Trends and Impacts of Palliative Care Evaluation on Functional Status, Length-of-stay, and Discharge Destinations for Critically Ill Neurosurgical Patients: A 17-year Institutional Experience

Introduction: Nearly half of US deaths occur in health care institutions. Critically ill neurosurgical patients with poor prognoses frequently undergo prolonged hospitalization with minimal improvement. In these settings, palliative evaluation is critical in maximizing comfort for the patient and their family.

Methods: This study reviews 86 patients with pathologies including primary brain tumors (glioblastoma, meningioma, oligodendroglioma), brain metastases, traumatic intracranial hemorrhages (SDH, SAH, IPH, IVH) with palliative consults for goals of care, hospice, or pain management. A median Karnofsky performance score (KPS) of 40 at admission and 10 at discharge was observed. Ethnic representation included 72% White, 14% Hispanic, and 14% Black.

Results: On ANOVA analysis, admission KPS scores were not significantly different between ethnic groups in the cohort (p=0.8692), however, they were significantly lower for traumatic intracranial hemorrhage (median 25) when compared to primary brain tumor or brain metastasis patients (p=0.0475). Patients with and without code status change from full code to DNR did not differ in duration of hospitalization (p=0.2855) or ICU duration (p=0.7606). When KPS < 40, length of stay was found to be greater for the code status change subgroup (p= 0.0409). Additionally, when KPS scores < 40, the early palliative group experienced KPS worsening more than the late palliative group (p=0.0004). Although Black patients had quicker code status changes (median 4 days) after palliative consult than White (median 9 days) or Hispanic (median 11.5 days) patients (p=0.0375), they were not more likely to be discharged to hospice facilities (p=0.5571).

Conclusion : Significant emotional and financial burden incurred from prolonging hospitalization of critically ill neurosurgical patients. We have found earlier palliative consultation results in decreased length of stay and more time for patients/ families to process grief and transition from hospitalization to more comfortable alternatives, particularly when low admission KPS scores prognosticate high risk for deterioration in functional status.