An Objective Trigger for Early Palliative Care in Severely Injured Trauma Patients

Early palliative care is recommended for severely injured patients at risk of outcomes that survivors may consider worse than death. The American College of Surgeons Committee on Trauma's Quality Improvement Program guidelines advise palliative care discussions within 72 h of admission for patients with a high risk of death, permanent disability, or prognostic uncertainty. However, objective measures are lacking. This study aimed to develop objective criteria for palliative care in patients at risk for possible value-incongruent outcomes (pVIOs), defined as death after 24 h, institutional or hospice discharge, or tracheostomy or gastrostomy tube placement.

Following institutional review board approval, a retrospective cohort study was conducted in adults admitted to the trauma intensive care unit at a level 1 trauma center from January 7, 2017, to June 30, 2021. Injury/patient characteristics associated with pVIO were analyzed to determine independent predictors of this outcome. Predictive factors were identified using the first 3 y of data and tested using the subsequent year.

Between January 7, 2017, and June 30, 2020, 2272 trauma intensive care unit patients were evaluated to determine risk factors for pVIO. Eight hundred and twelve of these (35.7%) met criteria for experiencing a pVIO. Multivariable logistic analysis identified two patterns: in patients ≤50 y old, only Glasgow Coma Scale score on postinjury day 3 (GCS_PID3) predicted death or pVIO. Age, GCS_PID3, anticoagulation status, and comorbidities were predictors of pVIO in those aged >50 y. Areas under Receiver Operating Characteristic curves in patients ages ≤50 y and > 50 y were 0.88 and 0.77, respectively. Models were tested against 923 patients admitted between January 7, 2020, and June 30, 2021. In the ≤50 group, positive and negative predictive values were 64.9% and 93.0% for pVIOs. In those >50, positive and negative predictive values were 56.5% and 75.9%, respectively.

GCS_PID3 ≤11 in those ≤50 y old accurately identifies candidates for early palliative care discussion. The model for those >50 performs less well but is the best objective trigger developed to date.