Association of Palliative Care Consultation with Resource Utilization and Infectious Outcomes in Advanced Age Surgical ICU Patients with Sepsis

Authors:
Francesca Bragg, Ryan Desrochers, Daithi Heffernan, Andrew Stephen

Body of Abstract:
Background: Surgical ICU patients with sepsis often face rapidly progressive deterioration, multisystem failure requiring a high degree of supportive care, and ultimately face a high mortality. Surgeons are trained to view sepsis as a reversible condition if timely operative source control is achieved which is often in contrast to other medical conditions which are more commonly accepted as displaying a terminal, or irreversible trajectory. This mindset may delay important goals-of-care discussions when frailty, advanced age, and organ failure limit the physiologic benefit of aggressive interventions. Earlier palliative care (PC) integration may align treatment decisions with prognosis and reduce non-beneficial invasive care, but its role in septic surgical patients remains poorly defined.

Methods: We conducted a retrospective analysis of critically ill surgical patients ≥65 years with sepsis requiring a procedural intervention. Patients receiving PC consultation were compared with those without PC involvement on mortality, infection-related complications, ventilator exposure, invasive interventions, and health care utilization. Continuous data is presented as mean and standard deviation

Results: A total of 11,090 patients were included; 5,520 (50%) received PC consultation and 5,570 (50%) did not. PC patients were older (76.4+/-0.9 vs 74.6+/-0.9; p<0.001) and had higher rates of heart failure (53% vs 39%; p<0.001), COPD (35% vs 26%; p<0.001) and chronic kidney disease (45% vs 34%; p<0.001). PC patients exhibited higher mortality (60% vs 16%; RR 3.8, 95% CI 3.548-4.036; p<0.001). PC involvement was associated with significantly greater downstream infection-related complications, including pneumonia (17% vs 12%; RR 1.3, p<0.001) and bacteremia (11% vs 9%; RR 1.3, p<0.001), and significantly fewer UTI (12% vs 15%; RR 0.83, p=<0.001). PC patients underwent fewer invasive procedures (56% vs 71%; RR 0.79, p<0.001), fewer specialist consults (66% vs 68%; RR 0.97, p=0.03), fewer CT scans (42% vs 47%; RR 0.88, p<0.001), and reduced antimicrobial exposure (83% vs 88%; RR 0.95, p<0.001). Conversely, ventilator (28% vs 22%; RR 1.3, p<0.001) and vasopressor (18% vs 12%; RR 1.5, p<0.001) utilization was higher in the PC group. Conclusions: In older septic surgical ICU patients, palliative care consultation is associated with higher rates of pneumonia and bacteremia but lower rates of urinary tract infection, underscoring the complexity of downstream infection-related outcomes in this population. Palliative care involvement is associated with decreased procedural intervention while appropriately identifying those with terminal illness trajectories. These findings support normalizing and earlier integration of palliative care in sepsis management, particularly when physiologic reserve is limited, to ensure patient-centered decision making and avoid non-beneficial escalation of care.