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Davies H, Safdar NZ, Yi Kwan J, Jain K, Sciberras P, Hurlow A, Po Tam SK, Coughlin P, Mees BME, Scott DJA. End of Life Care for Unplanned Vascular Admissions. Ann Vasc Surg 2024; 99:280-289. [PMID: 37852363 DOI: 10.1016/j.avsg.2023.08.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2023] [Revised: 08/13/2023] [Accepted: 08/16/2023] [Indexed: 10/20/2023]
Abstract
BACKGROUND Unplanned vascular admissions have a high mortality. Previous studies have indicated that end of life care (EoLC) among this group of patients is low but there exist limited data on EoLC in the United Kingdom. The aim of this study was to evaluate the quality and predictors of EoLC for unplanned vascular admissions to a tertiary center in the United Kingdom. METHODS This was a retrospective single-center cohort study of unplanned vascular surgery admissions from August 1, 2019 to January 22, 2020. Data on patient demographics, markers of quality of palliative care, mortality, and cause of death of unplanned admission to the vascular surgery department were collected from hospital and general practitioner records and evaluated against EoLC to evaluate predictors and efficacy of EoLC. Quality of palliative care markers included documentation of preferred place of death and care priorities, time spent in hospital and the intensive care unit toward the end of life, and realization of documented care objectives. EoLC input was defined as a dedicated palliative care consultation (PCC) by a palliative care professional, medical doctor, surgeon, or advanced care practitioner. We also conducted a subgroup analysis of patients within this group with chronic limb-threatening ischemia (CLTI), diabetic foot, and ruptured aortic aneurysms, as all patients in this group should be offered EoLC according to international guidelines. RESULTS One-hundred and fifty patients were included. Median age at presentation was 70.5 years, and the cohort consisted of mostly men (72%). CLTI (31%) was the most common reason for admission. Surgical intervention was carried out in 60% of patients. Two-year mortality was 36%, and pneumonia (22%) was the most common cause of death. Seven percent of patients received PCC, which occurred a median of 10 days before death. Only a minority of patients had preferred place of care/death (14%), care priorities (37%), and family involvement during advance care planning (17%) documented in their notes; 29% of patients had Recommended Summary Plan for Emergency Care and Treatment forms in place. A diagnosis of left ventricular systolic dysfunction, chronic kidney disease, and increasing age predicted Recommended Summary Plan for Emergency Care and Treatment form completion. Patients with PCC were more likely to have advance care planning, but this did not translate into improvements in the other markers of quality of palliative and, consequently, EoLC. CONCLUSIONS EoLC was insufficient and of low quality despite a high mortality in this group. Clinical guidelines and pathways are needed to ensure these patients are considered for EoLC and those with CLTI, diabetic foot sepsis or ruptured abdominal aortic aneurysms are offered it by default. Further research is needed to help identify vascular patients who would benefit from EoLC earlier to improve quality at end of life.
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Affiliation(s)
- Henry Davies
- Leeds Vascular Institute, Leeds Teaching Hospitals NHS Trust, Leeds, UK.
| | | | - Jing Yi Kwan
- Leeds Vascular Institute, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Kinshuk Jain
- School of Medicine, University of Leeds, Leeds, UK
| | - Peter Sciberras
- Hull Royal Infirmary, Hull University Teaching Hospitals NHS Trust, Hull, UK
| | - Adam Hurlow
- Department of Palliative Care, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Sharon Ka Po Tam
- Department of Anaesthetics, University of Leicester Teaching Hospitals NHS Trust, Leicester, UK
| | - Patrick Coughlin
- Leeds Vascular Institute, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Barend M E Mees
- Department of Vascular Surgery, Maastricht University Medical Center, Maastricht, Netherlands
| | - D Julian A Scott
- Leeds Vascular Institute, Leeds Teaching Hospitals NHS Trust, Leeds, UK
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Tao Z, Hays E, Meyers G, Siegel T. Frailty and Preoperative Palliative Care in Surgical Oncology. Curr Probl Cancer 2023; 47:101021. [PMID: 37865539 DOI: 10.1016/j.currproblcancer.2023.101021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Revised: 08/31/2023] [Accepted: 09/06/2023] [Indexed: 10/23/2023]
Abstract
In this paper, we discuss surgical palliative care for patients with cancer through the lens of frailty and the preoperative context. Historically, palliative care principles such as complex symptom management, high-risk decision-making and communication have played an important role in preoperative discussions of oncologic surgery for both palliative and curative intent. There is increasing motivation among surgeons to integrate palliative care into the perioperative period in order to more effectively and comprehensively address potential adverse functional and quality of life outcomes. We discuss how the concept of frailty, and various instruments to measure frailty, have impacted perioperative decision-making, review the roots of surgical risk stratification and counseling on acceptable perioperative risk, and explore the preoperative setting as a possible avenue by which primary and specialty palliative care integration may have beneficial impact for patients considering oncologic resections.
