Missed Opportunities for use of Advanced Care Planning and Palliative Care in Open Aortic Surgery

Background: Major vascular surgery, including open aortic procedures, is associated with having a 30-day mortality rate greater than 6% and a perioperative complication rate greater than 50%. Published literature suggests that patients undergoing high-risk procedures benefit from having a care plan in place to not only maximize quality of life but also to ensure medical interventions align with care goals. Currently, there is a paucity of published data on the prevalence of goals of care conversations, advance care planning documentation, and palliative care (PC) evaluations in patients undergoing high-risk vascular operations. Methods: A retrospective chart review of all patients who underwent open aortic surgery at a tertiary care academic medical center from July 2014 to March 2023 was performed. Patient demographics, comorbidities, type and timing of advanced care planning (ACP), PC evaluations, and clinical outcomes during the periprocedural period were recorded. For patients who died during the study period, the use of PC prior to death was noted. Patients who received ACP or PC were compared with those who did not. Results: The cohort consisted of 192 patients who underwent major open aortic surgery. The mean age was 63 years (standard deviation [SD] 12.3) and the majority of patients were male (73.4%) and white (64.1%). Thirty-nine (20.6%) operations were classified as emergent. At the time of their operation, 16.7% (n- 32) of patients had an ACP document on file. Of the 38 documents on file, most were durable power of attorney (DPOA) (86.8%) documents while a smaller percentage were physician orders for life-sustaining treatment (POLST) (13.2%). There were no patients with do not resuscitate and/or intubate (DNR/DNI), living will, or organ/tissue donation orders noted in their chart prior to surgery. One percent (n- 2) of patients had a palliative evaluation prior to their operation. During the perioperative period, an additional 2 (1%) of patients had ACP documentation and 7 (3.7%) of patients underwent PC evaluation. Fifteen percent of patients (n- 28) died during the perioperative period and an additional 21 patients died by the end of the study period for a total mortality of 25.2% in the study population. Among patients that died during the perioperative period, 28.6% (n- 8 out of 28) received PC. Overall, 28.6% of all study patients that died (n- 14 out of 49) received a PC evaluation prior to or during their terminal hospitalization. Patients who had ACP documents or who received PC consultations prior to surgery were older (P- 0.01), more likely to be on Medicare or Medicaid (P- 0.004), and more likely to have a history of solid organ malignancy (P- 0.03). The median interval between surgery and receiving PC was 20 (interquartile range [IQR] 3-71) days. The median interval between PC and death was 5 (IQR 2-13) days. Patients who utilized ACP or PC were more likely to die at home (P- 0.05). Conclusions: Despite a high mortality and morbidity rate, ACP documentation is poor for patients undergoing major open aortic surgery. PC interventions tend to be performed closer to the end of life, suggesting a missed opportunity to define goals of care.