Quantitative futility in emergency laparotomy: an exploration of early-postoperative death in the National Emergency Laparotomy Audit

Futility occurs when ‘there is a goal, there is an action and activity aimed at achieving this goal and there is virtual certainty that the action will fail in achieving this goal’ [1]. Quantitative futility is the scientific assessment of the probability of the failure of a treatment [2], demonstrated by evidence-based risk prediction models like the National Surgical Quality Improvement Program (NSQIP), National Emergency Laparotomy Audit (NELA) and Portsmouth Physiological Operative Severity Score (P-POSSUM) [3‐5]. These risk prediction models calculate the percentage risk of 30-day mortality after emergency laparotomy in order to guide clinical decision-making [3‐5]. The concept of futility in surgery is highly controversial [6], but it is incontrovertible that in surgery there is an important balance to maintain between under and over treatment. Treatment that is not in concordance with a patient’s goals and priorities has been associated with post-traumatic stress disorder and complex grief for their families, and is associated with moral distress and burnout in clinicians [7‐10].

For those who do not survive, an emergency laparotomy has provided negligible therapeutic benefit. This may represent a missed opportunity in the multidisciplinary discussion on goals of treatment to consider changing the focus of active management to palliation. Significant quality improvement work, led by NELA, has improved the 30-day mortality rates of emergency laparotomy patients in England and Wales [11, 12]. In contrast, very little work has explored early-postoperative mortality, arguably a group for which emergency laparotomy has provided the least benefit [12, 14, 15]. Work that has attempted to define quantitative futile surgery and examine the patient group that has futile surgery, has used different definitions of futility and has failed to incorporate frailty, which has become a key marker for poor postoperative outcomes [12, 14, 15].

The aims of this study were to define a timeframe for quantitative surgical futility in the emergency laparotomy setting and to apply that definition to the NELA dataset, allowing characterisation of this patient population and exploration of predictors of early mortality.

We used a two-stage methodology. Stage 1 aimed to seek a consensus definition of a timeframe for futile emergency surgery using an online survey and a scoping review followed by a steering group consensus discussion. Stage 2 applied this accepted timeframe to the NELA database for analysis.

This work has resulted in a quantitative definition of emergency surgical futility as early-postoperative death within 72 h. Applying this definition to the world’s largest emergency surgery database has reassuringly found only 4% of surgeries result in a quantitatively futile outcome strongly suggesting that appropriate decision-making is part of current emergency surgery practice in the UK.

Combining results of a survey and a scoping review have allowed increased understanding into what perioperative decision-makers think about futility. Although there was a majority agreement from the survey supported by the small number of publications [12, 14, 15], the differing responses from different specialties highlight the varying experiences and values that a multidisciplinary team can provide to these high-risk patients. Where a decision to operate or not may not be clear to a single surgeon, a multidisciplinary council assessment including anaesthetics, critical care and, if appropriate, geriatricians should be routinely considered.

Many of the influencing factors significantly associated with early post-laparotomy mortality are already well known: age, higher blood lactate and CRP, frailty, signs of end organ dysfunction, poor cardiorespiratory reserve and surgery for ischaemia or perforation [12, 16, 21]. Indeed, several are included in the current 30-day mortality risk scoring systems [3‐5, 22]. However, none of the risk scoring systems includes frailty and none is tailored to the specific surgical pathology of the patient, only to predicted degree and nature of contamination which may not be immediately obvious from initial CT [3, 4]. Notably, while surgical pathology was a significant predictor of early-postoperative mortality, it was ranked the least important factor to clinicians making the determination that a surgery would be futile when surveyed, suggesting the major role pathology plays in survival is underestimated by clinicians. This is significant as it recognised that the NELA risk prediction score underestimates mortality risk for patients with ischaemia and bleeding [4].