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Affiliation(s)
- Zoe Tao
- Department of Surgery, Oregon Health & Science University, Portland, Oregon
| | - Elizabeth Hays
- Department of Hospital Medicine, Oregon Health & Science University, Portland, Oregon; Section of Geriatrics, Oregon Health & Science University, Portland, Oregon
| | - Gabrielle Meyers
- Division of Hematology and Medical Oncology, Oregon Health & Science University, Portland, Oregon; Section of Geriatrics, Oregon Health & Science University, Portland, Oregon
| | - Timothy Siegel
- Department of Surgery, Oregon Health & Science University, Portland, Oregon; Section of Palliative Care, Division of Hematology & Medical Oncology, Oregon Health & Science University, Portland, Oregon.
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Javanmard-Emamghissi H, Doleman B, Lund JN, Frisby J, Lockwood S, Hare S, Moug S, Tierney G. Quantitative futility in emergency laparotomy: an exploration of early-postoperative death in the National Emergency Laparotomy Audit. Tech Coloproctol 2023; 27:729-738. [PMID: 36609892 PMCID: PMC10404199 DOI: 10.1007/s10151-022-02747-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Accepted: 12/13/2022] [Indexed: 01/08/2023]
Abstract
BACKGROUND Quantitative futility is an appraisal of the risk of failure of a treatment. For those who do not survive, a laparotomy has provided negligible therapeutic benefit and may represent a missed opportunity for palliation. The aim of this study was to define a timeframe for quantitative futility in emergency laparotomy and investigate predictors of futility using the National Emergency Laparotomy Audit (NELA) database. METHODS A two-stage methodology was used; stage one defined a timeframe for futility using an online survey and steering group discussion; stage two applied this definition to patients enrolled in NELA December 2013-December 2020 for analysis. Futility was defined as all-cause mortality within 3 days of emergency laparotomy. Baseline characteristics of this group were compared to all others. Multilevel logistic regression was carried out with potentially clinically important predictors defined a priori. RESULTS Quantitative futility occurred in 4% of patients (7442/180,987). Median age was 74 years (range 65-81 years). Median NELA risk score was 32.4% vs. 3.8% in the surviving cohort (p < 0.001). Early mortality patients more frequently presented with sepsis (p < 0.001). Significant predictors of futility included age, arterial lactate and cardiorespiratory co-morbidity. Frailty was associated with a 38% increased risk of early mortality (95% CI 1.22-1.55). Surgery for intestinal ischaemia was associated with a two times greater chance of futile surgery (OR 2.67; 95% CI 2.50-2.85). CONCLUSIONS Quantitative futility after emergency laparotomy is associated with quantifiable risk factors available to decision-makers preoperatively. These findings should be incorporated qualitatively by the multidisciplinary team into shared decision-making discussions with extremely high-risk patients.
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Affiliation(s)
- H Javanmard-Emamghissi
- Department of Medicine and Health Science, University of Nottingham at Derby, Royal Derby Hospital, Derby, UK.
