Importance of Advanced Care Planning in Elderly Trauma Patients

New research from University of Alberta highlights the importance of early advanced care planning to improve patient and family-centred care for geriatric trauma patients. In an article published in the World Journal of Emergency Surgery, UAlberta researchers outline the benefits of this approach that led to improvements in goals of care documentation for elderly patients at a level 1 trauma centre.
Geriatric trauma has high morbidity and mortality, often requiring extensive hospital stays and interventions. The number of geriatric trauma patients is also increasing significantly and accounts for a large proportion of trauma care. Despite trauma being a leading cause of death in Canada, there is a relative dearth of studies focusing on “goals of care” (GOC) discussions in trauma patients.
Advanced care planning (ACP) facilitates discussions around patient’s healthcare goals (i.e., cardiopulmonary resuscitation) along with a realistic presentation of what intensive, invasive treatments can provide. ACP processes can guide complex treatment decision-making (including end-of-life discussions between allied health professionals, patients, and their families) to promote patient and family-centred care (PFCC) and eliminate uncertainty regarding the patient’s wishes.
The province of Alberta implemented an ACP programme in April of 2012. The researchers applied a before and after study design to assess the GOC documentation in elderly trauma patients at a level 1 trauma centre following implementation of the standardised provincial ACP tool on 1 April 2012.
The researchers found that documentation of ACP in elderly major trauma patients following the implementation of this tool increased significantly from 16 to 35 percent. Additionally, secondary outcomes demonstrated that many more patients received GOC documentation within 24 hours of admission, and 93 percent of patients had goals of care documented prior to intensive care unit (ICU) admission. The number of trauma patients that were admitted to the ICU also decreased from 17 to 5 percent.
“Although we achieved improvement, this result shows that many patients did not have their goals documented — indicating that barriers continue to exist that limit ACP discussions,” the authors note. “The source of the GOC decision was documented in our study and shows that in both the before and after groups, most decisions regarding GOC were provided by a substitute decision-maker or an advanced care directive. This is likely because geriatric trauma patients have injuries, comorbidities, and complications (i.e., delirium) that would prevent them from making GOC decisions.”
Due to the high risk of intervention, prolonged ICU admission, life-threatening complications, and mortality in geriatric trauma, early ACP discussion is key.
“We suggest that ICU providers are likely accustomed to undergoing ACP discussion due to their highly acute patient population and specialised training around PFCC and communication, lending to the ease of transition for their unit. It may be beneficial to involve these types of practitioners in GOC discussion early in a geriatric trauma patient’s hospital admission. Having these practitioners involved with medical education to provide tools and approaches for these discussions may also be beneficial,” the authors explain.
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