Terminal care cases in the Australian and New Zealand Audit of Surgical Mortality

The Australian and New Zealand Audit of Surgical Mortality (ANZASM) has observed some variations in the interpretation of the opening question on the Surgical Case Form (SCF), which asks: ‘Was terminal care planned for this patient prior to or on admission?’

There has been a gradual increase in the number of cases identified as Terminal Care (TC) that on review, have been found to be inaccurately classified. The confusion mainly relates to cases where it is decided not to manage the patient with surgery, but to offer an active treatment that is capped short of an operation. When the patient fails to progress, active surgical treatment is withdrawn, and TC commenced. For these patients, TC was not planned prior to or on admission, so it is not appropriate that the TC question is affirmatively answered. The four abbreviated reports below provide some examples of TC interpretations. Case 1 A middle-aged patient, with several comorbidities, was admitted to a regional hospital and the clinical diagnosis of gallstone pancreatitis was confirmed on a Computed Tomography (CT) scan. The patient was transferred by the Royal Flying Doctor Service for management of the gallstone pancreatitis. On arrival at the tertiary hospital, antibiotics were commenced and an Endoscopic Retrograde Cholangiopancreatography (ERCP) undertaken. After the ERCP, the patient was admitted to the Intensive Care Unit (ICU). When the liver function tests became deranged, an ultrasound was undertaken. The patient then aspirated, and a chest x-ray was performed, and high flow oxygen commenced. The patient was not progressing and, after discussion with the family, surgical treatment was withdrawn.

The Palliative Care team became involved 12 days after admission, and the patient died 14 days after admission. When completing the SCF, the surgeon excluded this patient from the audit by answering ‘yes’ to the question: ‘Was terminal care planned for this patient prior to or on admission?’ This patient was not admitted for Terminal Care. The patient was transferred from the regional hospital for an ERCP, to specifically receive active treatment. In the days after the ERCP, the patient had several assessments, including blood tests and an ultrasound, and antibiotics. None of these would have been required, or appropriate, if admitted for TC. The medical notes then clearly record when treatment was withdrawn, and TC commenced.

Case 2 An elderly patient attended the Emergency Department (ED) of an outer metropolitan hospital, with a clinical diagnosis of small bowel obstruction, which was confirmed on a CT scan. The patient was admitted for conservative treatment and 48 hours after admission, was given Gastrografin. Although this appeared successful, the patient developed a productive cough— perhaps from aspiration—and antibiotics were administered. Over the next few days, the patient struggled with respiratory problems and developed atrial fibrillation and was admitted to the ICU for intravenous amiodarone. While in the ICU, the patient’s abdomen became distended and a CT scan showed large bowel obstruction

(cause not clear). On day 12, surgical care was withdrawn after discussions with the family. The patient died the same day. When completing the SCF, the surgeon excluded this patient from the audit by answering ‘yes’ to the question: ‘Was terminal care planned for this patient prior to or on admission?’ This patient was clearly not admitted for TC, but for active treatment that was capped when the patient deteriorated, as the patient was not fit for surgery. Case 3 A young patient was admitted following a fall at work. On arrival in the ED, the patient had fixed dilated pupils and a Glasgow Coma Scale of 3. The neurosurgical opinion was that this was a non-survivable injury and active treatment was not appropriate. The patient’s family lived some hours away, so the patient was admitted to the ICU pending the arrival of the family. Once the family had had an opportunity to pay their respects, surgical treatment was withdrawn, and the patient died shortly afterwards.

Although the patient did not attend the ED for TC, the decision not to offer active treatment was made immediately in the ED. The active care given in the ICU was not to treat the patient, but to give the family time to travel to the hospital. It was therefore appropriate for the surgeon to answer ‘yes’ to the question: ‘Was terminal care planned for this patient prior to or on admission?’ Case 4 An elderly and dependent patient with multiple comorbidities was admitted from a nursing home with sepsis from a severe lower limb soft tissue infection. Urgent debridement was the only treatment option, but the patient was unfit for surgery. The patient’s family had an Advance Health Care Directive stipulating no care if such an eventuality occurred. It was not feasible to send the patient back to the nursing home overnight, so the patient was admitted and died a few hours later. It was therefore appropriate for the surgeon to answer ‘yes’ to the question: ‘Was terminal care planned for this patient prior to or on admission?’ There is no suggestion that the care of these patients has been anything other than appropriate. However, there is increasing interest in End of Life Care and it is important that ANZASM correctly records those who were actively managed—but without surgery—as opposed to those who had no active treatment.

Professor Guy Maddern, Chair, Australian and New Zealand Audit of SUrgerical Mortality.