| | - B Doleman
- Department of Medicine and Health Science, University of Nottingham at Derby, Royal Derby Hospital, Derby, UK
| | - J N Lund
- Department of Medicine and Health Science, University of Nottingham at Derby, Royal Derby Hospital, Derby, UK
| | - J Frisby
- Department of Palliative Care Medicine, Royal Derby Hospital, Derby, UK
| | - S Lockwood
- Department of Colorectal Surgery, Bradford Royal Infirmary, Bradford, UK
| | - S Hare
- Department of Anaesthesia, Medway Maritime Hospital, Kent, UK
| | - S Moug
- Department of Colorectal Surgery, Royal Alexandra Hospital, Paisley, UK
| | - G Tierney
- Department of Colorectal Surgery, Royal Derby Hospital, Derby, UK
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Coret M, Martimianakis MA(T. Conceptualizations of "good death" and their relationship to technology: A scoping review and discourse analysis. Health Sci Rep 2023; 6:e1374. [PMID: 37455704 PMCID: PMC10339797 DOI: 10.1002/hsr2.1374] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Revised: 05/22/2023] [Accepted: 06/13/2023] [Indexed: 07/18/2023] Open
Abstract
Background and Aims By the 1960s, medicine experienced technological revolutions that enabled it to control and medicalize death in many circumstances. The modern conceptualization of "good death" emerged in the late 1960s with the beginning of the hospice movement, and palliative care became an official medical specialty in 1987. This project aims to elucidate how the idea of "good death" has been discussed and perceived since then, as well as the impact of medical technologies on death. Methods The terms "good death," "technology," and "palliative care" were searched. One hundred ninety English sources that discussed "good death" explicitly or implicitly, published between 1987 and 2020, were included in the final analysis. Texts were analyzed for discursive themes related to "good death" and technology and demographic data related to authors, geographies, types of text, and date of publication. Results The discourse of a "good death" with the patient being in control dominated the archive. Other discourses include a good death being peaceful and comfortable, one where the patient is not alone, and one that is not prolonged. Medical technology discourses are largely negative in the setting of death. Conclusion Findings indicate a strong critique of the medicalization of death in the literature. This also complements the dominance of discourses on patient autonomy. Medical discourses of "good death" and technology permeate discussion outside of the healthcare context, and there is an absence of spirituality and neutrality in "good death" discourses. The results of this study are relevant for ethics and communication in geriatric and palliative care.
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Affiliation(s)
- Michal Coret
- Department of Medicine, Temerty Faculty of MedicineUniversity of TorontoTorontoOntarioCanada
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Proaño-Zamudio JA, Argandykov D, Gebran A, Renne A, Paranjape CN, Maroney SJ, Onyewadume L, Kaafarani HMA, King DR, Velmahos GC, Hwabejire JO. Open Abdomen in Elderly Patients With Surgical Sepsis: Predictors of Mortality. J Surg Res 2023; 287:160-167. [PMID: 36933547 DOI: 10.1016/j.jss.2023.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2022] [Revised: 10/26/2022] [Accepted: 02/15/2023] [Indexed: 03/19/2023]
Abstract
INTRODUCTION Elderly patients are frequently presenting with emergency surgical conditions. The open abdomen technique is widely used in abdominal emergencies needing rapid control of intrabdominal contamination. However, specific predictors of mortality identifying candidates for comfort care are understudied. METHODS The 2013-2017 the American College of Surgeons-National Surgical Quality Improvement Program database was queried for emergent laparotomies performed in geriatric patients with sepsis or septic shock in whom fascial closure was delayed. Patients with acute mesenteric ischemia were excluded. The primary outcome was 30-d mortality. Univariable analysis, followed by multivariable logistic regression, was performed. Mortality was computed for combinations of the five predictors with the highest odds ratios (OR). RESULTS A total of 1399 patients were identified. The median age was 73 (69-79) y, and 54.7% were female. 30-d mortality was 50.6%. In the multivariable analysis, the most important predictors were as follows: American Society of Anesthesiologists status 5 (OR = 4.80, 95% confidence interval [CI], 1.85-12.49 P = 0.002), dialysis dependence (OR = 2.65, 95% CI 1.54-4.57, P < 0.001), congestive hearth failure (OR = 2.53, 95% CI 1.52-4.21, P < 0.001), disseminated cancer (OR = 2.61, 95% CI 1.55-4.38, P < 0.001), and preoperative platelet count of <100,000 cells/μL (OR = 1.87, 95% CI 1.15-3.04, P = 0.011). The presence of two or more of these factors resulted in over 80% mortality. The absence of all these risk factors results in a survival rate of 62.1%. CONCLUSIONS In elderly patients, surgical sepsis or septic shock requiring an open abdomen for surgical management is highly lethal. The presence of several combinations of preoperative comorbidities is associated with a poor prognosis and can identify patients who can benefit from timely initiation of palliative care.
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Affiliation(s)
- Jefferson A Proaño-Zamudio
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Dias Argandykov
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Anthony Gebran
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Angela Renne
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Charudutt N Paranjape
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Stephanie J Maroney
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Louisa Onyewadume
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Haytham M A Kaafarani
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - David R King
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - George C Velmahos
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - John O Hwabejire
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts.
