Skip to main content

Advertisement

Log in

Palliative Care in the Elderly Injured Patient

  • Geriatric Trauma (F Luchette, Section Editor)
  • Published:
Current Trauma Reports Aims and scope Submit manuscript

Abstract

Purpose of Review

The purpose of this review is to provide up-to-date insight into the current practices of palliative care in elderly trauma patients.

Recent Findings

The use and need of palliative care programs have grown substantially throughout the USA in both public and not-for-profit hospitals. The geriatric trauma outcome score has been proposed as a tool to help better explain to patients and their stakeholders the likelihood of mortality in injured geriatric trauma patients. The study of frailty and the differences between patients of similar age has become a focus of many surgical societies. Recent studies also address how to improve end-of-life communication through training programs for health-care professionals.

Summary

Palliative care in trauma and other populations is evolving. Adequately trained staff are needed for facilitating care in this vulnerable patient population, while also providing education on best practices for appropriate discussion of palliation and end-of-life care in the trauma population.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Fig. 1

Similar content being viewed by others

References

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. Valente S. Fact sheet on end-of-life care. Washington D.C: American Psychological Association; 2000.

    Google Scholar 

  2. DeCato TW, Engelberg RA, Downey L, Nielsen EL, Treece PD, Back AL, et al. Hospital variation and temporal trends in palliative and end-of-life care in the ICU. Crit Care Med. 2013;41(6):1405–11. doi:10.1097/CCM.0b013e318287f289.

    Article  PubMed  PubMed Central  Google Scholar 

  3. Nabozny MJ, Kruser JM, Steffens NM, Brasel KJ, Campbell TC, Gaines ME, et al. Constructing high-stakes surgical decisions: it’s better to die trying. Ann Surg. 2016;263(1):64–70. doi:10.1097/sla.0000000000001081.

    Article  PubMed  PubMed Central  Google Scholar 

  4. Sharma RK, Prigerson HG, Penedo FJ, Maciejewski PK. Male-female patient differences in the association between end-of-life discussions and receipt of intensive care near death. Cancer. 2015;121(16):2814–20. doi:10.1002/cncr.29417.

    Article  PubMed  PubMed Central  Google Scholar 

  5. Ranganathan A, Gunnarsson O, Casarett D. Palliative care and advance care planning for patients with advanced malignancies. Ann Palliat Med. 2014;3(3):144–9. doi:10.3978/j.issn.2224-5820.2014.07.04.

    PubMed  Google Scholar 

  6. Chow WB, Ko CY, Rosenthal RA, Esnaola NF. ACS NSQIP/AGS best practice guidelines: optimal preoperative assessment of the geriatric surgical patient. 2012. https://www.facs.org//media/files/qualityprograms/nsqip/acsnsqipagsgeriatric2012guidelines.ashx. Accessed 20 Aug 2016.

  7. •• Mohanty S, Rosenthal RA, Russell MM, Neuman MD, Ko CY, Esnaola NF. Optimal perioperative management of the geriatric patient: best practices guideline from ACS NSQIP/American Geriatric Society Best. 2016. https://www.facs.org//media/files/qualityprograms/geriatric/acsnsqipgeriatric2016guidelines.ashx. Accessed 20 Aug 2016. New ACS NSQIP/AGS joint guidelines for perioperative care of geriatric patients.

  8. • Bonne S, Schuerer DJ. Trauma in the older adult: epidemiology and evolving geriatric trauma principles. Clin Geriatr Med. 2013;29(1):137–50. doi:10.1016/j.cger.2012.10.008. Succinct review of comorbidities and other confounding factors that affect care of geriatric trauma patients.

    Article  PubMed  Google Scholar 

  9. Hashmi A, Ibrahim-Zada I, Rhee P, Aziz H, Fain MJ, Friese RS, et al. Predictors of mortality in geriatric trauma patients: a systematic review and meta-analysis. J Trauma Acute Care Surg. 2014;76(3):894–901. doi:10.1097/TA.0b013e3182ab0763.

