Planning Together: Shared Decision-Making and End-of-Life Care in Patients Not Undergoing Emergency Laparotomy (NoLap)

Introduction

The National Emergency Laparotomy Audit (NELA) reports outcomes for patients who undergo surgery, but it also identifies a group of patients considered for laparotomy who did not proceed to theatre. This ‘NoLap’ cohort is often frail and at high predicted mortality risk yet receives far less scrutiny than the operative group. We audited these patients to assess how dying was recognised, how decisions were made, and what end-of-life care they received. 

Methods

NoLap patients admitted to the Grange University Hospital in year 1 of the NELA were reviewed (n=18). Cases were assessed for demographics, pathology, NELA mortality risk, frailty documentation, specialties included in decision-making, patient and family involvement, palliative care input, and end-of-life care planning. 

Results

18 NoLap cases were identified from the NELA for inclusion. Median age was 84 years (range 55-99); 89% were over 65 and 78% were female. An objective NELA score was documented in 56% of cases, however, median retrospective mortality risk was 51.65%. All patients met the ‘very high risk’ threshold. Tripartite discussion involving surgery, anaesthetics, and ITU took place in 17% of cases, although anaesthetics or ITU were involved in 56%. 72% of patients were included in decision-making with those who weren’t excluded because they were too unwell or lacked capacity. Frailty was formally scored in only 6% of patients, despite ‘frailty’ being documented in 67%. Palliative care was involved in 72% of cases, and 56% had an advanced care plan. All patients died during initial admission or subsequent step-down, and all had an end-of-life care plan in place. 

Discussion

Every patient in the NoLap cohort died. Objective frailty and risk scoring was used inconsistently despite this being a uniformly high-risk group. End-of-life care was delivered well once implemented, but earlier, more consistent objective assessment would support timelier recognition and better shared decision-making.