Incidence of the initiation of comfort care immediately following emergent neurosurgical and endovascular procedures

Restricted access

OBJECTIVE

It is unknown what proportion of patients who undergo emergent neurosurgical procedures initiate comfort care (CC) measures shortly after the operation. The purpose of the present study was to analyze the proportion and predictive factors of patients who initiated CC measures within the same hospital admission after undergoing emergent neurosurgery.

METHODS

This retrospective cohort study included all adult patients who underwent emergent neurosurgical and endovascular procedures at a single center between 2009 and 2014. Primary and secondary outcomes were initiation of CC measures during the initial hospitalization and determination of predictive factors, respectively.

RESULTS

Of the 1295 operations, comfort care was initiated in 111 (8.6%) during the initial admission. On average, CC was initiated 9.3 ± 10.0 days postoperatively. One-third of the patients switched to CC within 3 days. In multivariate analysis, patients > 70 years of age were significantly more likely to undergo CC than those < 50 years (70–79 years, p = 0.004; > 80 years, p = 0.0001). Two-thirds of CC patients had been admitted with a cerebrovascular pathology (p < 0.001). Admission diagnosis of cerebrovascular pathology was a significant predictor of initiating CC (p < 0.0001). A high Hunt and Hess grade of IV or V in patients with subarachnoid hemorrhage was significantly associated with initiation of CC compared to a low grade (27.1% vs 2.9%, p < 0.001). Surgery starting between 15:01 and 06:59 hours had a 1.70 times greater odds of initiating CC compared to surgery between 07:00 and 15:00.

CONCLUSIONS

Initiation of CC after emergent neurosurgical and endovascular procedures is relatively common, particularly when an elderly patient presents with a cerebrovascular pathology after typical operating hours.

ABBREVIATIONS CC = comfort care; EMERSE = Electronic Medical Record Search Engine; PGY = postgraduate year; SAH = subarachnoid hemorrhage; SST = surgical start time.
Article Information

Contributor Notes

Correspondence Aditya S. Pandey: University of Michigan, Ann Arbor, MI. adityap@med.umich.edu.INCLUDE WHEN CITING Published online December 14, 2018; DOI: 10.3171/2018.7.JNS181226.Disclosures The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.
Headings
References
  • 1

    Albers GWMarks MPKemp SChristensen STsai JPOrtega-Gutierrez S: Thrombectomy for stroke at 6 to 16 hours with selection by perfusion imaging. N Engl J Med 378:7087182018

    • Search Google Scholar
    • Export Citation
  • 2

    Berwick DMHackbarth AD: Eliminating waste in US health care. JAMA 307:151315162012

  • 3

    Byrne RWBagan BTSlavin KVCurry DKoski TROrigitano TC: Neurosurgical emergency transfers to academic centers in Cook County: a prospective multicenter study. Neurosurgery 62:7097162008

    • Search Google Scholar
    • Export Citation
  • 4

    Choi HAFernandez AJeon SBSchmidt JMConnolly ESMayer SA: Ethnic disparities in end-of-life care after subarachnoid hemorrhage. Neurocrit Care 22:4234282015

    • Search Google Scholar
    • Export Citation
  • 5

    Garrido MMBalboni TAMaciejewski PKBao YPrigerson HG: Quality of life and cost of care at the end of life: The role of advance directives. J Pain Symptom Manage 49:8288352015

    • Search Google Scholar
    • Export Citation
  • 6

    Geurts Mde Kort FASde Kort PLMvan Tuijl JHKappelle LJvan der Worp HB: Predictive accuracy of physicians’ estimates of outcome after severe stroke. PLoS One 12:e01848942017

    • Search Google Scholar
    • Export Citation
  • 7

    Geurts MMacleod MRvan Thiel GJvan Gijn JKappelle LJvan der Worp HB: End-of-life decisions in patients with severe acute brain injury. Lancet Neurol 13:5155242014

    • Search Google Scholar
    • Export Citation
  • 8

    Guha RBoehme ADemel SLLi JJCai XJames ML: Aggressiveness of care following intracerebral hemorrhage in women and men. Neurology 89:3493542017

    • Search Google Scholar
    • Export Citation
  • 9

    Hanauer DAMei QLaw JKhanna RZheng K: Supporting information retrieval from electronic health records: A report of University of Michigan’s nine-year experience in developing and using the Electronic Medical Record Search Engine (EMERSE). J Biomed Inform 55:2903002015

    • Search Google Scholar
    • Export Citation
  • 10

    Huynh TNKleerup ECWiley JFSavitsky TDGuse DGarber BJ: The frequency and cost of treatment perceived to be futile in critical care. JAMA Intern Med 173:188718942013

    • Search Google Scholar
    • Export Citation
  • 11

    Izzy SCompton RCarandang RHall WMuehlschlegel S: Self-fulfilling prophecies through withdrawal of care: do they exist in traumatic brain injury, too? Neurocrit Care 19:3473632013

    • Search Google Scholar
    • Export Citation
  • 12

    Keehan SPSisko AMTruffer CJPoisal JACuckler GAMadison AJ: National health spending projections through 2020: economic recovery and reform drive faster spending growth. Health Aff (Millwood) 30:159416052011

    • Search Google Scholar
    • Export Citation
  • 13

    Kelley ASEttner SLMorrison RSDu QWenger NSSarkisian CA: Determinants of medical expenditures in the last 6 months of life. Ann Intern Med 154:2352422011

    • Search Google Scholar
    • Export Citation
  • 14

    Lewis AVarelas PGreer D: Prolonging support after brain death: When families ask for more. Neurocrit Care 24:4814872016