    Article  PubMed  Google Scholar 

  10. Morris JA, MacKenzie EJ, Damiano AM, Bass SM. Mortality in trauma patients: the interaction between host factors and severity. J Trauma. 1990;30(12):1476–82.

    Article  PubMed  Google Scholar 

  11. Phillips S, Rond PC, Kelly SM, Swartz PD. The failure of triage criteria to identify geriatric patients with trauma: results from the Florida Trauma Triage Study. J Trauma. 1996;40(2):278–83.

    Article  CAS  PubMed  Google Scholar 

  12. Richmond R, Aldaghlas TA, Burke C, Rizzo AG, Griffen M, Pullarkat R. Age: is it all in the head? Factors influencing mortality in elderly patients with head injuries. J Trauma. 2011;71(1):E8–11. doi:10.1097/TA.0b013e3181fbaa46.

    Article  PubMed  Google Scholar 

  13. Soreide K, Desserud KF. Emergency surgery in the elderly: the balance between function, frailty, fatality and futility. Scand J Trauma Resusc Emerg Med. 2015;23:10. doi:10.1186/s13049-015-0099-x.

    Article  PubMed  PubMed Central  Google Scholar 

  14. Wright AS, Schurr MJ. Geriatric trauma: review and recommendations. WMJ. 2001;100(2):57–9.

    CAS  PubMed  Google Scholar 

  15. Hollis S, Lecky F, Yates DW, Woodford M. The effect of pre-existing medical conditions and age on mortality after injury. J Trauma. 2006;61(5):1255–60. doi:10.1097/01.ta.0000243889.07090.da.

    Article  PubMed  Google Scholar 

  16. Pudelek B. Geriatric trauma: special needs for a special population. AACN Clin Issues. 2002;13(1):61–72.

    Article  PubMed  Google Scholar 

  17. Keller JM, Sciadini MF, Sinclair E, O’Toole RV. Geriatric trauma: demographics, injuries, and mortality. J Orthop Trauma. 2012;26(9):e161–5. doi:10.1097/BOT.0b013e3182324460.

    Article  PubMed  Google Scholar 

  18. •• Campbell-Furtick M, Moore BJ, Overton TL, Laureano Phillips J, Simon KJ, Gandhi RR, et al. Post-trauma mortality increase at age 60: a cutoff for defining elderly? Am J Surg. 2016. doi:10.1016/j.amjsurg.2015.12.018. Proposes a new defining age for “elderly” persons.

    PubMed  Google Scholar 

  19. Fried TR, Tinetti ME, Iannone L. Primary care clinicians’ experiences with treatment decision making for older persons with multiple conditions. Arch Intern Med. 2011;171(1):75–80. doi:10.1001/archinternmed.2010.318.

    PubMed  Google Scholar 

  20. •• Cooper Z, Courtwright A, Karlage A, Gawande A, Block S. Pitfalls in communication that lead to nonbeneficial emergency surgery in elderly patients with serious illness: description of the problem and elements of a solution. Ann Surg. 2014;260(6):949–57. doi:10.1097/sla.0000000000000721. Excellent review of dilemmas in communication facing surgeons, patients and surrogates when dealing with decision making for elderly patients with serious illness and acute, life-threatening surgical conditions.

    Article  PubMed  Google Scholar 

  21. Cauley CE, Panizales MT, Reznor G, Haynes AB, Havens JM, Kelley E, et al. Outcomes after emergency abdominal surgery in patients with advanced cancer: opportunities to reduce complications and improve palliative care. J Trauma Acute Care Surg. 2015;79(3):399–406. doi:10.1097/ta.0000000000000764.

    Article  PubMed  PubMed Central  Google Scholar 

  22. •• Cook AC, Joseph B, Inaba K, Nakonezny PA, Bruns BR, Kerby JD, et al. Multicenter external validation of the geriatric trauma outcome score: a study by the Prognostic Assessment of Life and Limitations after Trauma in the Elderly (PALLIATE) consortium. J Trauma Acute Care Surg. 2016;80(2):204–9. doi:10.1097/ta.0000000000000926. Prognostic study successfully evaluating the accuracy of GTOS as a predictor of geriatric mortality after injury.

