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Lin J, Cook M, Siegel T, Marterre B, Chapman AC. Time is Short: Tools to Integrate Palliative Care and Communication Skills Education into Your Surgical Residency. JOURNAL OF SURGICAL EDUCATION 2023; 80:1669-1674. [PMID: 37385930 DOI: 10.1016/j.jsurg.2023.06.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/25/2023] [Revised: 05/25/2023] [Accepted: 06/02/2023] [Indexed: 07/01/2023]
Abstract
The need to integrate palliative care (PC) training into surgical education has been increasingly recognized. Our aim is to describe a set of PC educational strategies, with a range of requisite resources, time, and prior expertise, to provide options that surgical educators can tailor for different programs. Each of these strategies has been successfully employed individually or in some combination at our institutions, and components can be generalized to other training programs. Asynchronous and individually paced PC training can be provided using existing resources published by the American College of Surgeons and upcoming SCORE curriculum modules. A multiyear PC curriculum, with didactic components of increasing complexity for more advanced residents, can be applied based on available time in the didactic schedule and local expertise. Simulation-based training in PC skills can be developed to provide objective competency-based training. Finally, a dedicated rotation on a surgical palliative care service can provide the most immersive experience with steps toward clinical entrustment of PC skills for trainees.
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Affiliation(s)
- Joseph Lin
- Department of Surgery, University of California San Francisco, San Francisco, California; Division of Palliative Medicine, Department of Medicine, University of California San Francisco, San Francisco, California
| | - Mackenzie Cook
- Department of Surgery, Oregon Health & Science University, Portland, Oregon
| | - Timothy Siegel
- Department of Surgery, Oregon Health & Science University, Portland, Oregon; Division of Hematology/Medical Oncology, Department of Medicine, Oregon Health & Science University, Portland, Oregon
| | - Buddy Marterre
- Department of Surgery, Wake Forest School of Medicine, Winston-Salem, North Carolina; Section of Gerontology and Geriatric Medicine, Department of Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Allyson Cook Chapman
- Department of Surgery, University of California San Francisco, San Francisco, California; Division of Palliative Medicine, Department of Medicine, University of California San Francisco, San Francisco, California.
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Spencer AL, Nunn AM, Miller PR, Russell GB, Carmichael SP, Neri KE, Marterre B. The value of compassion: Healthcare savings of palliative care consults in trauma. Injury 2023; 54:249-255. [PMID: 36307268 PMCID: PMC11210453 DOI: 10.1016/j.injury.2022.10.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Revised: 10/03/2022] [Accepted: 10/18/2022] [Indexed: 11/05/2022]
Abstract
BACKGROUND The effects of palliative care (PC) consultation on patient costs and hospitalization metrics in the adult trauma population are unclear. STUDY DESIGN We interrogated our Level I trauma center databases from 1/1/19 to 3/31/21 for patients age ≥18 admitted to the trauma service. Patients undergoing PC consult were matched using propensity scoring to those without PC consultation based on age, admission Glasgow Coma Scale score, Injury Severity Score and Head Abbreviated Injury Scale. Total costs, total cost per day, hospital length of stay (LOS), ICU LOS, intubation days, discharge disposition, and rates of nephrology consultation and tracheostomy/feeding tube placements were compared. RESULTS 140 unique patients underwent PC consultation and were matched to a group not receiving PC consult during the same period. Median total costs in the PC cohort were $39,532 compared to $70,330 in the controls (p<0.01). Median costs per day in the PC cohort were $3,495 vs $17,970 in the controls (p<0.01). Median costs per ICU day in the PC cohort were $3,774 vs $17,127 in the controls (p<0.01). Mean hospital LOS (15.7 vs 7 days), ICU LOS (7.9 vs 2.9 days), and ventilator days (5.1 vs 1.5) were significantly higher in the PC cohort (all p<0.01). Rates of nephrology consultation (8.6 vs 2.1%, p = 0.03) and tracheostomy/feeding tube placements (12.1 vs 1.4%, p<0.01) were also higher in the PC group. Patients were more likely to discharge to hospice if they received a PC consult (33.6 vs 2.1%, p<0.01). Mean time to PC consult was 7.2 days (range 1 hour to 45 days). LOS post-consult correlated positively with time to PC consultation (r = 0.27, p<0.01). CONCLUSION Expert PC services are known to alleviate suffering and avert patient goal- and value-incongruent care. While trauma patients demand significant resources, PC consultation offered in concordance with life-sustaining interventions is associated with significant savings to patients and the healthcare system. Given the correlation between LOS following PC consult and time to PC consult, savings may be amplified by earlier PC consultation in appropriate patients.
