Integrating Palliative Care on an Adult Trauma Service.

Background: In 2017, the American College of Surgeons' Trauma Quality Improvement Program adopted a Palliative Care Best Practices Guidelines that calls for early palliative care for hospitalized injured patients. Objective: To develop an educational intervention to address the palliative needs of injured patients. Design: Palliative faculty presented a three-part monthly lecture series focused on core primary palliative skills, including the components of palliative care; conducting family conferences; communication skills for complex medical decision making; pain management; and, end-of-life planning. Additionally a palliative provider joined trauma team rounds every other week to highlight opportunities for enhanced palliative assessments, identify appropriate consults, and provide just-in-time teaching. Setting: Urban, level-1 trauma center. Measurements: Surgical residents completed a survey at the beginning and end of the academic year, during which the intervention took place. All survey questions were answered with a 5-point Likert scale. Rate of palliative care consultation was also tracked. Results: There were statistically significant perceived improvements in goals-of-care discussions (initial discussion-4.30 vs. 3.52, p = 0.4; follow-up discussion-3.89 vs. 3.05, p = 0.021) and documentation (3.89 vs. 2.9, p = 0.032), incorporation of patient preferences into decision making (4.20 vs. 3.43, p = 0.04), discussion of palliative needs during rounds (4.30 vs. 2.81; p < 0.001) and care transitions (3.90 vs. 3.05, p = 0.008), respect for decisions to forgo life-sustaining treatments (4.40 vs. 3.52, p = 0.004), and identification of advance directives (4.11 vs. 3.05, p = 0.002) and surrogate decision maker (4.44 vs. 3.60, p = 0.015). The overall rate of palliative specialist consultation also increased (8.4% vs. 16.1%, p < 0.001). Conclusion: Embedding primary palliative education into usual didactic and rounding time for an inpatient trauma team is an effective way to help residents develop palliative skills and foster culture change. Educational partnerships such as this may serve as an example to other trauma programs.

Late referral to hospice and bereaved family member perception of quality of end-of-life care.

The Family Evaluation of Hospice Services was used to document bereaved family members' perceptions of whether their loved ones were referred too late to hospice and to examine the association of that perception and quality of end-of-life care. A mortality follow-back survey of bereaved family members from two not-for-profit hospices found that 13.7% of decedents were referred at a time too late for hospice services. Family members of persons referred too late reported lower satisfaction with hospice services, a higher rate of unmet needs for information about what to expect at time of death, lower confidence in participating in patient care at home, more concerns with coordination of care, and lower overall satisfaction. Families reported physicians as an important barrier to earlier hospice referral in nearly one-half of cases. These results indicate a need for improved services for shorter-stay hospice patients/families and for physicians to help facilitate earlier hospice admission.