  • 15

    Linzey JRBurke JFSabbagh MASullivan SThompson BGMuraszko KM: The effect of surgical start time on complications associated with neurological surgeries. Neurosurgery 83:5015072018

    • Search Google Scholar
    • Export Citation
  • 16

    Miranda SPBernacki REPaladino JMNorden ADKavanagh JEPalmor MC: A descriptive analysis of end-of-life conversations with long-term glioblastoma survivors. Am J Hosp Palliat Care 35:8048112018

    • Search Google Scholar
    • Export Citation
  • 17

    Muñoz Venturelli PWang XZahuranec DBLavados PMStapf CLindley R: Withdrawal of active treatment after intracerebral haemorrhage in the INTERACT2 study. Age Ageing 46:3293322017

    • Search Google Scholar
    • Export Citation
  • 18

    Nogueira RGJadhav APHaussen DCBonafe ABudzik RFBhuva P: Thrombectomy 6 to 24 hours after stroke with a mismatch between deficit and infarct. N Engl J Med 378:11212018

    • Search Google Scholar
    • Export Citation
  • 19

    Noh TWalbert T: Brain metastasis: clinical manifestations, symptom management, and palliative care. Handb Clin Neurol 149:75882018

    • Search Google Scholar
    • Export Citation
  • 20

    Pace ADirven LKoekkoek JAFGolla HFleming JRudà R: European Association for Neuro-Oncology (EANO) guidelines for palliative care in adults with glioma. Lancet Oncol 18:e330e3402017

    • Search Google Scholar
    • Export Citation
  • 21

    Paratz EDFlynn E: Rapid death after admission to palliative care. Intern Med J 42:9849892012

  • 22

    Prabhakaran SCox MLytle BSchulte PJXian YZahuranec D: Early transition to comfort measures only in acute stroke patients: Analysis from the Get With The Guidelines-Stroke registry. Neurol Clin Pract 7:1942042017

    • Search Google Scholar
    • Export Citation
  • 23

    Quadri SZHuynh TCappelen-Smith CWijesuriya NMamun ABeran RG: Reflection on stroke deaths and end-of-life stroke care. Intern Med J 48:3303342018

    • Search Google Scholar
    • Export Citation
  • 24

    Ramsey SBlough DKirchhoff AKreizenbeck KFedorenko CSnell K: Washington State cancer patients found to be at greater risk for bankruptcy than people without a cancer diagnosis. Health Aff (Millwood) 32:114311522013

    • Search Google Scholar
    • Export Citation
  • 25

    Rubin MBonomo JHemphill JC III: Intersection of prognosis and palliation in neurocritical care. Curr Opin Crit Care 23:1341392017

    • Search Google Scholar
    • Export Citation
  • 26

    Schaller CKessler M: On the difficulty of neurosurgical end of life decisions. J Med Ethics 32:65692006

  • 27

    Sison JTran HMargol ATiwari NGarcia KMCotter J: Palliative care options for a young adult patient with a diffuse intrinsic pontine glioma. Cureus 9:e15802017

    • Search Google Scholar
    • Export Citation
  • 28

    Souter MVan Norman G: Ethical controversies at end of life after traumatic brain injury: defining death and organ donation. Crit Care Med 38 (9 Suppl):S502S5092010

    • Search Google Scholar
    • Export Citation
  • 29

    Tawil IBrown LHComfort DCrandall CSWest SDRollstin AD: Family presence during brain death evaluation: a randomized controlled trial. Crit Care Med 42:9349422014

    • Search Google Scholar
    • Export Citation
  • 30

    Tin MKFrench PLeung KK: The needs of the family of critically ill neurosurgical patients: a comparison of nurses’ and family members’ perceptions. J Neurosci Nurs 31:3483561999

    • Search Google Scholar
    • Export Citation
  • 31

    Unterhofer CHartmann SFreyschlag CFThomé COrtler M: Severe head injury in very old patients: to treat or not to treat? Results of an online questionnaire for neurosurgeons. Neurosurg Rev 41:1831872018

    • Search Google Scholar
    • Export Citation
  • 32

    Walbert T: Integration of palliative care into the neuro-oncology practice: patterns in the United States. Neurooncol Pract 1:372014

    • Search Google Scholar
    • Export Citation
  • 33

    Walbert TChasteen K: Palliative and supportive care for glioma patients. Cancer Treat Res 163:1711842015

  • 34

    Walbert TGlantz MSchultz LPuduvalli VK: Impact of provider level, training and gender on the utilization of palliative care and hospice in neuro-oncology: a North-American survey. J Neurooncol 126:3373452016

    • Search Google Scholar
    • Export Citation
  • 35

    Walbert TKhan M: End-of-life symptoms and care in patients with primary malignant brain tumors: a systematic literature review. J Neurooncol 117:2172242014

    • Search Google Scholar
    • Export Citation
  • 36

    Walbert TPace A: End-of-life care in patients with primary malignant brain tumors: early is better. Neuro-oncol 18:782016

  • 37

    Wright AAZhang BRay AMack JWTrice EBalboni T: Associations between end-of-life discussions, patient mental health, medical care near death, and caregiver bereavement adjustment. JAMA 300:166516732008

    • Search Google Scholar
    • Export Citation
  • 38

    Zahuranec DBFagerlin ASánchez BNRoney METhompson BBFuhrel-Forbis A: Variability in physician prognosis and recommendations after intracerebral hemorrhage. Neurology 86:186418712016

    • Search Google Scholar
    • Export Citation
TrendMD
Metrics

Metrics

All Time Past Year Past 30 Days
Abstract Views 73 73 73
Full Text Views 36 36 36
PDF Downloads 36 36 36
EPUB Downloads 0 0 0
PubMed
Google Scholar