Brittne Halford, MD, MPH

Background: In the final year before death, surgery is common for many patients. Prior studies have shown that fewer than 38% of surgical patients receive palliative care services before death. Palliative care involvement has been shown to improve quality of life and coordination of care in surgical patients.

Study design: Retrospective cross-sectional analysis of administrative data.

Setting: 129 Veteran Affairs medical centers.

Synopsis: In a retrospective review of 95,204 patients who underwent high-risk surgical procedures, the authors identified a 90-day mortality rate of 6.0%. Only 3.5% of patients received a perioperative palliative care consult. Multivariate analysis of bereaved family survey scores of patients who died within 90 days of surgery showed that families of patients who received a palliative care consult were significantly more likely to rate the care (odds ratio, 1.47), end-of-life communication (OR, 1.43), and support (OR, 1.31) as excellent, compared with those who did not. The use of survey responses and the Veteran Affairs population possibly introduces selection bias and limitations to the generalizability of the study.

Bottom line: Palliative care consultation for patients undergoing high-risk surgery remains underutilized but may be beneficial for patients.

Citation: Yefimova M et al. Palliative care and end-of-life outcomes following high-risk surgery. JAMA Surg. 2020 Jan 2;155(2):138-46.

Dr. Halford is a hospitalist at Beth Israel Deaconess Medical Center, and instructor in medicine, Harvard Medical School, both in Boston.

Background: In the final year before death, surgery is common for many patients. Prior studies have shown that fewer than 38% of surgical patients receive palliative care services before death. Palliative care involvement has been shown to improve quality of life and coordination of care in surgical patients.

Study design: Retrospective cross-sectional analysis of administrative data.

Setting: 129 Veteran Affairs medical centers.

Synopsis: In a retrospective review of 95,204 patients who underwent high-risk surgical procedures, the authors identified a 90-day mortality rate of 6.0%. Only 3.5% of patients received a perioperative palliative care consult. Multivariate analysis of bereaved family survey scores of patients who died within 90 days of surgery showed that families of patients who received a palliative care consult were significantly more likely to rate the care (odds ratio, 1.47), end-of-life communication (OR, 1.43), and support (OR, 1.31) as excellent, compared with those who did not. The use of survey responses and the Veteran Affairs population possibly introduces selection bias and limitations to the generalizability of the study.

Bottom line: Palliative care consultation for patients undergoing high-risk surgery remains underutilized but may be beneficial for patients.

Citation: Yefimova M et al. Palliative care and end-of-life outcomes following high-risk surgery. JAMA Surg. 2020 Jan 2;155(2):138-46.

Dr. Halford is a hospitalist at Beth Israel Deaconess Medical Center, and instructor in medicine, Harvard Medical School, both in Boston.

Background: In the final year before death, surgery is common for many patients. Prior studies have shown that fewer than 38% of surgical patients receive palliative care services before death. Palliative care involvement has been shown to improve quality of life and coordination of care in surgical patients.

Study design: Retrospective cross-sectional analysis of administrative data.

Setting: 129 Veteran Affairs medical centers.

Synopsis: In a retrospective review of 95,204 patients who underwent high-risk surgical procedures, the authors identified a 90-day mortality rate of 6.0%. Only 3.5% of patients received a perioperative palliative care consult. Multivariate analysis of bereaved family survey scores of patients who died within 90 days of surgery showed that families of patients who received a palliative care consult were significantly more likely to rate the care (odds ratio, 1.47), end-of-life communication (OR, 1.43), and support (OR, 1.31) as excellent, compared with those who did not. The use of survey responses and the Veteran Affairs population possibly introduces selection bias and limitations to the generalizability of the study.

Bottom line: Palliative care consultation for patients undergoing high-risk surgery remains underutilized but may be beneficial for patients.

Citation: Yefimova M et al. Palliative care and end-of-life outcomes following high-risk surgery. JAMA Surg. 2020 Jan 2;155(2):138-46.

Dr. Halford is a hospitalist at Beth Israel Deaconess Medical Center, and instructor in medicine, Harvard Medical School, both in Boston.

Background: For patients receiving palliative care who develop respiratory distress, conventional oxygen therapy may not adequately relieve symptoms of dyspnea, and noninvasive ventilation may not promote comfort. Few randomized controlled trials have investigated the use of high-flow nasal cannula (HFNC) for treatment of palliative care patients who present to the hospital with respiratory distress.