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Affiliation(s)
- Audrey L Spencer
- Department of Surgery, University of Arizona College of Medicine, 1501 North Campbell Avenue, Room 5411, Tower 4, Tucson, AZ 85724, United States of America.
| | - Andrew M Nunn
- Department of Surgery, Atrium Health Wake Forest Baptist, 1 Medical Center Boulevard, Winston-Salem, NC 27157, United States of America.
| | - Preston R Miller
- Department of Surgery, Atrium Health Wake Forest Baptist, 1 Medical Center Boulevard, Winston-Salem, NC 27157, United States of America.
| | - Gregory B Russell
- Department of Biostatistics & Data Science, Atrium Health Wake Forest Baptist, 1 Medical Center Boulevard, Winston-Salem, NC 27157, United States of America.
| | - Samuel P Carmichael
- Department of Surgery, Atrium Health Wake Forest Baptist, 1 Medical Center Boulevard, Winston-Salem, NC 27157, United States of America.
| | - Kristina E Neri
- Wake Forest University School of Medicine, Bowman Gray Center for Medical Education, 475 Vine Street, Winston-Salem, NC 27101, United States of America.
| | - Buddy Marterre
- Departments of Surgery & Internal Medicine, Atrium Health Wake Forest Baptist, 1 Medical Center Boulevard, Winston-Salem, NC 27157, United States of America.
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Palliative care management of head and neck cancer patients among otolaryngology surgeons: a novel national survey assessing knowledge, decision making, perceived confidence and training in the UK. The Journal of Laryngology & Otology 2022; 136:799-808. [DOI: 10.1017/s0022215122001037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
AbstractObjectiveManagement of head and neck cancer patients provides unique challenges. Palliation serves to optimise quality-of-life by alleviating suffering and maintaining dignity. Prompt recognition and management of suffering is paramount to achieving this. This study aimed to assess perceived confidence, knowledge and adequacy of palliative training among UK-based otolaryngologists.MethodEight multiple-choice questions developed by five palliative care consultants via the Delphi method were distributed over five weeks. Knowledge, perceived confidence and palliative exposure among middle-grade and consultant otolaryngologists were assessed, alongside training deficits.ResultsOverall, 145 responses were collated from middle-grade (n = 88, 60.7 per cent) and consultant (n = 57, 39.3 per cent) otolaryngologists. The mean knowledge score was 5 out of 10, with 22.1 per cent (n = 32) stating confidence in palliative management. The overwhelming majority (n = 129, 88.9 per cent) advocated further training.ConclusionA broad understanding of palliative care, alongside appropriate specialist involvement, is key in meeting the clinical needs of palliative patients. Curriculum integration of educational modalities such as simulation and online training may optimise palliative care.
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Whitsett MP, Ufere NN, Patel A, Shea JA, Jones CA, Fix OK, Serper M. Palliative care experience and perceived gaps in training among transplant hepatology fellows: A national survey. Hepatol Commun 2022; 6:1680-1688. [PMID: 35411683 PMCID: PMC9234628 DOI: 10.1002/hep4.1939] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Revised: 01/25/2022] [Accepted: 02/17/2022] [Indexed: 11/20/2022] Open
Abstract
Despite the likely benefits of palliative care (PC) for patients with cirrhosis, physician experiences and perspectives about best practices are variable. We aimed to assess PC experience and gaps in training among transplant hepatology fellows. We conducted a national survey of all transplant hepatology fellows enrolled in accredited fellowship programs during the 2020-2021 academic year. We assessed the frequency of PC provision and comfort with physical and psychological symptom management, psychosocial care, communication skills, advance care planning, and end-of-life care. A total of 45 of 56 (79%) of transplant hepatology fellows responded to the survey; 50% (n = 22) were female. Most trained at centers performing over 100 transplants per year (67%, n = 29) distributed evenly across geographic regions. Most fellows (69%, n = 31) had a PC or hospice care rotation during residency, and 42% (n = 19) of fellows received education in PC during transplant hepatology fellowship. Fellows reported feeling moderately to very comfortable with communication skills such as breaking bad news (93%, n = 41) and leading family meetings (75%, n = 33), but nearly one-third (30%, n = 13) reported feeling not very or not at all comfortable assessing and managing anxiety and depression (30%, n = 13) and spiritual distress (34%, n = 15). Nearly one-quarter (22%, n = 10) had never discussed or documented advance care plans during fellowship. Fellows wished to receive future instruction on the assessment and management of physical symptoms (68%, n = 30) and anxiety and depression (64%, n = 28). Conclusion: Our survey highlights gaps in PC experience and education during transplant hepatology fellowship, lack of comfort in managing psychological distress and advance care planning, and desire to improve skills, particularly in symptom management. Future studies should investigate how to enhance transplant hepatology competencies in these PC domains and whether this impacts clinical care, advance care planning, or patient experience.
