How to Provide Palliative Care for Surgical Patients
February 7, 2020 | By Ana Berlin
Health systems must find ways to effectively integrate palliative care delivery into surgical care for people with serious illness.
Surgical patients often have meaningful palliative care needs – including high risk of mortality, heavy pre- and post-operative symptom burdens, and the need for goal-setting and complex medical decision-making. Although surgical teams routinely balance the risks and benefits of surgery, usual workflows do not take into account the time required for detailed goals of care conversations and other cornerstones of patient-centered care. Interdisciplinary palliative care teams can give dedicated attention to managing complex symptoms, providing an added layer of support for families, resolving conflicts over treatment goals, and assisting with transitions.
Surgical patients often have meaningful palliative care needs – including high risk of mortality, heavy pre- and post-operative symptom burdens, and the need for goal-setting and complex medical decision-making.
The emerging literature on the outcomes of palliative care for surgical patients shows considerable promise. A systematic review of twenty-five palliative care interventions in surgical patients showed that preoperative decision-making interventions were associated with lower mortality, and other interventions were associated with improved symptoms, higher quality communication, reduced healthcare utilization and lower cost.[i] The American College of Surgeons has called for surgeons to address the palliative care needs of seriously ill patients and families since at least 2005, emphasizing that palliative care can and should be delivered at any stage of disease and concurrently with curative or life-prolonging treatment. And yet studies document that compared with medical patients, surgical patients with serious illness seldom receive specialist palliative care, although they have a higher likelihood of dying in the hospital and in the intensive care unit in the final year of life.[ii],[iii]
Palliative care specialists who hope to work more closely with their colleagues in surgery can build more successful collaborations by considering the needs and perceptions of surgical departments, and framing palliative care as part of a solution to their challenges.
Palliative care specialists [...] can build more successful collaborations by considering the needs and perceptions of surgical departments, and framing palliative care as part of a solution to their challenges.
Learn to speak the surgeons’ language
One of the biggest barriers to palliative care for surgical patients is a persistent misunderstanding among surgeons about what palliative care is, and when it is appropriate for their patients. As Emily Rivet — a colorectal surgeon and palliative care specialist at Virginia Commonwealth University — puts it, “a major factor remains the “rescue culture” of surgery and the pervasive sense that recovery and palliation are sequential rather than parallel elements of an individual’s medical trajectory.”[iv]
One of the biggest barriers to palliative care for surgical patients is a persistent misunderstanding among surgeons about what palliative care is, and when it is appropriate for their patients.
Surgeons also tend to have a bias against palliative care teams, believing that they lack understanding of surgical illness and recovery. Overcoming these biases takes patience, education, and relationship-building so that surgical teams understand that palliative care is appropriate for all patients with serious illness, at any stage of their disease, and alongside life-prolonging or restorative treatment. One way to build trust is for palliative care specialists to attend surgical morbidity and mortality reviews. This is useful not only for the clinical learning, but also to absorb the language and culture of surgery, and to forge relationships with surgical colleagues. Building these relationships may also grant some insight into the pressure that surgeons are under to sustain referral patterns by accepting patients who may not benefit from surgery.
One way to build trust is for palliative care specialists to attend surgical morbidity and mortality reviews.
Focus on quality
Surgical chairs and division chiefs are motivated by concerns with quality and cost. One key driver of quality in surgery is careful patient selection and proactive risk management, an area in which palliative care specialists can be supportive by advocating for systematic pre-operative palliative care assessments for patients with complex risk profiles. Palliative care can support prognostication for these patients, guide communication and decision-making, and put strategies in place to prevent post-operative delirium and other geriatric syndromes. For example, a 2014 study conducted at the VA used a systematic frailty screening to identify at-risk surgical patients and refer them for a palliative care consultation.[v] Frailty is a powerful predictor of adverse outcomes in the surgical setting, including death, complications, functional and cognitive decline.[vi] Palliative care consultation, particularly when provided pre-operatively, was associated with a dramatic reduction in mortality for these patients.
Surgical chairs and division chiefs are motivated by concerns with quality and cost.
By supporting quality care with improved patient selection and risk management, palliative care may in turn help to move the needle on other key concerns for surgical leaders: costs, throughput, and workforce burnout. Palliative care for surgical patients can improve outcomes, generate cost savings, and reduce ICU lengths of stay.[v,vii] Collateral benefits include reduced logjams for surgical teams, by mitigating the common problem of patients being kept waiting for routine procedures because recovery rooms and ICUs are full. It can also help to prevent moral distress, burnout, and costly staff turnover.
