The Monty Python Paradox: Using GIP Hospice to Optimize End-of-Life Care

General Information

Institution Name: Stanford Health Care

ACS Quality Program(s): Trauma

Years of Study: 2022 to Present

Author Name and Title: Joseph D Forrester, MD, MSc, FACS, Trauma Medical Director; and Kris Gallegos, RN, BSN, TCRN, Trauma Program Manager

Name of Case Study: The Monty Python Paradox: Using GIP Hospice to Optimize End-of-Life Care

Identification of Local Problem

Trauma surgeons are faced with an increasing professional conundrum. Trauma surgery has traditionally been defined by years of surgical expertise and training focused on saving lives in dire situations. That ethos must be integrated with the reality of modern trauma care. Many trauma patients are aging, suffer devastating injuries in later stages of life, with intervention unlikely to lead to meaningful salvage. This leads to a Monty Python paradox; patients arrive with injury superimposed upon considerable co-morbid burden and frailty and the focus of the trauma team shifts from life preservation to symptom palliation. Our center has seen this global trend play out within our own trauma population. At our center, more than 50% of trauma admissions are ≥65 years old. Review of deaths from January 2019–December 2022 found that 61% occurred in this age group, with severe traumatic brain injury and comorbidities contributing to 65% of those deaths. Increasingly, trauma care involves transitioning from aggressive intervention to goal-concordant end-of-life care.

Context of the QI Activity

In 2021, our center developed a general inpatient hospice (GIP) program. The program intent was to provide hospice care to patients actively or imminently dying who are hemodynamically unstable or have end-of-life symptoms that preclude transfer to another care setting. This hospice service was initiated enterprise-wide as a joint venture between a private hospice company and our palliative service team. Our trauma team identified this hospice service as an opportunity to integrate improved end-of-life services for patients and family members of gravely injured patients. Prior to integration, we identified three primary hurdles: i) changing the perception of what a trauma surgeon does and what a trauma service can provide; ii) developing a collaborative and sustainable protocol to ensure seamless integration with existing care pathways; and iii) scaling the process to adapt to the growing need to provide dignified, patient-centered, end-of-life care in an acute care setting.

Interventions and Implementation

Our first step was to create dialogue between our trauma service and the GIP team. The GIP team was invited to our Performance Improvement and Patient Safety meeting to present the program, field questions in a psychologically safe environment, have ethical discussions, and review patients that met criteria for screening. Our service began using this service Spring of 2022. We integrated hospice discussions into our rounding practice and advanced care planning meetings. We emphasized standardized messaging with the trauma team. The trauma office reviewed all GIP-enrolled cases and missed referral opportunities.

There were several early roadblocks. Initially, enrollment to GIP was limited by symptom needs. Without active symptoms, insurance would not approve enrollment. Second, enrollment was limited by prognosis, as fluctuating pathology could lead to de-enrollment. Third, the electronic medical record (EMR) process also proved difficult. It required discharging and readmitting patients on the same service, leading to provider frustration. Lastly, the service only covered Monday through Friday leading to limited engagement in off hours. Despite the aforementioned initial barriers, the program demonstrated clear value to patients and families, prompting key enhancements: expansion to 7-day coverage with advanced practice provider support, streamlined EMR processes, removal of symptom-based enrollment restrictions, and increased collaboration through a dedicated GIP liaison. Within one month of removing symptom criteria, consults doubled and acceptance increased by 20%.

Costs and Funding Sources

There have been no direct costs associated with this program attributed to the trauma service, and GIP hospice is available hospital wide. GIP hospice is a CMS-covered service for admitted trauma patients.

Overall Results and Analysis

From April 2022 to December 2025, 29 (16%) of 179 trauma patients who died were enrolled in GIP hospice. Early review of 2026 data reflects that more than 50% of all admitted trauma deaths are now going to GIP hospice. More importantly, cultural transformation has occurred within the trauma team. Discussions of death and dignity are now more open and proactive, reducing stigma and fostering transparency in care decisions. Goals-of-care (GOC) discussion timelines are systematically monitored and evaluated through our Performance Improvement (PI) program, with a target of completion within 48 hours of admission. The geriatrics service has been instrumental in the early initiation and facilitation of these discussions.

The trajectory from maximal intervention to abrupt withdrawal has shifted toward a more deliberate, patient-centered transition focused on comfort and alignment with patient wishes.

Limitations

Limitations still remain with the program. The absence of overnight GIP coverage is limiting. Pre-existing family and cultural barriers can limit understanding of the services and support available through the GIP hospice program. Finally, although GIP hospice consultation has been successfully integrated into the overall trauma workflow, further EMR enhancements may improve efficiency and identification of appropriate patients, including trauma-specific admission order set additions and automated EMR triggers based on patient history and current clinical condition.

Lessons Learned

Sustaining an integrated trauma/GIP hospice program requires ongoing collaboration between the GIP Hospice team and the trauma program. At our institution, this work has been reinforced through EMR integration, a GIP reference manual housed in the trauma guidelines app, annual in-service education, expansion of GIP service line members, and trauma registry data capture and review.

Although formal pre-implementation targets were not established at the start of the project, future goals include ensuring that 80% of eligible patients receive an initial palliative care consult within 48 hours. The team is also considering standardizing this expectation within admission order sets. Additional metrics related to eligible and completed hospice assessments are currently in development as the service line expands coverage.

Future measurements will also include broader outcomes and resource utilization metrics, including hospital length of stay, ICU days, and procedures near the end of life. These measures will help the team better understand the program’s impact beyond referral and enrollment processes.

A key lesson from this work is the importance of reframing the role of the trauma program. While trauma care will always emphasize dynamic decision-making, life-saving intervention, surgical precision, and expertise in critical situations, trauma teams can also provide exceptional end-of-life care. Patient autonomy, comfort, and empathy should remain central to decision-making for seriously injured patients and their families.