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Affiliation(s)
- Maureen P Whitsett
- Division of Gastroenterology and HepatologyCleveland ClinicClevelandOhioUSA
| | - Nneka N Ufere
- Liver CenterGastrointestinal UnitMassachusetts General HospitalBostonMassachusettsUSA
| | - Arpan Patel
- Vatche and Tamar Manoukian Division of Digestive Diseases, Department of MedicineDavid Geffen School of Medicine at UCLALos AngelesCaliforniaUSA.,Veterans Affairs Greater Los Angeles Healthcare SystemLos AngelesCaliforniaUSA
| | - Judy A Shea
- Division of General Internal MedicineDepartment of MedicineUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
| | - Christopher A Jones
- Department of Internal MedicineDuke University School of MedicineDurhamNorth CarolinaUSA
| | - Oren K Fix
- Division of Gastroenterology and HepatologyUniversity of North CarolinaChapel HillNorth CarolinaUSA
| | - Marina Serper
- Division of Gastroenterology and HepatologyUniversity of Pennsylvania Perelman School of MedicinePhiladelphiaPennsylvaniaUSA.,Corporal Michael J. Crescenz VA Medical CenterPhiladelphiaPennsylvaniaUSA.,Leonard Davis InstituteUniversity of Pennsylvania Perelman School of MedicinePhiladelphiaPennsylvaniaUSA
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Keon-Cohen ZM, Story DA, Moran JA, Jones DA. An audit of perioperative end-of-life care practices and documentation relating to patients who died in a surgical unit in three Victorian hospitals. Anaesth Intensive Care 2022; 50:234-242. [PMID: 35301860 DOI: 10.1177/0310057x211032652] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The number of older, frail patients undergoing surgery is increasing, prompting consideration of the benefits of intensive treatment. Despite collaborative decision-making processes such as advance care planning being supported by recent Australian legislation, their role in perioperative care is yet to be defined. Furthermore, there has been little evaluation of the quality of end-of-life care in the surgical population. We investigated documentation of the premorbid functional status, severity of illness, intensity of treatment, operative management and quality of end-of-life care in patients who died in a surgical unit, with a retrospective study of surgical mortality which was performed across three hospitals over a 23-month period in Victoria, Australia. Among 99 deceased patients in the study cohort, 68 had a surgical operation. Preoperative functional risk assessment by medical staff was infrequently documented in the medical notes (5%) compared with activities of daily living (69%) documented by nursing staff. Documented preoperative discussions regarding the risk of death were rarely and inconsistently done, but when done were extensive. Documented end-of-life care discussions were identified in 71%, but were frequently brief, inconsistent, and in 60% did not occur until 48 hours from death. In 35.4% of instances, documented discussions involved junior staff (registrars or residents), and 43.4% involved intensive care unit staff. Palliative or terminal care referrals also occurred late (1-2 days prior to death). Not-for-resuscitation orders were frequently changed when approaching the end of life. Overall, 57% of deceased patients had a documented opportunity for farewell with family. We conclude that discussions and documentation of end-of-life care practices could be improved and recommend that all surgical units undertake similar audits to ensure that end-of-life care discussions occur for high-risk and palliative care surgical patients and are documented appropriately.
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Affiliation(s)
- Zoe M Keon-Cohen
- Department of Anaesthesia, Royal Victorian Eye and Ear Hospital, Melbourne, Australia.,Department of Epidemiology and Preventative Medicine, Monash University, Melbourne, Australia.,Anaesthesia Department, Austin Health, Australia
| | - David A Story
- Anaesthesia Department, Austin Health, Australia.,Department of Critical Care, University of Melbourne, Melbourne, Australia
| | - Juli A Moran
- Department of Palliative Care, 3805Austin Health, Austin Health, Australia
| | - Daryl A Jones
- Department of Epidemiology and Preventative Medicine, Monash University, Melbourne, Australia.,Intensive Care Unit, Austin Health, Australia
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Abstract
The importance of integrated palliative care in surgical oncology has been established by high-level evidence demonstrating improved patient-centered outcomes. There has been substantial improvement in efforts to incorporate palliative medicine training into medical and surgical education over the last decade. However, although trainees may feel confident in managing patients at the end of life, they may not have the insight or proficiency to provide optimal palliative care. Surgeons and palliative care physicians should collaborate on methods to optimize palliative care education for both trainees and practicing surgeons. A growing number of palliative care resources are available to this end.