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Zaza SI, Zimmermann CJ, Taylor LJ, Kalbfell EL, Stalter L, Brasel K, Arnold RM, Cooper Z, Schwarze ML. Factors Associated With Provision of Nonbeneficial Surgery: A National Survey of Surgeons. Ann Surg 2023; 277:405-411. [PMID: 36538626 PMCID: PMC9905263 DOI: 10.1097/sla.0000000000005765] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
OBJECTIVE We tested the association of systems factors with the surgeon's likelihood of offering surgical intervention for older adults with life-limiting acute surgical conditions. BACKGROUND Use of surgical treatments in the last year of life is frequent. Improved risk prediction and clinician communication are solutions proposed to improve serious illness care, yet systems factors may also drive receipt of nonbeneficial treatment. METHODS We mailed a national survey to 5200 surgeons randomly selected from the American College of Surgeons database comprised of a clinical vignette describing a seriously ill older adult with an acute surgical condition, which utilized a 2×2 factorial design to assess patient and systems factors on receipt of surgical treatment to surgeons. RESULTS Two thousand one hundred sixty-one surgeons responded for a weighted response rate of 53%. For an 87-year-old patient with fulminant colitis and advanced dementia or stage IV lung cancer, 40% of surgeons were inclined to offer an operation to remove the patient's colon while 60% were inclined to offer comfort-focused care only. Surgeons were more likely to offer surgery when an operating room was readily available (odds ratio: 4.05, P <0.001) and the family requests "do everything" (odds ratio: 2.18, P <0.001). CONCLUSIONS Factors outside the surgeon's control contribute to nonbeneficial surgery, consistent with our model of clinical momentum. Further characterization of the systems in which these decisions occur might expose novel strategies to improve serious illness care for older patients and their families.
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Affiliation(s)
- Sarah I Zaza
- Department of Surgery, University of Wisconsin. Madison, WI
| | | | | | | | - Lily Stalter
- Department of Surgery, University of Wisconsin. Madison, WI
| | - Karen Brasel
- Department of Surgery, Oregon Health and Science University, Portland, OR
| | - Robert M Arnold
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Zara Cooper
- Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
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Stonestreet J. Why did he say that? Teaching physicians-in-training how to recognize hidden emotions in end-of-life prognosis conversations: an autoethnography. MEDEDPUBLISH 2022. [DOI: 10.12688/mep.19098.3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Background: This article begins with two unconscionable end-of-life prognosis-related quotes from best-selling physician-author, Atul Gawande, and an unnamed doctor, asking: “Why did he say that?” The article then proceeds to answer this question by showing how physicians’ most common end-of-life communication blunders are rooted in their unexplored emotions. Healthcare’s only widespread communication training focused on examining the role of hidden emotions in influencing the flow of conversation is found in Spiritual Care’s “Verbatim” education modules. While the need for physicians’ emotional self-awareness for improved end-of-life communication has been identified in the literature, no one has explored how this need might be met by custom-tailoring Spiritual Care’s “Verbatim” education modules for physicians-in-training. Methods: This article utilizes the qualitative research method of autoethnography to grant physicians access to the content and power of Spiritual Care’s “Verbatim” education modules for identifying hidden emotions in clinical communication. Results: Using a profound personal example from the author’s firsthand experience of the suggested training tool, the “Verbatim” module is shown to grant revelatory self-knowledge and invaluable emotional intelligence. The same model then illuminates the physician cases. Conclusion: Spiritual Care’s “Verbatim” education modules address universal issues of clinical communication and emotional self-awareness that are applicable to physician-patient/family conversations surrounding end-of-life decision-making. Customizing these communication modules for physicians-in-training may help to address physicians’ emotionally-triggered conversational miscues in end-of-life prognosis communication. Existing programs for complementary end-of-life communication training are noted, and it is claimed that a combination of each of these models, together with the proposed module, may be ideal. It is also admitted that no form of education or training can ensure ethical communication. Therefore the ultimate solution is to supplement communication training with real-time, third-party support and accountability. This can be achieved by the "Doctor Body Cam" intervention protocol, introduced here: https://aquila.usm.edu/ojhe/vol17/iss1/7/.
