title: Surgery at the end of life: a pilot study comparing decedents and survivors at a tertiary care center.
abstract: BACKGROUND
  More than a quarter of medical costs for Medicare beneficiaries are incurred in the last year of life; surgical intensity during this time is significant. This study was performed to determine types of operations patients undergo in their terminal year, and compare characteristics of decedents with those of survivors.
  
  
  METHODS
  Population of 747 consecutive all-payer patients seen at the preoperative assessment center of a tertiary care hospital. Patient characteristics were obtained from the electronic medical record. Surgical indication (palliative, curative, diagnostic, elective) was assessed based on procedure performed and underlying diagnosis. Vital status was determined using the electronic medical record with confirmation via social security national death master file. Descriptive statistics were performed to compare patient characteristics and procedures performed on those who died within 1 yr of procedure with those of survivors.
  
  
  RESULTS
  Thirty-seven patients (5%) were confirmed dead at 1 yr. Ten (27%) of these had palliative procedures, 11 (30%) diagnostic, 14 (38%) curative, and 2 (5%) elective. Decedents were more likely to have undergone a palliative (27 vs. 3%) or diagnostic (30 vs. 14%) procedure and less likely to have undergone an elective procedure (5 vs. 42%) than survivors (P < 0.0001). Nearly half of decedents did not have an advanced directive by the date of surgical intervention.
  
  
  CONCLUSIONS
  Nearly 1 in 20 patients seen at the preoperative assessment clinic of a tertiary care hospital died within 1 yr of their procedure. Patient characteristics and procedure indication for decedents differed from those of survivors. Similar analyses based on institution and region may provide methodologies to compare variation in surgical intensity and assist preoperative care providers in evaluating appropriateness of resource allocation.
authors.affiliation: * Fellow in Cardiothoracic Anesthesiology, † Resident in Anesthesiology, Department of Anesthesiology, Brigham and Women's Hospital, Boston, Massachusetts. ‡ Associate Professor of Anaesthesia, § Assistant Professor of Anaesthesia, Harvard Medical School, Boston, Massachusetts, Department of Anesthesiology, Brigham and Women's Hospital. Professor of Surgery, Harvard Medical School, Brigham and Women's Hospital, Center for Surgery and Public Health; Department of Health Policy and Management, Harvard School of Public Health; and Department of Surgery, Brigham and Women's Hospital. # Associate Professor of Anaesthesia, Harvard Medical School, Department of Anesthesiology, Brigham and Women's Hospital; Center for Surgery and Public Health; and Department of Health Policy and Management, Harvard School of Public Health.
authors.forename: Caryn S
authors.initials: CS
authors.lastname: Barnet
authors.forename: Alexander F
authors.initials: AF
authors.lastname: Arriaga
authors.forename: David L
authors.initials: DL
authors.lastname: Hepner
authors.forename: Darin J
authors.initials: DJ
authors.lastname: Correll
authors.forename: Atul A
authors.initials: AA
authors.lastname: Gawande
authors.forename: Angela M
authors.initials: AM
authors.lastname: Bader
mesh_terms: D016223:Advance Directives / Q000706:statistics & numerical data; D017558:Elective Surgical Procedures / Q000379:methods / Q000401:mortality / Q000706:statistics & numerical data; D005260:Female; D006801:Humans; D008297:Male; D006278:Medicare / Q000706:statistics & numerical data; D008875:Middle Aged; D010166:Palliative Care / Q000379:methods / Q000706:statistics & numerical data; D010865:Pilot Projects; D012189:Retrospective Studies; D018709:Statistics, Nonparametric; D013514:Surgical Procedures, Operative / Q000379:methods* / Q000401:mortality / Q000706:statistics & numerical data*; D017741:Survivors / Q000706:statistics & numerical data*; D013727:Terminal Care / Q000379:methods*; D062606:Tertiary Care Centers / Q000706:statistics & numerical data*; D014481:United States