Surgery that resulted in early-postoperative death was most commonly performed on the older patient living with frailty, the patient with poor physiological reserve and the patient presenting in extremis. Whilst it is not surprising that these factors were associated with poorer outcomes, the number of patients operated on in these circumstances is significant; 49% of patients had some level of preoperative cardiac failure, and 28% had limiting exertional breathlessness or breathlessness at rest. Despite the evidence that a patient with a Rockwood Clinical Frailty Score of > 6 is ten times more likely to die in the first 30 days after surgery and seven times more likely to need care on discharge, nearly a third of the patients in the early-mortality cohort were living with this level of frailty or greater [13, 21]. Younger patients in the early-postoperative mortality group were significantly more likely to be frail or have a learning disability than the younger patients that survived the early-postoperative phase. This likely reflects the association these factors have with other health conditions and reduced physiological reserve. However, it is worth noting that this was not absolute and patients living with these factors also survived the early-postoperative period, although their longer term outcome is unknown. Future work to capture the shared decision-making process would be valuable to understand whether the “do everything” attitude and reluctance to suggest palliative care that has been seen in qualitative studies is at play in these decisions [23‐26]. The factors associated with early-postoperative mortality were largely predictable, quantifiable and were available to the multidisciplinary decision-making team prior to making the decision to perform an emergency laparotomy. A conscious decision was made by the authors not to create an additional risk score so as not to create a tool used to deny surgery to patients without shared decision-making. Risk scores have flaws in that they are unable to predict individual patient outcomes, and the authors felt there was greater value in defining high-risk markers of early mortality in a quantitative way so that they can be used qualitatively as part of shared decision-making.

A question that remains is whether “failure to rescue” and lack of pre- and intraoperative resuscitation plays a role in early-postoperative mortality. In this study presenting with sepsis worsened outcomes significantly, yet less than a third of these patients who had early mortality received antibiotics in the recommended first hour of presentation [27]. This represents an easily targeted area, that has been proven to reduce mortality [27]. There is also evidence that a > 20% fall from baseline of systolic blood pressure is associated with worse outcomes after emergency laparotomy including kidney injury, cardiac complications and mortality [28, 29]. Yet, a significant proportion of the patients who had early mortality were hypotensive preoperatively. It is not possible to comment on whether this was reversible for each individual patient. However, considering only 68% of patients requiring immediate surgery reach theatre in the appropriate timeframe [11], there may be opportunities in the preoperative period for concurrent resuscitation and surgical workup in order to improve timeliness to theatre and postoperative outcomes.

The Royal College of Surgeons document ‘The high-risk surgical patient’ mandated that patients with a predicted mortality of > 10% should be admitted to critical care postoperatively [30]. Only 85% of patients in the early-mortality group were admitted to critical care for postoperative ongoing resuscitation. While the management strategy for nearly two-thirds of the patients that did not get admitted to critical care was changed to palliative care following their surgery, almost all of the remainder of this group of patients were deemed to be high-risk preoperatively and, therefore, should have been routinely received critical care postoperatively [11]. This highlights the need to keep deaths following emergency laparotomy under constant review. To that end, the authors suggest that all mortality following emergency laparotomy be routinely reviewed at morbidity and mortality meetings to review that key processes and standards are being achieved for these patients.

A limitation of this work is the lack of granularity of the data; as a national collaborative project, it is imperative to minimise the data collection burden. As a result, NELA does not collect data on individual patient comorbidities, details of the decision-making process or cause of death which would be a useful addition to the discussion. In addition, as the questions in the dataset evolve, factors which we now know to be crucial to decision-making and outcomes such as frailty have been added over time and, therefore, are missing from the historical data. There is also a piece of the puzzle missing: patients who do not have emergency laparotomy and instead have palliative management. Even less is known about these patients than patients in the early-postoperative mortality cohort. However, a multicentre cohort study is currently underway looking at their decision-making process and outcomes [31]. Although we examined quantitative futility in this study, it is also important to recognise that to patients there is a spectrum of good and bad outcomes after surgery, not just the dichotomous outcome of survival vs. death. The patient perception of futile surgery was not included in this paper, however, days alive at home, patient-reported outcomes (PROMs) and patient-reported experience measures (PREMS) are increasingly being used as more patient-centred outcome measures following surgery [32‐34]. Further patient and public involvement work around the shared decision-making process, as well as the experience of families and carers of patients who did not survive emergency laparotomy, will be vital going forward.

This study has shown early-postoperative mortality is associated with quantifiable and predictable factors in addition to the known risk factors which make up NELA and NSQIP risk scoring systems. Surgical pathology and frailty are important predictors of poor early-postoperative outcomes, as are extremes of physiological derangement such as perioperative hypotension, lactataemia and preoperative cardiorespiratory dysfunction. This information should be incorporated into shared decision-making conversations with emergency laparotomy patients and their families. Further work to define long-term outcomes following emergency laparotomy examine the patient group that do not have an operation and patient and public involvement work is necessary to understand the nuance of decision-making in these extreme-risk patients.