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Stonestreet J. Why did he say that? Teaching physicians-in-training how to recognize hidden emotions in end-of-life prognosis conversations: an autoethnography. MEDEDPUBLISH 2022; 12:32. [PMID: 38298812 PMCID: PMC10828552 DOI: 10.12688/mep.19098.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/05/2022] [Indexed: 02/02/2024] Open
Abstract
Background : Intuitively accessible via WhyDidHeSayThat.com, this article begins with two unconscionable end-of-life prognosis-related quotes from best-selling physician-author, Atul Gawande, and an unnamed doctor, asking: "Why did he say that?" The article then proceeds to answer this question by showing how physicians' most common end-of-life communication blunders are rooted in their unexplored emotions. Healthcare's only widespread communication training focused on examining the role of hidden emotions in influencing the flow of conversation is found in Spiritual Care's "Verbatim" education modules. While the need for physicians' emotional self-awareness for improved end-of-life communication has been identified in the literature, no one has explored how this need might be met by custom-tailoring Spiritual Care's "Verbatim" education modules for physicians-in-training. Methods : This article utilizes the qualitative research method of autoethnography to grant physicians access to the content and power of Spiritual Care's "Verbatim" education modules for identifying hidden emotions in clinical communication. Results : Using a profound personal example from the author's firsthand experience of the suggested training tool, the "Verbatim" module is shown to grant revelatory self-knowledge and invaluable emotional intelligence. The same model then illuminates the physician cases. Conclusion : Spiritual Care's "Verbatim" education modules address universal issues of clinical communication and emotional self-awareness that are applicable to physician-patient/family conversations surrounding end-of-life decision-making. Customizing these communication modules for physicians-in-training may help to address physicians' emotionally-triggered conversational miscues in end-of-life prognosis communication. Existing programs for complementary end-of-life communication training are noted, and it is claimed that a combination of each of these models, together with the proposed module, may be ideal. It is also admitted that no form of education or training can ensure ethical communication. Therefore the ultimate solution is to supplement communication training with real-time, third-party support and accountability. This can be achieved by the "Doctor Body Cam" intervention protocol, accessible via DoctorBodyCam.com.
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9
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The Association Between Factors Promoting Nonbeneficial Surgery and Moral Distress: A National Survey of Surgeons. Ann Surg 2022; 276:94-100. [PMID: 33214444 PMCID: PMC9635854 DOI: 10.1097/sla.0000000000004554] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To assess the prevalence of moral distress among surgeons and test the association between factors promoting non-beneficial surgery and surgeons' moral distress. SUMMARY BACKGROUND DATA Moral distress experienced by clinicians can lead to low-quality care and burnout. Older adults increasingly receive invasive treatments at the end of life that may contribute to surgeons' moral distress, particularly when external factors, such as pressure from colleagues, institutional norms, or social demands, push them to offer surgery they consider non-beneficial. METHODS We mailed surveys to 5200 surgeons randomly selected from the American College of Surgeons membership, which included questions adapted from the revised Moral Distress Scale. We then analyzed the association between factors influencing the decision to offer surgery to seriously ill older adults and surgeons' moral distress. RESULTS The weighted adjusted response rate was 53% (n = 2161). Respondents whose decision to offer surgery was influenced by their belief that pursuing surgery gives the patient or family time to cope with the patient's condition were more likely to have high moral distress (34% vs 22%, P < 0.001), and this persisted on multivariate analysis (odds ratio 1.44, 95% confidence interval 1.02-2.03). Time required to discuss nonoperative treatments or the consulting intensivists' endorsement of operative intervention, were not associated with high surgeon moral distress. CONCLUSIONS Surgeons experience moral distress when they feel pressured to perform surgery they believe provides no clear patient benefit. Strategies that empower surgeons to recommend nonsurgical treatments when they believe this is in the patient's best interest may reduce nonbeneficial surgery and surgeon moral distress.
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Hui F. Research on the Construction of Emergency Network Public Opinion Emotional Dictionary Based on Emotional Feature Extraction Algorithm. Front Psychol 2022; 13:857769. [PMID: 35529545 PMCID: PMC9072777 DOI: 10.3389/fpsyg.2022.857769] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Accepted: 03/29/2022] [Indexed: 11/13/2022] Open
Abstract
How to strengthen emergency management and improve the ability to prevent and respond to emergencies is an important part of building a harmonious socialist society. This paper proposes a domain emotion dictionary construction method for network public opinion analysis of public emergencies. Using the advantages of corpus and semantic knowledge base, this paper extracts the seed words based on the large-scale network public opinion corpus and combined with the existing emotion dictionary, trains the word vector through the word2vec model in deep learning, expands the emotion words, and obtains the candidate emotion words according to the semantic similarity calculation, So as to generate a domain emotion dictionary. The accuracy rate of emotion discrimination by the emotion dictionary constructed in this paper is 0.86, the recall rate is 0.92. Through the verification of accuracy and recall rate, the construction method proposed in this paper has good accuracy and reliability. Because of the great differences in different experiences and situations of different groups, there will be great differences in views and perspectives on the same event. The key to prevent the public from blindly following the crowd should be to reach groups close to emotional distance, and targeted prevention and control of public opinion can be conducted according to different characteristics of different groups.
