Concurrent Palliative Care for Surgical Patients

Value of Hospice and Palliative Medicine Fellowship After Surgical Training: Bridging the Gap for Improved Patient Care

Objective: Surgeons comprise 2% of HPM-trained physicians. Little is known about the perceived value of HPM training to the surgeon or medical community. We aim to demonstrate the value of HPM fellowship training to surgeons and surgical practice from the point of view of HPM fellowship trained surgeons. Design: A qualitative analysis was performed using semi-structured zoom interviews that elicited the lived experiences of HPM trained surgeons. Data was analyzed using descriptive statistics and thematic analysis. Setting: Researchers were from the University of Kansas School of Medicine and the University of Alabama at Birmingham. Participants were trained and worked across the United States in a variety of settings. Participants: Eligibility included training in general surgery, obstetrics and gynecology, or affiliated subspecialties and completion of a 1-year HPM fellowship. Results: 17 interviews were performed. Several themes emerged regarding the transformative value of HPM training to their medical and surgical practice: (1) Learning to apply shared decision making and goal-concordant care to surgical decision making, and (2) Decreasing personal bias in medical decision making, and (3) Enabling wellness in surgeons. Two themes emerged regarding the perceived value to both the surgical community and the HPM community: (1) Value of the HPM Fellowship Trained Surgeon to the Surgical Community, and (2) Value of the HPM Fellowship Trained Surgeon to the HPM Community. All study participants valued their HPM training and felt highly valued by the healthcare team. Conclusion: HPM trained surgeons are highly valued on the healthcare team and improve patient-centered surgical care.

Facilitators and Barriers to Recruiting Surgeons into Hospice and Palliative Medicine Training

CONTEXT

Few individuals have fellowship training in both hospice and palliative medicine (HPM) and a surgical specialty including general surgery, general obstetrics and gynecology, or affiliated subspecialties. There is a paucity of data to explain why some surgeons choose to pursue HPM fellowship training.

OBJECTIVE

Identify facilitators and barriers to palliative medicine fellowship training among physicians from a surgical specialty.

METHODS

We conducted individual semistructured interviews with 17 surgeons who were also fellowship-trained in HPM. Interviews were recorded, transcribed, and thematic analysis was conducted to identify themes.

RESULTS

Participants reported pivotal experiences-either positive exposure to palliative care or suboptimal surgical care experiences-as a key motivator for pursuing specialty palliative care training. Additionally, participants chose HPM training because they felt that practicing from a HPM perspective aligned with their personal care philosophy, and in some cases, offered professional opportunities to help achieve career goals. Participants reported encountering bias from both HPM and surgical faculty, and also found that some HPM fellowship programs did not accept surgical trainees. Surgeons also reported logistical concerns related to coordinating a one-year fellowship as a barrier to formal HPM training.

CONCLUSIONS

Understanding the motivations of surgeons who pursue HPM training and identifying challenges to completing fellowship may inform solutions to expand surgeon representation in palliative care. Both HPM and surgical faculty should be educated on the benefits of specialty HPM training for surgical trainees and practicing surgeons. Further research should explore HPM fellowship best practices for welcoming and training surgeons and other underrepresented specialties.

Concordant palliative care delivery in advanced head and neck cancer

OBJECTIVES

To describe the palliative care consultation practices in an academic head and neck surgery practice.

METHODS

This is a retrospective review of a palliative care database and the health record for all palliative care consultations of patients suffering from advanced stage head and neck cancer within a 21-month period.

RESULTS

Ten head and neck cancer patients received palliative care consults while on the otolaryngology service. One consultation occurred preoperatively; nine occurred postoperatively, on a median of hospital day 9. At the time of referral, seven patients were in the ICU and three were on a surgical floor. Code status de-escalation occurred in six patients and psycho-socio-spiritual suffering was supported in all consultations. Nine patients died within six months, with a median post-consultation survival of 35 days. Of these, two died in an ICU, five were discharged to hospice, one to a SNF, and one to a LTACH.

CONCLUSION

Palliative care consultation in this advanced head and neck cancer cohort was commonly late, however, significant suffering was mitigated following most consults. Palliative care specialists are experts at eliciting patient values, determining acceptable tradeoffs and suffering limitations by employing a shared decision-making process that ends with a patient-centered value-congruent treatment recommendation. Oftentimes, this embraces curative-intent or palliative surgery, along with contingency plans for unacceptable value-incongruent postoperative outcomes. Enhanced awareness of the benefits of embracing concordant palliative care in advanced head and neck cancer patients may help overcome the significant barriers to involving palliative care experts earlier.