    Article  PubMed  Google Scholar 

  23. DeMaria EJ. Evaluation and treatment of the elderly trauma victim. Clin Geriatr Med. 1993;9(2):461–71.

    CAS  PubMed  Google Scholar 

  24. Jacobs DG, Plaisier BR, Barie PS, Hammond JS, Holevar MR, Sinclair KE, et al. Practice management guidelines for geriatric trauma: the EAST Practice Management Guidelines Work Group. J Trauma. 2003;54(2):391–416. doi:10.1097/01.ta.0000042015.54022.be.

    Article  PubMed  Google Scholar 

  25. Jacobs DG. Special considerations in geriatric injury. Curr Opin Crit Care. 2003;9(6):535–9.

    Article  PubMed  Google Scholar 

  26. Mitra B, Cameron PA, Gabbe BJ, Rosenfeld JV, Kavar B. Management and hospital outcome of the severely head injured elderly patient. ANZ J Surg. 2008;78(7):588–92. doi:10.1111/j.1445-2197.2008.04579.x.

    Article  PubMed  Google Scholar 

  27. Demetriades D, Karaiskakis M, Velmahos G, Alo K, Newton E, Murray J, et al. Effect on outcome of early intensive management of geriatric trauma patients. Br J Surg. 2002;89(10):1319–22. doi:10.1046/j.1365-2168.2002.02210.x.

    Article  CAS  PubMed  Google Scholar 

  28. Staudenmayer KL, Hsia RY, Mann NC, Spain DA, Newgard CD. Triage of elderly trauma patients: a population-based perspective. J Am Coll Surg. 2013;217(4):569–76. doi:10.1016/j.jamcollsurg.2013.06.017.

    Article  PubMed  Google Scholar 

  29. Tabah A, Philippart F, Timsit JF, Willems V, Francais A, Leplege A, et al. Quality of life in patients aged 80 or over after ICU discharge. Crit Care. 2010;14(1):R2. doi:10.1186/cc8231.

    Article  PubMed  PubMed Central  Google Scholar 

  30. •• Zhao FZ, Wolf SE, Nakonezny PA, Minhajuddin A, Rhodes RL, Paulk ME, et al. Estimating geriatric mortality after injury using age, injury severity, and performance of a transfusion: the geriatric trauma outcome score. J Palliat Med. 2015;18(8):677–81. doi:10.1089/jpm.2015.0027. Excellent sentinel paper, detailing the creation of the GTOS and estabilishing its efficacy.

    Article  PubMed  PubMed Central  Google Scholar 

  31. •• Clegg A, Young J, Iliffe S, Rikkert MO, Rockwood K. Frailty in elderly people. Lancet. 2013;381(9868):752–62. doi:10.1016/S0140-6736(12)62167-9. Excellent discussion of the physiology of frailty, models to better understand frailty and interventions to improve outcomes.

    Article  PubMed  Google Scholar 

  32. Rockwood K, Song X, MacKnight C, Bergman H, Hogan DB, McDowell I, et al. A global clinical measure of fitness and frailty in elderly people. CMAJ. 2005;173(5):489–95. doi:10.1503/cmaj.050051.

    Article  PubMed  PubMed Central  Google Scholar 

  33. • Joseph B, Pandit V, Zangbar B, Kulvatunyou N, Tang A, O’Keeffe T, et al. Validating trauma-specific frailty index for geriatric trauma patients: a prospective analysis. J Am Coll Surg. 2014;219(1):10–7.e1. doi:10.1016/j.jamcollsurg.2014.03.020. Prospective analysis validating the Trauma-Specific Frailty Index (TSFI) which predicts discharge disposition in geriatric trauma patients.

    Article  PubMed  Google Scholar 

  34. Joseph B, Pandit V, Zangbar B, Kulvatunyou N, Hashmi A, Green DJ, et al. Superiority of frailty over age in predicting outcomes among geriatric trauma patients: a prospective analysis. JAMA Surg. 2014;149(8):766–72. doi:10.1001/jamasurg.2014.296.