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Affiliation(s)
- Fang Hui
- Northwestern Polytechnical University, Xi'an, China
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11
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Stonestreet J. Why did he say that? Teaching physicians-in-training how to recognize hidden emotions in end-of-life prognosis conversations: an autoethnography. MEDEDPUBLISH 2022. [DOI: 10.12688/mep.19098.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Background: Intuitively accessible via WhyDidHeSayThat.com, this article begins with two unconscionable end-of-life prognosis-related quotes from best-selling physician-author, Atul Gawande, and an unnamed doctor, asking: “Why did he say that?” The article then proceeds to answer this question by showing how physicians’ most common end-of-life communication blunders are rooted in their unexplored emotions. Healthcare’s only widespread conversation analysis training focused on examining the role of hidden emotions in influencing the flow of conversation is found in Spiritual Care’s “Verbatim” education modules. While the need for physicians’ emotional self-awareness for improved end-of-life communication has been identified in the literature, no one has explored how this need might be met by custom-tailoring Spiritual Care’s “Verbatim” education modules for physicians-in-training. Methods: This article utilizes the qualitative research method of autoethnography to grant physicians access to the content and power of Spiritual Care’s “Verbatim” education modules for conversation analysis and emotional intelligence. Results: Using a profound personal example from the author’s firsthand experience of the suggested training tool, the “Verbatim” module is shown to grant revelatory self-knowledge and invaluable emotional intelligence. The same model then illuminates the physician cases. Conclusion: Spiritual Care’s “Verbatim” education modules address universal issues of clinical communication and emotional self-awareness that are applicable to physician-patient/family conversations surrounding end-of-life decision-making. Customizing these conversation analysis modules for physicians-in-training may help to address physicians’ emotionally-triggered conversational miscues in end-of-life prognosis communication. Existing programs for complementary end-of-life communication training are noted, and it is claimed that a combination of each of these models, together with the proposed module, may be ideal. It is also admitted that no form of education or training can ensure ethical communication. Therefore the ultimate solution is to supplement communication training with real-time, third-party support and accountability. This can be achieved by the "Doctor Body Cam" intervention protocol, accessible via DoctorBodyCam.com.
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Erel M, Marcus EL, Dekeyser-Ganz F. Practice of end-of-life care for patients with advanced dementia by hospital physicians and nurses: Comparison between medical and surgical wards. DEMENTIA 2022; 21:1328-1342. [PMID: 35344387 PMCID: PMC9109210 DOI: 10.1177/14713012221077533] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Patients with advanced dementia are commonly hospitalized in acute care wards, yet there is limited data regarding the end-of-life (EOL) care delivered to this population. The aim of the study was to examine EOL care delivered to patients with advanced dementia hospitalized on acute wards as reported by physicians and nurses. METHODS Participants were physicians and nurses from medical and surgical wards of two tertiary hospitals in Israel. Participants completed a self-report questionnaire evaluating EOL care experiences, knowledge, performance, assessment, communication, and perceived futile care regarding patients with dementia. RESULTS The questionnaire was completed by 315 providers. There were 190 medical ward respondents and 125 from general surgical wards. Of them, 48.6% recognized dementia as a terminal disease, while 26.0% of the participants reported that they knew the end-of-life preferences for less than 10% of their patients. Among the providers, 53.3% reported that end-of-life ward discussions took place only when there was a life-threatening situation and 11.1%-16.5% never engaged in end-of-life communication regarding EOL patient's preferences, appointing an attorney for the patient, disease trajectory or the essence of palliative care, with patients or their representatives. Only 17.1% reported "never" performing care they considered to be futile for patients with advanced dementia. Controlling for gender, age, role, position (senior/junior), and exposure to patients with advanced dementia, surgical ward respondents reported performing less EOL care than medical ward respondents in almost all aspects of palliative care. CONCLUSIONS Despite growing attention, a significant portion of staff in acute care wards do not report applying EOL care to patients with advanced dementia in clinical practice, especially surgical ward staff.