Retrospective Review of Trauma ICU Patients With and Without Palliative Care Intervention

BACKGROUND

Older trauma patients present with poor preinjury functional status and more comorbidities. Advances in care have increased the chance of survival from previously fatal injuries with many left debilitated with chronic critical illness and severe disability. Palliative care (PC) is ideally suited to address the goals of care and symptom management in this critically ill population. A retrospective chart review was done to identify the impact of PC consults on hospital length of stay (LOS), ICU LOS, and surgical decisions.

STUDY DESIGN

A Level 1 Trauma Center Registry was used to identify adult patients who were provided PC consultation in a selected 3-year time period. These PC patients were matched with non-PC trauma patients on the basis of age, sex, race, Glasgow Coma Scale, and Injury Severity Score. Chi-square tests and Student's t-tests were used to analyze categorical and continuous variables, respectively. Any p value >0.05 was considered statistically significant.

RESULTS

PC patients were less likely to receive a percutaneous endoscopic gastric tube or tracheostomy. PC patients spent less time on ventilator support, spent less time in the ICU, and had a shorter hospital stay. PC consultation was requested 16.48 days into the patient's hospital stay. Approximately 82% of consults were to assist with goals of care.

CONCLUSION

Specialist PC team involvement in the care of the trauma ICU patients may have a beneficial impact on hospital LOS, ICU LOS, and surgical care rendered. Earlier consultation during hospitalization may lead to higher rates of goal-directed care and improved patient satisfaction.

Prevalence and characteristics of patients with heart failure needing palliative care

Background

Few hospitals and heart failure (HF) clinics offer concurrent palliative care (PC) together with life-prolonging therapies. To know the prevalence of patients in HF clinics needing PC and useful tools to recognize them are the first steps to extending PC in those settings. However, it is still unknown whether tools commonly used to identify patients with HF needing PC can correctly distinguish them. Two systematic reviews found that the NECesidades PALiativas (NECPAL) tool was one of the two most commonly used tools to asses PC needs in HF patients. Therefore, we assessed 1) the prevalence of PC needs in HF clinics according to the NECPAL tool, and 2) the characteristics of the patients identified as having PC; mainly, their quality of life (QoL), symptom burden, and psychosocial problems.

Methods

This cross-sectional study was conducted at two HF clinics in Colombia. We assessed the prevalence of PC in the overall sample and in subgroups according to clinical and demographic variables. We assessed QoL, symptom burden, and psychosocial problems using the 12-Item Short-Form Health Survey (SF-12), the Kansas City Cardiomyopathy Questionnaire (KCCQ) and the Edmonton Symptom Assessment System (ESAS). We compared the results of these tools between patients identified as having PC needs (+NECPAL) and patients identified as not having PC needs (–NECPAL).

Results

Among the 178 patients, 78 (44%) had PC needs. The prevalence of PC needs was twice as nigh in patients NYHA III/IV as in patients NYHA I/II and almost twice as high in patients older than 70 years as in patients younger than 70 years. Compared to –NECPAL patients, +NECPAL patients had worse QoL, more severe shortness of breath, tiredness, drowsiness, and pain, and more psychosocial problems.

Conclusion

The prevalence of PC needs in outpatient HF clinics is high and is even higher in older patients and in patients at more advanced NYHA stages. Compared to patients identified as not having PC needs, patients identified as having PC needs have worse QoL, more severe symptoms, and greater psychosocial problems. Including a PC provider in the multidisciplinary team of HF clinics may help to assess and cover these needs.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12904-021-00850-y.

More than Means to an End: Assessing Surgical Provider Familiarity with Palliative Care

BACKGROUND

As palliative medicine concepts emerge as essential surgical education, there has been a resulting spike in surgical palliative care research. Historic surgical dogma viewed mortality and comfort-focused care as a failure of the providers' endurance, knowledge base, or technical skill. Therefore, many providers avoided consultation to a palliative medicine service until it became evident a patient could not survive or was actively dying. As the need for surgical palliative care grows, the identification of deficits in surgical providers' understanding of the scope of palliative medicine is necessary to direct further training and development efforts.

METHOD

A ten-question survey was emailed to all residents, physician assistants, nurse practitioners, and attending physicians in the general surgery and subspecialty surgical departments within the Einstein Healthcare Network.

RESULTS

30 non-trainees (attending surgeons, nurse practitioners, and physician assistants) and 26 trainees (PGY-1 to PGY-5) completed the survey. Less than half of participants reported training in conversations regarding withdrawal of life-prolonging treatments in the setting of expected poor outcomes, 55% reported receiving training in pain management, and 64% reported receiving training in delivery of bad news. 54% report being involved in five or more end-of-life discussions in the last year with trainees reporting fewer end-of-life discussions than non-trainees; 67% of trainees reported zero to four discussions while 23% of non-trainees reported over twenty discussions (P = .009).

CONCLUSIONS

Despite many participants training in intensive care settings, providers lack the training to carry out major discussions regarding life-limiting illness, goals of care, and end-of-life independently.