to choose high-intensity treatment at the end of life. “Our findings suggest that the most vulnerable patients are potentially being subjected to the most burdensome treatment, have fewer days at home, and are not receiving hospice care,” Cooper explains.
Of individuals who survived hospitalization but died within one year, those with moderate-to-severe frailty were most likely to be hospitalized again, to visit an ED, or be admitted to the ICU vs. individuals who were not frail. Overall, says Cooper, the study’s findings “highlight opportunity for targeted interventions for all older patients, especially frail older adults, undergoing emergency general surgery to establish better prognostic understanding and discuss advance care planning before hospital discharge.”
- Sokas C, Lee KC, Sturgeon D. Preoperative frailty status and intensity of end-of-life care among older adults after emergency surgery. J Pain Symptom Manage 2020 Nov 16;S0885-3924(20)30877-0. doi: 10.1016/j.jpainsymman.2020.11.013. [Online ahead of print].
There is an opportunity for targeted interventions for all older patients, especially frail older adults, undergoing emergency general surgery to establish better prognostic understanding and discuss advance care planning before hospital discharge.
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