Palliative care can also support surgical leaders’ quality goals with respect to patient satisfaction metrics, including key components of HCAHPS scores (Hospital Consumer Assessment of Healthcare Providers and Systems) such as communication, pain management, and patient experience. Trinity Health, the United States’ second-largest health system, in 2015 undertook a system-wide initiative to target improvements in HCAHPS scores by deploying palliative care competency training for all frontline clinicians – including surgeons – providing a model for how palliative care training can support value. An analysis of the HCAHPS Pain Domain Scores for the Trinity hospital units that implemented the palliative care training program showed net positive improvement during the pilot training period.
While it is important to identify surgical champions for palliative care at all levels within their departments and divisions, the value of top-down leadership in surgery cannot be overlooked. Palliative care specialists seeking closer partnerships with surgical departments can use the above concerns as angles with which to engage surgical leaders at the top of the departmental hierarchy. Surgical chairs, division chiefs, and quality officers can set the tone for the department and drive behavior of individual surgeons through a variety of strategies. Examples include routinely focusing conference discussions on improving preoperative risk assessment and how well surgical teams address the palliative care needs of patients, including specialty palliative care consultation when appropriate.
While it is important to identify surgical champions for palliative care at all levels within their departments and divisions, the value of top-down leadership in surgery cannot be overlooked.
Find the model to match
Health systems can deliver palliative care for surgical patients in a variety of ways depending on the particular resources and practice culture of their institution. Some considerations for the choice of model include:
1. Palliative care delivered by the surgical teams versus specialist palliative care
Although surgeons frequently care for seriously ill patients, many report receiving little to no education about palliative care.[viii] Surgical teams can and should be trained in the palliative care skills needed for basic management of pain and symptoms, and discussions of prognosis, goals of care, suffering and advance directives. While educational mandates support this learning for current surgical trainees, they do not address the skill gaps of practicing surgeons. Health systems can augment the palliative care skills of surgeons by rewarding adherence to existing training requirements, fostering innovative partnerships between specialist palliative care divisions and surgical departments for enhanced learning opportunities for trainees and practicing surgeons alike, and supporting support mid-career surgeons in expanding their palliative care skills through continuing medical education such as the online courses offered by CAPC. This can be as simple as including a palliative care specialist in surgical rounds for six months, or as long as the program can accommodate to boost surgeons’ skills and confidence in identifying and meeting patients’ palliative care needs.
Surgical teams can and should be trained in the palliative care skills needed for basic management of pain and symptoms, and discussions of prognosis, goals of care, suffering and advance directives.
Specialist palliative care includes management of refractory pain and symptoms, complex depression, anxiety, grief and existential distress, and assistance with conflict resolution around the goals, methods and appropriateness of treatment.[ix] Hospitals may choose to expand specialist palliative care consults for high-risk surgical patients – perhaps identified with triggers and stratification tools to help normalize the need – while others may choose to help their surgical teams build their skills in communication and symptom management. The most effective model may be to pursue a combination of these two strategies – particularly given the national shortage of palliative care specialists – thereby reserving specialist level palliative care for all but the most complex cases.
2. Upstream versus downstream intervention
Consider existing workflows, and when the optimal time for palliative care intervention may be in different circumstances; then build triggers that meet the need. Triggers for palliative care assessment are reported in the literature on an ongoing basis, but may need adaptation for a specific institution. In general, upstream interventions – in which patients’ palliative care needs are assessed early in their trajectory – are more aligned with patient needs than downstream interventions – in which palliative care can be perceived as presenting a barrier to workflows. For example, palliative care assessment is appropriate for patients when considering feeding tube placement,[x] but may be undermined by the hospital’s need to prepare a patient for discharge to rehabilitation. In these circumstances, the “customer” served by the surgical team is the hospital and not the patient. This can be overcome by triggering a palliative care consultation upstream of the surgical consult for the feeding tube, so that any patient seen by speech and swallow and receiving a nil by mouth recommendation is seen by palliative care.[xi]
3. Consultative versus integrated palliative care
For patients in need of a palliative care specialist, surgical departments may use a consultation model in which interdisciplinary palliative care teams are called on when appropriate, or they may choose to embed palliative care specialists into surgical teams. At the Mount Sinai Health System in New York, for example, the model is consultative, with surgeons calling on the system’s multiple interdisciplinary palliative care teams. At Rutgers Health University Hospital in New Jersey, where there is no specialty physician-led palliative care service, palliative care specialists are integrated with the surgical team. Two of the trauma attendings are board-certified in hospital and palliative medicine, and a family support team of social workers and nurse practitioners work in close collaboration with the surgical teams, particularly in the surgical and trauma intensive care unit.
Dual-specialty providers are few and far between, however, with just seventy-nine specialists certified in hospice and palliative medicine (HPM) under the American Board of Surgery (ABS). Employment models for dual-certified specialists are rarer still. As the seventy-seventh HPM-certified diplomate of the ABS, the author has a dual clinical appointment at Columbia Presbyterian in the Department of Surgery and the Department of Medicine on the adult palliative medicine service, switching “hats” monthly. While it is not feasible to rely on dual-certified providers to integrate surgery and palliative care system-wide, they can be champions in leading other models of palliative care delivery.