    Article  PubMed  Google Scholar 

  35. Joseph B, Pandit V, Khalil M, Kulvatunyou N, Zangbar B, Friese RS, et al. Managing older adults with ground-level falls admitted to a trauma service: the effect of frailty. J Am Geriatr Soc. 2015;63(4):745–9. doi:10.1111/jgs.13338.

    Article  PubMed  Google Scholar 

  36. Limehouse WE, Feeser VR, Bookman KJ, Derse A. A model for emergency department end-of-life communications after acute devastating events—part I: decision-making capacity, surrogates, and advance directives. Acad Emerg Med Off J Soc Acad Emerg Med. 2012;19(9):E1068–72. doi:10.1111/j.1553-2712.2012.01426.x.

    Article  Google Scholar 

  37. Visser M, Deliens L, Houttekier D. Physician-related barriers to communication and patient- and family-centred decision-making towards the end of life in intensive care: a systematic review. Crit Care. 2014;18(6):604. doi:10.1186/s13054-014-0604-z. Excellent review of issues that affect decisions regarding patient centered EOLC from perspective of health professionals, stresses importance of need for improved palliative care training.

    Article  PubMed  PubMed Central  Google Scholar 

  38. Grant SB, Modi PK, Singer EA. Futility and the care of surgical patients: ethical dilemmas. World J Surg. 2014;38(7):1631–7. doi:10.1007/s00268-014-2592-1.

    Article  PubMed  PubMed Central  Google Scholar 

  39. Venkat A, Baker EF, Schears RM. Ethical controversies surrounding the management of potential organ donors in the emergency department. J Emerg Med. 2014;47(2):232–6. doi:10.1016/j.jemermed.2013.10.023.

    Article  PubMed  Google Scholar 

  40. Sadler E, Hales B, Henry B, Xiong W, Myers J, Wynnychuk L, et al. Factors affecting family satisfaction with inpatient end-of-life care. PLoS One. 2014;9(11):e110860. doi:10.1371/journal.pone.0110860.

    Article  PubMed  PubMed Central  Google Scholar 

  41. Shih CY, Hu WY, Cheng SY, Yao CA, Chen CY, Lin YC, et al. Patient preferences versus family physicians’ perceptions regarding the place of end-of-life care and death: a nationwide study in Taiwan. J Palliat Med. 2015;18(7):625–30. doi:10.1089/jpm.2014.0386.

    Article  PubMed  PubMed Central  Google Scholar 

  42. Deschepper R, Vander Stichele R, Bernheim JL, De Keyser E, Van Der Kelen G, Mortier F, et al. Communication on end-of-life decisions with patients wishing to die at home: the making of a guideline for GPs in Flanders, Belgium. Br J Gen Pract. 2006;56(522):14–9.

    PubMed  PubMed Central  Google Scholar 

  43. Seymour JE, Kumar A, Froggatt K. Do nursing homes for older people have the support they need to provide end-of-life care? A mixed methods enquiry in England. Palliat Med. 2011;25(2):125–38. doi:10.1177/0269216310387964.

    Article  PubMed  PubMed Central  Google Scholar 

  44. Slatyer S, Pienaar C, Williams AM, Proctor K, Hewitt L. Finding privacy from a public death: a qualitative exploration of how a dedicated space for end-of-life care in an acute hospital impacts on dying patients and their families. J Clin Nurs. 2015;24(15-16):2164–74. doi:10.1111/jocn.12845.

    Article  PubMed  Google Scholar 

  45. Gries CJ, Curtis JR, Wall RJ, Engelberg RA. Family member satisfaction with end-of-life decision making in the ICU. Chest. 2008;133(3):704–12. doi:10.1378/chest.07-1773.

    Article  PubMed  PubMed Central  Google Scholar 

  46. Kortes-Miller K, Jones-Bonofiglio K, Hendrickson S, Kelley ML. Dying with Carolyn: using simulation to improve communication skills of unregulated care providers working in long-term care. J Appl Gerontol. 2015. doi:10.1177/0733464815577139.

