Almost 50% of children hospitalized for a terminal condition undergo surgery, most commonly to address hardware or catheter issues. Researchers concluded, therefore, that pediatric surgical care is an important piece of end-of-life care for such hospitalized children.
Other findings include that Hispanic children were less likely to undergo surgery, and surgical procedures become less common as children aged. Results are published in Pediatrics.
“[I]n this national-level multicenter case series of pediatric terminal hospitalizations, we describe the incidence, type, and likely purpose of surgical procedures performed near or at the end-of-life for hospitalized infants, children, and adolescents. Given the known differences in mortality across the pediatric age range, medical care needs based on underlying conditions, and end-of-life care patterns by race and ethnicity, we also examined variation in surgical care by age, underlying chronic complex conditions (CCCs), and race and ethnicity,” wrote Michael D. Traynor, Jr., MD, MPH, of the Mayo Clinic, Rochester, Minnesota, and fellow researchers.
Using data from 4,424,886 hospitalizations from January 2013 through December 2019 in 49 U.S. children’s hospitals (the Pediatric Health Information System database), Traynor and fellow researchers identified children less than 20 years old who died.
Among these 33,693 terminal hospitalizations, 90.3% were for non-traumatic causes, and the median duration of hospitalization was 7 days.
A full 49.7% of these children underwent surgery during hospitalization (P<0.001). These surgeries became increasingly less likely with increasing patient age, less likely in Hispanic children (47.8% versus 51.9% White children; P<0.001), and less likely in Black, Asian American, and Hispanic children compared with White patients (P<0.001). Over time, the number of patients undergoing surgical procedures decreased, from 54% in 2015, to 46% in 2019 (P for trend<0.001).
In all, 70,191 surgical procedures were completed. Traynor and colleagues classified surgeries according to indications, and these included insertion or adjustment of hardware or catheters, attempts to rescue the patient from death, exploration, biopsy, tissue resection, care for cardiac congenital conditions, and care for noncardiac congenital conditions.
Most procedures involved the thoracic system (28%), followed by gastrointestinal (23%), cardiac (20%), and vascular and lymphatic systems (16%). Procedures to insert or address hardware or catheters were the most common (31%), followed by procedures to aid diagnoses (14%), rescue patient from death (13%), and biopsy (13%).
Patients’ age at death had no significant association with the probability of undergoing surgery at the end of life (P=0.85).
“An increase of 1 year in age was associated with decreasing odds of surgery to resect tissue (OR: 0.98 [95% CI: 0.97–0.99]), rescue patients from mortality (OR: 0.98 [95% CI: 0.97–0.99]), explore or aid in diagnosis (OR: 0.94 [95% CI: 0.94–0.95]), and address congenital cardiac (OR: 0.92 [95% CI: 0.90–0.93]) and noncardiac (OR: 0.92 [95% CI: 0.91–0.94]) conditions (all P<0.001). Conversely, increasing age was associated with greater odds of surgery to obtain a biopsy specimen (OR: 1.08 [95% CI: 1.07–1.09], P<0.001),” wrote Traynor and colleagues.
Finally, among the 96% of children with CCC, 51% underwent surgery during terminal hospitalization.
“Pediatric surgical interventions frequently occur during terminal hospitalizations. Although we cannot ascertain whether the underlying goals guiding the care of these patients were focused on cure, life prolongation, comfort, or quality of life enhancement, these findings underscore the importance of surgical care as an aspect of palliative care for hospitalized infants, children, and adolescents,” concluded Traynor et al.
These results have several important implications in the care of children during a terminal hospitalization, according to Lisa Humphrey, MD, The Ohio State University, Columbus, and Lindsay Ragsdale, MD, of Kentucky Children’s Hospital and University of Kentucky, Lexington.
“This finding is important for surgeons engaging in shared decision-making with patients receiving palliative care and their families. This also emphasizes the importance of having surgeons as allied members of the interdisciplinary palliative care team,” they wrote in an accompanying editorial. “Traynor et al also highlight racial disparities in the rates of surgical care for Hispanic, Asian American, and Black children compared with White children during this final admission. Health disparities have been shown at end of life in adult and pediatric care. Although the data do not yield the reason behind the disparity, as a field we should be paying specific attention to the interventions that are offered to patients and preventing systemic bias.”
But, they added, these results leave much unanswered.
“Missing from this work is the context of the decision to pursue surgery. What was the surgeon’s and family’s understanding of their child’s pending mortality before pursuing intervention? Did the family know this was a terminal condition and/or hospitalization? Was the child’s code status discussed before pursuing surgery? Similarly, this study does not reveal the surgeon’s or the family’s intentions with surgery (eg, life prolongation or to mitigate a distressing symptom),” wrote Humphrey and Ragsdale.
For this reason, both the researchers and editorialists stress the need for further study on variables such as how many families chose against surgery, how many received decisional support from palliative care givers, and how many children underwent surgery and died only after discharge.
“What is clear from the work by Traynor et al is that families and surgeons are frequently pursuing surgical interventions in terminal hospitalizations. Pediatricians need to be aware of this, embrace that surgery has a role in end-of-life care, and join with our surgical colleagues to ensure outcomes that meet the needs of patients and families, even while in hospice,” concluded Humphrey and Ragsdale.
Study limitations included lack of data on necessity or reasonableness of surgical care, descriptive limitations inherent in using ICD-9-CM and ICD-10-CM codes, inclusion of only children who died during terminal hospitalization rather than those who were discharged and died under hospice care, non-inclusion of previous surgical procedures, and researchers’ inability to “assess the actual intention of a specific surgeon for any specific procedure performed on an individual patient.”
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Nearly half of terminal hospitalizations in children involve surgical procedures.
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Surgery was less common among Hispanic patients and became less common as patients aged, an effect more pronounced among multiracial patients.
Liz Meszaros, Deputy Managing Editor, BreakingMED™
Traynor, Humphrey, and Ragsdale reported no disclosures.
Cat ID: 138
Topic ID: 85,138,138,192,925,159
