Integration of Palliative Care Consultation Into the Management of Patients With Chronic Limb-Threatening Ischemia: A Pilot Study

Abstract

We assessed the feasibility of integrating palliative care consultation into management of patients with chronic limb-threatening ischemia (CLTI). This was a single institution, prospective, observational study supported by the Society of Vascular Surgery Vascular Quality Initiative that looked at the impact of palliative care consultation for patients with CLTI. A health-related quality-of-life questionnaire comprising Vascu-Qol-6 and a modified palliative care survey was administered before and after palliative consultation to patients admitted to the vascular service for ≥48 hours. Length of stay and mortality were compared between our study group and a historically matched cohort of patients with CLTI. Over a 14-month enrollment period, 44% of patients (N = 39) with CLTI (rest pain = 36%, tissue loss = 64%) admitted to the vascular service received palliative care consultation, compared with 5% of patients who would have met criteria over the preceding 14 months before our protocol was instituted. The mean age was 69, 23% were female, 97% White, and 49% were independently ambulatory (Table). Revascularization included bypass (46%), peripheral vascular intervention (23%), and femoral endarterectomy (21%). A total of 26% underwent minor amputation or wound debridement, 15% underwent major amputation, and no patients received medical management alone. The mean Vascu-Qol-6 on admission was 10.4 (standard deviation: 4.2). After receiving palliative care consultation, patients reported experiencing less emotional distress than before consultation (2.1 vs 2.7, P = .03). They also reported being less bothered by uncertainty regarding what to expect from the course of their illness (2.5 vs 3.4, P = .002). Fewer patients reported being unsure of the purpose of their medical care after palliative care consultation (8%) vs before (18%) although this was not statistically significant (P = .10). Median length of stay was longer in the study group compared with the historic cohort (8 vs 7 days, P = .02). There was no difference in 30-day mortality (3% vs 8%, P = .42) between the study group and the historic cohort (N = 77). Integrating inpatient palliative care consultation into the routine management of patients with CLTI is feasible and beneficial. Patients reported improved emotional domains of health-related quality of life. This study laid the foundation for a future randomized controlled trial to further assess the impact of palliative care as part of the routine management for this challenging patient population.TablePatient demographics, comorbidities, and hospitalization characteristicsUnitStudy cohort (N = 39)Historic cohort (N = 77)P valueaA. Demographics AgeYears, mean (SD)69 (10)70 (12).82 SexFemale, N (%)9 (23)21 (27).66 RaceNon-White, N (%)3 (8)2 (3).33 EthnicityHispanic, N (%)0 (0)0 (0)–Insurance MedicaidN (%)6 (15)9 (12).04a MedicareN (%)31 (79)46 (60) PrivateN (%)2 (5)18 (23) Self-pay/otherN (%)0 (0)4 (6)B. Comorbidities BMIMean (SD)28.6 (7.9)27.7 (6.8).56Smoking status CurrentN (%)14 (36)26 (34).97 FormerN (%)18 (46)38 (49) NeverN (%)7 (18)13 (17)DiabetesYes, N (%)23 (59)38 (50).74HTNYes, N (%)33 (85)72 (94).18CADYes, N (%)21 (54)45 (58).69COPDYes, N (%)12 (31)26 (34).84CHFYes, N (%)8 (21)24 (31).28Renal diseaseYes, N (%)13 (33)24 (31).84 Dialysis dependentYes, N (%)2 (15)5 (21)1.00Prior PVIYes, N (%)16 (41)39 (51).43Prior bypassYes, N (%)9 (23)22 (29).66Prior major amputationYes, N (%)3 (8)7 (9)1.00Prior FEYes N (%)1 (3)12 (16).06C. Hospitalization AmbulationIndependentN (%)19 (49)48 (62).36With assistanceN (%)15 (38)21 (27)NonambulatoryN (%)5 (13)8 (10) Indication for admissionRest painN (%)14 (36)26 (34).20Tissue lossN (%)25 (64)51 (66) Admission proceduresMean (SD)1.1 (0.64)1.2 (0.46).10 Admission procedure typePVIN (%)9 (23)20 (26).82BypassN (%)18 (46)41 (53).56Femoral endarterectomyN (%)8 (21)15 (19)1.00Minor amputation or wound debridementN (%)10 (26)20 (26)1.00Major amputationN (%)6 (15)11 (14)1.00Medical management onlyN (%)0 (0)1 (1)1.00 Length of stayMedian (IQR)8 (4-14)7 (4-9).02aICU admissionYes, N (%)9 (23)12 (16).32Length of ICU stayMedian (IQR)3 (2-3)3 (2-4.5).7730-day mortalityDied, N (%)1 (3)6 (8).42BMI, Body mass index; CAD, coronary artery disease; CHF, congestive heart failure; COPD, chronic obstructive pulmonary disease; FE, femoral endarterectomy; HTN, hypertension; ICU, intensive care unit; IQR, interquartile range; PVI, peripheral vascular intervention; SD, standard deviation.aDenotes significance where P ≤ .05. Open table in a new tab