How Palliative Care Can Expand its Reach in Surgical Settings

As a palliative care clinician, you know how much you can help seriously ill patients and their families. But what if you could do more? What if you could reach more patients?

Many surgical patients have historically been just beyond reach for palliative care—despite their high needs—due to multiple barriers. However, you may be closer than you think to being able to help surgeons, other specialists, and their patients meet their goals. By taking the initiative to grow your network and showing clinicians and their patients how you can help, you can make a big impact—widening your lane to help even more people.

Palliative care, by definition, is focused on improving the quality of life for people living with serious illness. But it also aligns closely with the principles of age-friendly care. The Centers for Medicare & Medicaid Services (CMS) recently started requiring hospitals that participate in Medicare’s Hospital Inpatient Quality Reporting (IQR) Program to implement protocols that meet age-friendly care standards for older adults. Surgical service lines nationwide are evaluating how to comply with these measures to improve care outcomes and avoid costly penalties.

Age-Friendly Health Systems is an initiative of The John A. Hartford Foundation and the Institute for Healthcare Improvement, in partnership with the American Hospital Association and the Catholic Health Association. CMS based its Age-Friendly Hospital Measure in part on the evidence-based elements of care known as the 4Ms Framework, which is the cornerstone of the age-friendly movement:

• What Matters, which addresses the patient’s priorities, including their goals and care preferences
• Medication, which should not interfere with what matters most to the patient
• Mentation, which includes the management of dementia, depression and delirium
• Mobility, which allows the patient to move and function safely.

While palliative care clinicians are often seen as being focused primarily on What Matters, the other Ms fall well within our expertise. In fact, these elements are deeply intertwined. For example, getting a patient up and moving after surgery for optimal recovery or managing medications to reduce the risk of delirium. You can’t manage one M without addressing the others.

By showing your surgical colleagues how your expertise can help them meet the Age-Friendly measures, you’re widening your lane. The 4Ms tie directly into our expertise as palliative care clinicians. We work with patients, their families, and their caregivers to understand and help them articulate their goals for care. We also oversee medication management to manage pain and other symptoms, while keeping a sharp eye on our patients’ mental status and their ability to function as normally as possible.

In short, we work with patients and their families to ensure that their treatment offers them “the greatest benefit with the least possible harm.” We can accomplish this goal while also helping our colleagues and institutes meet the Age-Friendly care requirements.

While a few organizations have begun offering pre-operative palliative care consultations as a standard practice—a proactive approach that gets the palliative care team involved before surgery to prepare for the future—that’s not yet a widespread strategy. Your organization doesn’t need to have an elaborate, free-standing preoperative palliative care clinic in order for you to provide excellent palliative care to patients who need it or reach age-friendly care requirements.

Instead, working behind the scenes to build relationships with others in your organization can generate inroads that lead to more opportunities to contribute to patient care. In fact, building relationships with other clinicians, specialists, and departments really is the key to expanding your palliative care team’s reach.

A concern that palliative care clinicians may have is the perception that they are stepping on the toes of one of their surgical colleagues. One approach is to empower surgical teams to deliver age-friendly care themselves, equipping them with the tools to do so. Offer to work with your surgical service line to incorporate a brief palliative care or age-friendly assessment into their daily rounds for critically ill patients, for new acute surgical admissions, or for high-risk elective cases. As surgical teams begin to appreciate the value of these approaches in optimizing surgical quality, they will be more inclined to ask for help when they need it.

Another possible hurdle to overcome is the persistent misunderstanding of the role of palliative care and the belief that palliative care begins after surgery. You may have to provide some education about the role of palliative care to clear up any misconceptions. It’s not overstepping to let the surgical team know that you’re available and committed to providing the best possible care to their patients. However, it does take time to build trust, so do not expect immediate dividends.  Over time, patience and persistence coupled with demonstration of your positive impact will likely lead to more and earlier requests for consultations.

It is always helpful if someone on your team has an “in,” such as a dual specialty or a background in a surgical specialty, that can help foster those relationships. It can be reassuring to surgeons to know that the palliative care team understands their culture and concerns, too. Assuring them of your commitment to quality, patient satisfaction, and a nuanced understanding of caring for patients with high-risk profiles can also be helpful.

You could also expand your practice and impact in other ways. For example, I attend my department’s weekly surgical Morbidity and Mortality conference.  A few years ago, any time a case was presented where I felt that palliative care could have been helpful, I messaged the surgeon or the service and reminded them that the palliative care team is always here to help. Over time, this has created a level of awareness of palliative care that has changed the culture and practice patterns of our department.  You could participate in M & M conferences in your own institution, too.

Other ways that you could potentially widen your lane:

• Serve on a tumor board or participate in other multispecialty team meetings
• Ask to serve on a departmental quality committee – whether in Surgery or in another department of particular interest to you that matches your unique background or your institution’s needs
• Contact other departments tasked with implementing age-friendly measures and ask if they would like to have support from the palliative care team.  Be sure to describe how the palliative care approach can directly contribute to meeting the measures!

Your lane is wider than you—and your colleagues—may realize.

Palliative care is appropriate at any and every step of the patient’s journey, medical or surgical. Thus, providing symptom and pain management while helping patients navigate the goal-setting and decision-making processes is squarely within a palliative care physician’s scope of practice. Plus, palliative care clinicians contribute to their organization’s overall success by making sure that age-friendly measures are consistently met. It may require stepping out of your comfort zone to expand your reach, but ultimately, everyone can benefit.