Models of palliative care integration into surgical practice are only beginning to emerge and have yet to be fully tested, but the patient need is real and urgent. By developing relationships with surgical teams and looking for levers, palliative care specialists can improve the quality of care for patients in partnership with their surgeons.
By developing relationships with surgical teams and looking for levers, palliative care specialists can improve the quality of care for patients in partnership with their surgeons.
As told to Saskia Siderow, Ormond House LLC
[i] Lilley, Elizabeth J., Kashif T. Khan, Fabian M. Johnston, Ana Berlin, Angela M. Bader, Anne C. Mosenthal, and Zara Cooper. “Palliative Care Interventions for Surgical Patients a Systematic Review.” JAMA Surgery, 2016. https://www.ncbi.nlm.nih.gov/pubmed/26606747.
[ii] Rodriguez, Rodrigo, Lisa Marr, Ashwani Rajput, and Bridget N. Fahy. “Utilization of Palliative Care Consultation Service by Surgical Services.” Annals of Palliative Medicine, 2015. https://doi.org/10.3978/j.issn.2224-5820.2015.09.03.
[iii] Olmsted, Courtney L., Amy M. Johnson, Peter Kaboli, Joseph Cullen, and Mary S. Vaughan-Sarrazin. “Use of Palliative Care and Hospice among Surgical and Medical Specialties in the Veterans Health Administration.” In JAMA Surgery, 2014. https://doi.org/10.1001/jamasurg.2014.2101.
[iv] Rivet, Emily B., Egidio Del Fabbro, and Paula Ferrada. “Palliative Care Assessment in the Surgical and Trauma Intensive Care Unit.” JAMA Surgery 153, no. 3 (2018): 280–81. https://doi.org/10.1001/jamasurg.2017.5077.
[v] Ernst, Katherine F., Daniel E. Hall, Kendra K. Schmid, Georgia Seever, Pierre Lavedan, Thomas G. Lynch, and Jason Michael Johanning. “Surgical Palliative Care Consultations over Time in Relationship to Systemwide Frailty Screening.” JAMA Surgery 149, no. 11 (2014): 1121–26. https://doi.org/10.1001/jamasurg.2014.1393.
[vi] Farhat, Joseph S., Vic Velanovich, Anthony J. Falvo, H. Mathilda Horst, Andrew Swartz, Joe H. Patton, and Ilan S. Rubinfeld. “Are the Frail Destined to Fail? Frailty Index as Predictor of Surgical Morbidity and Mortality in the Elderly.” Journal of Trauma and Acute Care Surgery, 2012. https://doi.org/10.1097/TA.0b013e3182542fab.
[vii] Mosenthal, Anne & Murphy, Patricia & Barker, Lyn & Lavery, Robert & Retano, Angela & Livingston, David. (2008). Changing the Culture Around End-of-Life Care in the Trauma Intensive Care Unit. The Journal of trauma. 64. 1587-93. 10.1097/TA.0b013e318174f112.
[viii] Suwanabol, Pasithorn A., Arielle E. Kanters, Ari C. Reichstein, Lauren M. Wancata, Lesly A. Dossett, Emily B. Rivet, Maria J. Silveira, and Arden M. Morris. “Characterizing the Role of U.S. Surgeons in the Provision of Palliative Care: A Systematic Review and Mixed-Methods Meta-Synthesis.” Journal of Pain and Symptom Management 55, no. 4 (2018): 1196-1215.e5. https://doi.org/10.1016/j.jpainsymman.2017.11.031.
[ix] Quill, Timothy E., and Amy P. Abernethy. “Generalist plus Specialist Palliative Care - Creating a More Sustainable Model.” New England Journal of Medicine, 2013. https://doi.org/10.1056/NEJMp1215620.
[i] McGreevy, Christopher M., Sri Ram Pentakota, Omar Mohamed, Kevin Sigler, Anne C. Mosenthal, and Ana Berlin. “Gastrostomy Tube Placement: An Opportunity for Establishing Patient-Centered Goals of Care.” In Surgery (United States), 2017. https://doi.org/10.1016/j.surg.2016.10.034.
[xi] Hwang F, Boardingham C, Walther S, Jacob M, Hidalgo A, Gandhi CD, Mosenthal AC, Lamba S, Berlin A. Establishing Goals of Care for Patients With Stroke and Feeding Problems: An Interdisciplinary Trigger-Based Continuous Quality Improvement Project. J Pain Symptom Manage. 2018 Oct;56(4):588-593.
Ana Berlin, MD, MPH, FACS
Department of Surgery, Division of General Surgery and Department of Medicine, Division of Hematolo…
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