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Patients discharged to hospice after gastrointestinal surgery, which was typically done urgently or emergently, usually had multiple prior admissions, found a retrospective study suggesting room for improvement in advance care planning.

Fully 89% of the 2,688 such patients in a statewide database had urgent or emergent gastrointestinal procedures immediately before hospice enrollment, of which 57% were performed for complications of cancer and 21% for bowel obstruction, reported Elizabeth Wick, MD, of the University of California San Francisco, and colleagues.

A significant burden of end-of-life care was observed for these patients, with 2.21 mean hospitalizations per patient (26% for surgery) in the 3 years prior to hospice enrollment. Of those, 60% were within 1 year of hospice enrollment, the authors wrote in .

While there were many questions the dataset couldn't answer about appropriateness of care, the study presented an overall portrait "that end-of-life care is burdensome and suboptimal," M. Andrew Millis, MD, MPH, and Pasithorn Suwanabol, MD, MS, both of the University of Michigan in Ann Arbor, stated in an .

They agreed with the researchers that "advance care planning and discussions about care goals are important opportunities to improve end-of-life care for patients undergoing surgery. To operate preemptively and/or without aligning preferences potentially subjects a vulnerable population to unnecessary surgery -- an aggressive yet avoidable approach."

End-of-life palliative care or hospice can optimize the lives of terminally ill patients who have a predefined prognosis of 6 months or less, Wick's group noted. Patients undergoing surgery in access to hospice services, and limited data exist on the characteristics of surgical patients who do enroll in hospice.

In the study, those readmitted to the hospital after hospice enrollment were less likely to be white (53% vs 64%), but more likely to be underserved, compared with those who were not readmitted:

• Younger (mean age 70 vs 74)
• Non-English native speakers (17% vs 13%)
• Medicaid beneficiaries (19% vs 10%)
• From economically distressed communities (55% vs 49%)

Wick and colleagues examined data on 2,688 adults who were discharged to hospice (whether at home or in a facility) following a surgical hospitalization for a digestive disorder between 2015 and 2019 across all licensed California hospitals.

Mean age in the cohort was 73, and 54% of the patients were women. Most patients were white (62%), followed by Hispanic (19%), and Asian or Pacific Islander (8%). Overall, 13% were non-native English speakers, and nearly three-fourths were on Medicare.

Patients most commonly underwent procedures for gastric bypass, bowel resection, fecal diversion, paracentesis, and inferior vena cava filter placement.

After hospice enrollment, 14% (n=368) were readmitted to the hospital, which was mostly for infection, followed by acute kidney disease, bowel obstruction, or psychiatric disorders.

This analysis "reveals multiple opportunities to elicit patient values and discuss future care among patients with gastrointestinal tract cancer undergoing surgical intervention and suggests that such conversations should begin at the time of diagnosis and continue even after hospice discharge," the editorialists wrote. "Unfortunately, for this cohort, it is unknown whether these conversations occurred and whether patient values were respected."

The authors acknowledged limitations to the data including potentially underestimating the number of hospice patients who underwent gastrointestinal surgery, since those who enrolled post-discharge were excluded. Data on any applicable advance care plans was not available. Use of distressed community indexes were based on zip codes, which were not representative of homogenous communities.

Using large data sets to capture the nuances of care at the end of life is challenging, the editorialists noted, and "large data sets do not capture patient wishes, and conclusions about the merit of surgery are not possible."

It also wasn't clear whether palliative care was involved in the hospitalizations that occurred before the gastrointestinal surgery leading to discharge to hospice, or whether goals of care had been discussed, Millis and Suwanabol added.

"Furthermore, although there may be a typical cancer trajectory, cancer can also be insidious and unpredictable," they wrote. "As such, it may not be truly accurate to conclude that surgery near death is a failure in the care pathway leading to untimely or aggressive care."

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