End of life care in chronic limb threatening ischemia: a retrospective cohort study

Objective

Chronic limb-threatening ischemia (CLTI) is the end-stage of peripheral artery disease, defined as 2 or more weeks of rest pain and/or tissue loss from objectively proven obstructive arterial disease. Mortality is high, yet literature on end-of-life and palliative care in this setting is scarce. Palliative care is care that is aimed at alleviating the physiological and psychological symptoms and addresses the social and spiritual needs of patients and family/carers. End-of-life care is an umbrella term for palliative care given alongside disease-modifying care. The aim of this study was to evaluate predictors of end-of-life and palliative care and corresponding outcomes using surgical revascularization and amputation as surrogate markers for CLTI.

Methods

This was a retrospective single-center cohort study of people with CLTI who underwent either surgical revascularization (bypass) or amputation between January 2018 and December 2019. Palliative care input was defined as a dedicated palliative care consultation by a palliative care professional, medical doctor, surgeon, or advanced care practitioner. Data was collected on patient demographics, cause and place of death, and palliative and end-of-life care outcomes, which included documentation of preferred place of care/death and care priorities, family involvement in advance care planning discussions, key workers allocated to coordinate palliative care, use of community palliative care registers, hospice referral, time spent in hospital and the intensive care unit toward the end of life, and realization of documented care objectives. The data was analyzed to determine predictors of palliative care and tangible outcomes.

Results

One-hundred and eighty-six patients were included (116 bypass and 70 amputation) with a median age of 67.5 years (interquartile range, 58-76 years) and most were male (73.7%) with a median survival of 46 months (interquartile range, 21-54 months) and a 2-year survival of 72% (95% confidence interval, 66%-79%). Palliative care consultations occurred for 10.8% of patients, with the median time from consultation to death of 5 days. Of the deceased, only a few had preferred place of care/death (8.1%), care priorities (18.3%), and family involvement during advance care planning (15.1%) documented in their notes. Cause of death was most commonly due to sepsis (n = 30), malignancy (n = 11), and myocardial infarction (n = 10). Mortality and in-hospital death were significantly higher in patients who underwent amputation in comparison to bypass surgery. There was an association of both cardiac and renal dysfunction with palliative care input. Patients with palliative care input were more likely to have documentation of preferred place of care/death, care priorities, and resuscitation decisions; and family involvement in advance care planning decisions. However, this did not translate into a reduction in hospital readmission or time spent in the hospital or intensive care unit towards the end of life.

Conclusions

Patients with CLTI are not being offered palliative care in line with The National Institute for Health and Care Excellence or The Vascular Society of Great Britain and Ireland guidance. There was an association between palliative care input and end-of-life care quality. However, input occurred too close to death to have a very significant effect. Further research, development of clinical pathways and services, and better integration between palliative and vascular services is needed to improve the end-of-life care of patients living with CLTI.