Study design: Randomized crossover study.

Setting: Emergency department of a single institution.

Synopsis: Forty-eight palliative care patients who presented to the ED with acute dyspnea were enrolled and randomized to receive HFNC for 1 hour, followed by conventional oxygen therapy for 1 hour, or vice versa. The authors found that patients using HFNC reported significantly less ­dyspnea on a breathlessness severity scale, compared with patients using conventional oxygen therapy. Additionally, patients using HFNC had significantly lower respiratory rates, and HFNC use was associated with significantly lower need for morphine in a 1-hour period. The study was limited because of its single institution and small sample size, and therefore the results may not be generalizable to other patient populations.

Bottom line: Treatment with a high-flow nasal cannula may improve symptoms of acute dysp-nea in palliative patients when compared with conventional oxygen therapy.

Citation: Ruangsomboon O et al. High-flow nasal cannula versus conventional oxygen therapy in relieving dyspnea in emergency palliative patients with do-not-intubate status: A randomized crossover study. Ann Emerg Med. 2019 Dec 18. doi: 10.1016/j.annemergmed.2019.09.009.

Dr. Halford is a hospitalist at Beth Israel Deaconess Medical Center, and instructor in medicine, Harvard Medical School, both in Boston.

Background: For patients receiving palliative care who develop respiratory distress, conventional oxygen therapy may not adequately relieve symptoms of dyspnea, and noninvasive ventilation may not promote comfort. Few randomized controlled trials have investigated the use of high-flow nasal cannula (HFNC) for treatment of palliative care patients who present to the hospital with respiratory distress.

Study design: Randomized crossover study.

Setting: Emergency department of a single institution.

Synopsis: Forty-eight palliative care patients who presented to the ED with acute dyspnea were enrolled and randomized to receive HFNC for 1 hour, followed by conventional oxygen therapy for 1 hour, or vice versa. The authors found that patients using HFNC reported significantly less ­dyspnea on a breathlessness severity scale, compared with patients using conventional oxygen therapy. Additionally, patients using HFNC had significantly lower respiratory rates, and HFNC use was associated with significantly lower need for morphine in a 1-hour period. The study was limited because of its single institution and small sample size, and therefore the results may not be generalizable to other patient populations.

Bottom line: Treatment with a high-flow nasal cannula may improve symptoms of acute dysp-nea in palliative patients when compared with conventional oxygen therapy.

Citation: Ruangsomboon O et al. High-flow nasal cannula versus conventional oxygen therapy in relieving dyspnea in emergency palliative patients with do-not-intubate status: A randomized crossover study. Ann Emerg Med. 2019 Dec 18. doi: 10.1016/j.annemergmed.2019.09.009.

Dr. Halford is a hospitalist at Beth Israel Deaconess Medical Center, and instructor in medicine, Harvard Medical School, both in Boston.

Background: For patients receiving palliative care who develop respiratory distress, conventional oxygen therapy may not adequately relieve symptoms of dyspnea, and noninvasive ventilation may not promote comfort. Few randomized controlled trials have investigated the use of high-flow nasal cannula (HFNC) for treatment of palliative care patients who present to the hospital with respiratory distress.

Study design: Randomized crossover study.

Setting: Emergency department of a single institution.

Synopsis: Forty-eight palliative care patients who presented to the ED with acute dyspnea were enrolled and randomized to receive HFNC for 1 hour, followed by conventional oxygen therapy for 1 hour, or vice versa. The authors found that patients using HFNC reported significantly less ­dyspnea on a breathlessness severity scale, compared with patients using conventional oxygen therapy. Additionally, patients using HFNC had significantly lower respiratory rates, and HFNC use was associated with significantly lower need for morphine in a 1-hour period. The study was limited because of its single institution and small sample size, and therefore the results may not be generalizable to other patient populations.

Bottom line: Treatment with a high-flow nasal cannula may improve symptoms of acute dysp-nea in palliative patients when compared with conventional oxygen therapy.

Citation: Ruangsomboon O et al. High-flow nasal cannula versus conventional oxygen therapy in relieving dyspnea in emergency palliative patients with do-not-intubate status: A randomized crossover study. Ann Emerg Med. 2019 Dec 18. doi: 10.1016/j.annemergmed.2019.09.009.

Dr. Halford is a hospitalist at Beth Israel Deaconess Medical Center, and instructor in medicine, Harvard Medical School, both in Boston.