Article 1
Palliative Delays Associated with Increased Length of Stay in Older Traumatic Brain Injury Patients.
Hatfield SA, Safe P, Siderides C, An A, Villegas CV, Goulet N, Winchell RJ, Gorman E. J Trauma Acute Care Surg. 2025 Dec 1;99(6):913-919.
This is a single center retrospective study that sought out to characterize palliative interventions in elderly patients (> 55 years of age) with moderate to severe traumatic brain injury. The authors further classified the patients into early (<3 days), late (>3 days) and no palliative intervention. These times were based on the ACS-TQIP recommendations which recommend palliative interventions within 72 hours of admissions for all patients that screen positive. Palliative interventions included a documented family meeting or goals of care conversation, consultation of the palliative care team or advance care planning including placement of do-not resuscitate and do not intubate orders. 337 patients were included in this study. Palliative interventions were only provided to 26% of patients, however 72% of patients that had a palliative intervention received it early. When comparing patients that received early vs late palliative intervention, patients with late palliative intervention experienced a higher rate of neurosurgical intervention, invasive intervention, longer hospital length of stay and longer ICU length of stay. There was no difference in mortality between the two groups.
This study highlights both the benefits of early palliative care and the under utilization in our trauma patients. This study adds to the trauma literature again showing early palliative care leads to decrease in invasive procedure and length of stay, without a difference in mortality. Despite the ACS TQIP Palliative Care Best Practice Guidelines recommending screening for palliative needs within 24 hours for all patients and early palliative care for all patients that screen positive, the literature continues to demonstrate the underutilization of palliative care. In this study only 26% of patients had a palliative intervention, which included something as simple as a goal of care conversation or family meeting. The authors offer some solutions to improve palliative interventions such as triggers, practice management guidelines and increased education for acute care surgeons. Future studies and initiatives should focus on increasing palliative interventions as it has been clearly demonstrated to be beneficial to our patients.
Article 2
Goals of care are rarely discussed prior to potentially futile trauma transfer: Is it okay to say “No”? Trenga-Schein N, Zonies D, Cook M. J Trauma Acute Care Surg. 2024 Apr 1;96(4):583-588.
This is a single-center retrospective case series conducted at a single Level 1 Trauma Center over a four year period, with the goal of determining the frequency of Goals of Care (GOC) discussions during physician-to-physician transfer conversations in patients who are futile trauma transfers (FTT). Inclusion criteria were patients that either died or were transferred to hospice within 48 hours of arrival without additional surgical or radiographic intervention. Patients were also included if they had additional imaging that could have been performed prior to transfer, or underwent immediate operative efforts but were deemed nonsurvivable intraoperatively. Transfer center calls were retrospectively reviewed for GOC conversations, including confirmation of code status and that the interventions available at the receiving hospital aligned with the patient’s goals. The finalized study population included 80 patients, with high rates of patients transferred for brain injury and neurosurgical capabilities (53%). The authors found that 20% of conversations had a code status discussion, with only 10% having an extended GOC discussion. Appropriateness of transfer was discussed for 21% of patients, and futility mentioned for 14%, though all were eventually transferred. Age was found to be a significant association with the presence of a GOC discussion, and extended discussions were more likely to be queried when the receiving team had a trauma or neurosurgeon.
This article explored the frequency of in-depth code status and GOC discussions occurring during transfer calls in FTT, finding a very low frequency of such conversations. Limitations of this study included the inability of investigators to obtain transfer calls from patients who were rejected, and the limited data size from one, Level 1 trauma center. Given the ACS TQIP guidelines of holding palliative care discussions within 24 hours of admission, this study highlights an opportunity for earlier GOC conversations to occur even prior to transfer to a higher level of care. Earlier GOC discussions may also be an opportunity to decrease unnecessary transfers of patients with nonsurviveable injuries, though any ‘refusal’ to accept transfer patients is complicated by regulations of the Emergency Medical Treatment and Labor Act (EMTALA). Additionally, this article suggests there may be opportunities for palliative care skill development at Level III and IV trauma centers, tools to prospectively identify patients at risk for FTT, or telemedicine input by specialists, particularly neurosurgery specialists. Overall, this article highlights a paltry 10% frequency of GOC discussions prior to transfer, suggesting potential for improvement in the care of trauma patients across the trauma care continuum.
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