    PubMed  Google Scholar 

  47. • Kinderman AL, Harris HA, Brousseau RT, Close P, Pantilat SZ. Starting and sustaining palliative care in public hospitals: lessons learned from a statewide initiative. J Palliat Med. 2016;19(9):908–16. doi:10.1089/jpm.2015.0534. Excellent description of challenges to providing palliative care in public hospitals.

    Article  PubMed  Google Scholar 

  48. Kross EK, Engelberg RA, Downey L, Cuschieri J, Hallman MR, Longstreth Jr WT, et al. Differences in end-of-life care in the ICU across patients cared for by medicine, surgery, neurology, and neurosurgery physicians. Chest. 2014;145(2):313–21. doi:10.1378/chest.13-1351.

    Article  PubMed  Google Scholar 

  49. Khandelwal N, Engelberg RA, Benkeser DC, Coe NB, Curtis JR. End-of-life expenditure in the ICU and perceived quality of dying. Chest. 2014;146(6):1594–603. doi:10.1378/chest.14-0182.

    Article  PubMed  PubMed Central  Google Scholar 

  50. Singal RK, Sibbald R, Morgan B, Quinlan M, Parry N, Radford M, et al. A prospective determination of the incidence of perceived inappropriate care in critically ill patients. Can Respir J. 2014;21(3):165–70.

    Article  PubMed  PubMed Central  Google Scholar 

  51. Parikh PP, Brown R, White M, Markert RJ, Eustace R, Tchorz K. Simulation-based end-of-life care training during surgical clerkship: assessment of skills and perceptions. J Surg Res. 2015;196(2):258–63. doi:10.1016/j.jss.2015.03.019.

    Article  PubMed  Google Scholar 

  52. Tchorz KM, Binder SB, White MT, Lawhorne LW, Bentley DM, Delaney EA, et al. Palliative and end-of-life care training during the surgical clerkship. J Surg Res. 2013;185(1):97–101. doi:10.1016/j.jss.2013.05.102.

    Article  PubMed  Google Scholar 

  53. Bradley CT, Webb TP, Schmitz CC, Chipman JG, Brasel KJ. Structured teaching versus experiential learning of palliative care for surgical residents. Am J Surg. 2010;200(4):542–7. doi:10.1016/j.amjsurg.2009.12.014.

    Article  PubMed  Google Scholar 

  54. Hough CL, Hudson LD, Salud A, Lahey T, Curtis JR. Death rounds: end-of-life discussions among medical residents in the intensive care unit. J Crit Care. 2005;20(1):20–5.

    Article  PubMed  Google Scholar 

  55. Klaristenfeld DD, Harrington DT, Miner TJ. Teaching palliative care and end-of-life issues: a core curriculum for surgical residents. Ann Surg Oncol. 2007;14(6):1801–6. doi:10.1245/s10434-006-9324-1.

    Article  PubMed  Google Scholar 

  56. Mosenthal AC, Weissman DE, Curtis JR, Hays RM, Lustbader DR, Mulkerin C, et al. Integrating palliative care in the surgical and trauma intensive care unit: a report from the Improving Palliative Care in the Intensive Care Unit (IPAL-ICU) Project Advisory Board and the Center to Advance Palliative Care. Crit Care Med. 2012;40(4):1199–206. doi:10.1097/CCM.0b013e31823bc8e7.

    Article  PubMed  PubMed Central  Google Scholar 

  57. Bloomfield JG, O’Neill B, Gillett K. Enhancing student communication during end-of-life care: a pilot study. Palliat Support Care. 2015;13(6):1651–61. doi:10.1017/s147895151500022x.

    Article  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

Authors

Corresponding author

Correspondence to Christine S. Cocanour.

Ethics declarations

Conflict of Interest

Drs. Curtis, Thomas, and Cocanour declare no conflicts of interest relevant to this manuscript.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

Additional information

This article is part of the Topical Collection on Geriatric Trauma

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Curtis, E., Thomas, D. & Cocanour, C.S. Palliative Care in the Elderly Injured Patient. Curr Trauma Rep 3, 13–18 (2017). https://doi.org/10.1007/s40719-017-0071-5

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s40719-017-0071-5

Keywords

Navigation