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Affiliation(s)
- Meira Erel
- 108369Henrietta Szold Hadassah University School of Nursing, Jerusalem, Israel
| | - Esther-Lee Marcus
- Faculty of Medicine, 54621Hebrew University of Jerusalem, Jerusalem, Israel
- Department of Geriatrics, 26733Herzog Medical Center, Jerusalem, Israel
| | - Freda Dekeyser-Ganz
- 108369Henrietta Szold Hadassah University School of Nursing, Jerusalem, Israel
- Faculty of Health and Life Sciences, Jerusalem College of Technology, Jerusalem, Israel
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Aaronson EL, Greenwald JL, Krenzel LR, Rogers AM, LaPointe L, Jacobsen JC. Adapting the serious illness conversation guide for use in the emergency department by social workers. Palliat Support Care 2021; 19:681-685. [PMID: 34140064 DOI: 10.1017/s1478951521000821] [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: 11/06/2022]
Abstract
OBJECTIVE Although important treatment decisions are made in the Emergency Department (ED), conversations about patients' goals and values and priorities often do not occur. There is a critical need to improve the frequency of these conversations, so that ED providers can align treatment plans with these goals, values, and priorities. The Serious Illness Conversation Guide has been used in other care settings and has been demonstrated to improve the frequency, quality, and timing of conversations, but it has not been used in the ED setting. Additionally, ED social workers, although integrated into hospital and home-based palliative care, have not been engaged in programs to advance serious illness conversations in the ED. We set out to adapt the Serious Illness Conversation Guide for use in the ED by social workers. METHODS We undertook a four-phase process for the adaptation of the Serious Illness Conversation Guide for use in the ED by social workers. This included simulated testing exercises, pilot testing, and deployment with patients in the ED. RESULTS During each phase of the Guide's adaptation, changes were made to reflect both the environment of care (ED) and the clinicians (social workers) that would be using the Guide. A final guide is presented. SIGNIFICANCE OF RESULTS This report presents an adapted Serious Illness Conversation Guide for use in the ED by social workers. This Guide may provide a tool that can be used to increase the frequency and quality of serious illness conversations in the ED.
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Affiliation(s)
- Emily Loving Aaronson
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA
- Lawrence Center for Quality and Safety, Massachusetts General Hospital and Massachusetts General Physicians' Organization, Boston, MA
| | - Jeffrey L Greenwald
- Core Educator Faculty, Department of Internal Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Lindsey R Krenzel
- Department of Social Work, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Angelina M Rogers
- Department of Social Work, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Lauren LaPointe
- Department of Social Work, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Juliet C Jacobsen
- Division of Palliative Care and Geriatric Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA
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14
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Haines LK, Cook AC, Hatchimonji JS, Ho VP, Kalbfell EL, O'Connell KM, Robenstine JC, Schlögl M, Toevs CC, Jones CA, Krouse RS, Martin ND. Top Ten Tips Palliative Care Clinicians Should Know About Trauma and Emergency Surgery. J Palliat Med 2021; 24:1072-1077. [PMID: 34128716 DOI: 10.1089/jpm.2021.0158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
There is growing interest in, and need for, integrating palliative care (PC) into the care of patients undergoing emergency surgery and those with traumatic injury. Thus, PC consults for these populations will likely grow in the coming years. Understanding the nuances and unique characteristics of these two acutely ill populations will improve the care that PC clinicians can provide. Using a modified Delphi technique, this article offers 10 tips that experts in the field, based on their broad clinical experience, believe PC clinicians should know about the care of trauma and emergency surgery patients.
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Affiliation(s)
- Lindsay K Haines
- Department of Medicine and the Palliative and Advanced Illness Research Center, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Allyson C Cook
- Department of Medicine and University of California San Francisco, San Francisco, California, USA.,Department of Surgery, University of California San Francisco, San Francisco, California, USA
| | - Justin S Hatchimonji
- Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Vanessa P Ho
- Division of Trauma, Critical Care, Burns, and Acute Care Surgery, MetroHealth Medical Center, Cleveland, Ohio, USA.,Department of Population and Quantitative Health Sciences, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Elle L Kalbfell
- Department of Surgery, University of Wisconsin-Madison, Wisconsin, USA
| | - Kathleen M O'Connell
- Department of Surgery, University of Washington, Harborview Medical Center, Seattle, Washington, USA
| | - Jacinta C Robenstine
- Division of Trauma, Critical Care, Burns, and Acute Care Surgery, MetroHealth Medical Center, Cleveland, Ohio, USA
| | - Mathias Schlögl
- Centre on Aging and Mobility, University Hospital Zurich and City Hospital Waid Zurich, Zurich, Switzerland.,University Clinic for Acute Geriatric Care, City Hospital Waid Zurich, Zurich, Switzerland
| | - Christine C Toevs
