Trauma care and palliative care: time to integrate the two?

The phrase “palliative care in trauma” might seem an oxymoron if we think of the traditional definitions of palliative care and trauma care. Palliative care as defined by the World Health Organization is “the active total care of patients whose disease is not responsive to curative treatment. Control of pain, of other symptoms, and of psychological, social, and spiritual problems is paramount.” The principles of palliative care encompass excellent communication, pain and symptom management, goals of care, bereavement, and spiritual support, usually for patients who are at the end of life. Conversely, trauma surgery is focused on acute care of the critically injured, where decisions and care are provided to rapidly cure the patient and prolong life, often no matter the cost in suffering and resources. If the patient dies it is often suddenly, in the emergency room or the operating room, leaving little room for the traditional notions of palliative care as we know it. Recent developments in society and medicine have highlighted the importance of end-of-life care and the gap between how we wish to die and how many of us do die. These developments have spread to surgery as well, with increased attention to palliative and end-of-life care in the practice and study of surgery, as demonstrated by the recent publications in this journal and others. But this trend brings with it inherent conflict in values, both for society at large and within medicine. Nowhere is this more apparent than on the trauma service. On one hand, the public increasingly values death with dignity, free of life-prolonging machines, but it also values hightechnology trauma and critical care, with its potential for cure and dramatic life-saving maneuvers. Death from trauma is a tragic event, often afflicting young and previously healthy people. It is rarely peaceful or dignified. This conflict is further played out in the current practice of trauma care. The role of end-of-life care in trauma surgery remains ill defined, and is often something to offer only when all other options have failed. The American College of Surgeons Committee on Trauma Optimal Resource Manual defines an ideal trauma system to “include all the components identified with optimal trauma care, such as prevention, access, acute hospital care, rehabilitation, and research activities.” Palliative or endof-life care has not been considered an essential feature of the trauma system and, if provided, is often relegated to other services or providers, often in the last minutes or hours of the patient’s life when care is deemed futile. Trauma surgeons and other specialists have little expertise and training in the skills of palliative care, such as communication, and pain and symptom management. If all of this is so, then how can palliative care be integrated into trauma care and, more importantly, should it? Several trends in healthcare in general and trauma care in particular suggest that palliative care can and should be integrated into trauma. First, despite all efforts, 10% to 15% of trauma patients who make it to the hospital will die from their injuries. An additional percentage of survivors will be disabled or functionally impaired. Clearly, because end-of-life care is increasingly valued, appropriate management of death must become part of the daily workings of a trauma service. Second, demographics suggest that the population is aging; this is reflected in the demographics of trauma admissions. The elderly are increasingly represented on the trauma service, with the oldest old a fast growing group suffering from injury. Outcomes studies clearly demonstrate increased mortality for the elderly trauma patient, both in the hospital and after discharge, compared with younger adults or age-matched elderly who have not been injured. This group is more likely to have chronic lifethreatening illness, advance directives, and preferences for end-of-life care that may involve limitation of lifesupporting technologies. As the situation of elderly trauma patients becomes more frequent, quality end-oflife care becomes a more important part of trauma care. Finally, the evolution of trauma care itself portends a This article is based on work supported by a Faculty Scholars Grant from the Project on Death in America, Soros Foundation.