Integration of Palliative Care Consultation into the Management of Patients with Chronic Limb Threatening Ischemia.

INTRODUCTION: We assessed the feasibility of integrating palliative care consultation into the routine management of patients with chronic limb threatening ischemia (CLTI). Additionally, we sought to describe patient reported outcomes from the palliative care and vascular literature in patients with chronic limb threatening ischemia receiving a palliative care consultation at our institution.

METHODS: This was a single institution, prospective, observational study that aimed to assess feasibility of incorporating palliative care consultation into the management of patients admitted to our tertiary academic medical center with chronic limb threatening ischemia by looking at utilization of palliative care before and after implementation of a protocol-based palliative care referral system. A survey comprised of patient reported outcomes from the palliative care literature was administered to patients before and after palliative consultation. Length of stay and mortality was compared between our study cohort and a historic cohort of patients admitted with chronic limb threatening ischemia.

RESULTS: 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 (N=4) who would have met criteria over the preceding 14 months before our protocol was instituted. The mean age was 69, 23% were female, 92% white and 49% were able to ambulate independently. Revascularization included bypass (46%), peripheral vascular intervention (23%), and femoral endarterectomy (21%). Additional procedures included minor amputation or wound debridement (26%) and major amputation (15%). No patients received medical management alone. After receiving palliative care consultation, patients reported experiencing less emotional distress than before consultation (p=0.03). They also reported being less bothered by uncertainty regarding what to expect from the course of their illness (p=0.002). 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=0.10). Median length of stay was longer in the study group compared with the historic cohort (8 vs. 7 days, p=0.02). There was no difference in 30-day mortality (3% vs. 8%, p=0.42) between the study group and the historic cohort (N=77).

CONCLUSIONS: Integrating inpatient palliative care consultation into the routine management of patients with chronic limb threatening ischemia is feasible and may improve emotional domains of health-related quality of life. This study laid the foundation for future studies on longer term outcomes of patients with chronic limb threatening ischemia undergoing palliative care consultation as well as the benefit of outpatient palliative care consultation in patients with CLTI.