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Affiliation(s)
- Alexandra C Istl
- Division of Surgical Oncology, Johns Hopkins Hospital, Blalock 684, 600 North Wolfe Street, Baltimore, MD 21287, USA. https://twitter.com/AllyIstl
| | - Fabian M Johnston
- Division of Surgical Oncology, Johns Hopkins Hospital, Blalock 684, 600 North Wolfe Street, Baltimore, MD 21287, USA.
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Bleicher J, Place A, Schoenhals S, Luppens CL, Grudziak J, Lambert LA, McCrum ML. Drivers of Moral Distress in Surgical Intensive Care Providers: A Mixed Methods Study. J Surg Res 2021; 266:292-299. [PMID: 34038851 DOI: 10.1016/j.jss.2021.04.017] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Revised: 03/08/2021] [Accepted: 04/10/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Moral distress is common among healthcare providers, leading to staff burnout and attrition. This study aimed to identify root causes of and potential solutions to moral distress experienced by surgical intensive care unit (SICU) providers. MATERIALS AND METHODS This is a mixed methods study of physicians and nurses from a single, academic SICU. We obtained quantitative data from the Measures of Moral Distress for Healthcare Professionals (MMD-HP) survey and qualitative data from semi-structured interviews. The MMD-HP is a 27 question, validated survey on triggers of moral distress. Survey and interview data were analyzed to identify drivers of moral distress using a convergent design. RESULTS 21 nurses and 25 physicians were surveyed and 17 providers interviewed. MMD-HP data demonstrated high levels of moral distress for nurses (mean total MMD-HP 132 ± 63.5) and physicians (121.7 ± 64.7), P = 0.68. The most frequent root cause of moral distress for all providers was participating in the delivery of aggressive care perceived to be futile. Nurses also reported caring for patients with unclear goals of care as a key driver of moral distress. Interview data supported these findings. Providers recommended improving access to palliative care to increase early communication on patient goals of care and end-of-life as a solution. Culture in the SICU often promotes supporting aggressive care however, acting as a potential barrier to increasing palliative resources. CONCLUSIONS Providing aggressive care that is perceived as futile was the primary driver of moral distress in the SICU. Interventions to improve early communication and access to end-of-life care should be prioritized to decrease moral distress in staff.
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Affiliation(s)
- Josh Bleicher
- Department of General Surgery, University of Utah, Salt Lake City, Utah.
| | - Aubrey Place
- Department of General Surgery, University of Utah, Salt Lake City, Utah
| | - Sarah Schoenhals
- Department of General Surgery, University of Utah, Salt Lake City, Utah
| | - Carolyn L Luppens
- Department of General Surgery, University of Utah, Salt Lake City, Utah
| | - Joanna Grudziak
- Department of General Surgery, University of Utah, Salt Lake City, Utah
| | - Laura A Lambert
- Department of General Surgery, University of Utah, Salt Lake City, Utah; Department of Surgical Oncology, Huntsman Cancer Institute at the University of Utah, Salt Lake City, Utah
| | - Marta L McCrum
- Department of General Surgery, University of Utah, Salt Lake City, Utah
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Cook M, Zonies D, Brasel K. Prioritizing Communication in the Provision of Palliative Care for the Trauma Patient. CURRENT TRAUMA REPORTS 2020; 6:183-193. [PMID: 33145148 PMCID: PMC7595000 DOI: 10.1007/s40719-020-00201-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/15/2020] [Indexed: 11/28/2022]
Abstract
Purpose of Review Communication skills in the ICU are an essential part of the care of trauma patients. The goal of this review is to summarize key aspects of our understanding of communication with injured patients in the ICU. Recent Findings The need to communicate effectively and empathetically with patients and identify primary goals of care is an essential part of trauma care in the ICU. The optimal design to support complex communication in the ICU will be dependent on institutional experience and resources. The best/worst/most likely model provides a structural model for communication. Summary We have an imperative to improve the communication for all patients, not just those at the end of their life. A structured approach is important as is involving family at all stages of care. Communication skills can and should be taught to trainees.
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Affiliation(s)
- Mackenzie Cook
- Division of Trauma, Critical Care and Acute Care Surgery, Department of Surgery, Oregon Health and Science University, Mail Code L611, 3181 SW Sam Jackson Park Rd, Portland, OR 97230 USA
| | - David Zonies
- Division of Trauma, Critical Care and Acute Care Surgery, Department of Surgery, Oregon Health and Science University, Mail Code L611, 3181 SW Sam Jackson Park Rd, Portland, OR 97230 USA
| | - Karen Brasel
- Division of Trauma, Critical Care and Acute Care Surgery, Department of Surgery, Oregon Health and Science University, Mail Code L611, 3181 SW Sam Jackson Park Rd, Portland, OR 97230 USA
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