- Department of Surgery, Terre Haute Regional Hospital, Indiana University School of Medicine, Terre Haute, Indiana, USA
| | | | - Robert S Krouse
- Department of Surgery, Perelman School of Medicine, University of Pennsylvania and the Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania, USA
| | - Niels D Martin
- Division of Traumatology, Surgical Critical Care and Emergency Surgery, Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
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15
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Follette C, Halimeh B, Chaparro A, Shi A, Winfield R. Futile trauma transfers: An infrequent but costly component of regionalized trauma care. J Trauma Acute Care Surg 2021; 91:72-76. [PMID: 34144558 DOI: 10.1097/ta.0000000000003139] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Appropriate interfacility transfers are a key component of highly functioning trauma systems but transfer of unsalvageable patients can overburden the resources of higher-level centers. We sought to identify the occurrence and associated reasons for futile transfers within our trauma system. METHODS Using prospectively collected data from our system database, a retrospective cohort study was conducted to identify patients who underwent interfacility transfer to our American College of Surgeons level I center. Adult patients from June 2017 to June 2019 who died, had comfort measures implemented, were discharged, or went to hospice care within 48 hours of admission without significant operation, procedure, or radiologic intervention were examined. Futility was defined as resulting in death or hospice discharge within 48 hours of transfer without major operative, endoscopic, or radiologic intervention. RESULTS A total of 1,241 patients transferred to our facility during the study period. Four hundred seven patients had a length of stay less than or equal to 48 hours. Eighteen (1.5%) met the criteria for futility. The most common reason for transfer in the futile population was traumatic brain injury (56%) and need for neurosurgical capabilities (62%). Futile patients had a median age and Injury Severity Score of 75 and 21. The main transportation method was ground 9 (50%) with 8 (44.4%) being transported by helicopter and 1 (5.6%) being transported by both. Combining transport costs with hospital charges, each futile transfer was estimated to cost US $56,396 (interquartile range, 41,889-106,393) with a total cost exceeding US $1.7 million. With an estimated 33,000 interfacility transfers annually for trauma in the United States, the cost of futile transfers to the American trauma system would exceed 27 million dollars each year. CONCLUSION Futile transfers represent a small but costly portion transfer volume. Identification of patients whose conditions preclude the benefit of transfer due to futility and development of appropriate support for referral will significantly improve appropriate allocation of health care resources. LEVEL OF EVIDENCE Economic; Care management, level IV.
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Affiliation(s)
- Craig Follette
- From the Department of Surgery at the University of Kansas Medical Center, Kansas City, Kansas
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16
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Udelsman B, Lee K, Qadan M, Lillemoe KD, Chang D, Lindvall C, Cooper Z. Management of Pneumoperitoneum: Role and Limits of Nonoperative Treatment. Ann Surg 2021; 274:146-154. [PMID: 31348040 DOI: 10.1097/sla.0000000000003492] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES The aim of this study was to compare morbidity and mortality between nonoperative and operative treatment of pneumoperitoneum. BACKGROUND Pneumoperitoneum is a potentially life-threatening condition that has been traditionally treated with surgical intervention. Adequately powered studies comparing treatment outcomes are lacking. METHODS Chart review and computer-assisted abstraction were used to identify patients with pneumoperitoneum at 5 hospitals from 2010 to 2015. Patients with recent abdominal procedures or contained perforation were excluded. Patients were grouped by treatment modality: comfort measures only (CMO), nonoperative treatment, or operative intervention. CMO included only symptom-palliation, whereas nonoperative therapy included all interventions (antibiotics, peritoneal drains, resuscitation) excluding surgery. Outcomes were mortality, discharge disposition, and 30-day complications. Covariates included demographics, comorbidities, and acuity at presentation. RESULTS Forty patients received CMO, 202 underwent nonoperative treatment, and 199 underwent operative intervention. CMO patients had 98% 30-day mortality. There was no difference in 30-day (P = 0.64) or 2-year mortality (P = 0.53) between patients treated nonoperatively and operatively. Compared with patients treated operatively, patients treated nonoperatively were more likely to have a colorectal source of pneumoperitoneum (37% vs 31%; P = 0.03). Using logistic regression, operative treatment was associated with increased dependence on enteral tube feeding or total parenteral nutrition [odds ratio (OR) 4.30, 95% confidence interval (CI), 1.99-9.29] and nonhome discharge (OR 3.61, 95% CI, 1.81-7.17). Among patients with clinical peritonitis, operative treatment was associated with reduced mortality (OR 0.17, 95% CI, 0.04-0.80). CONCLUSIONS Operative intervention is associated with reduced mortality in patients with pneumoperitoneum and peritonitis. In the absence of peritonitis, operative treatment is associated with increased morbidity and nonhome discharge.
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Affiliation(s)
- Brooks Udelsman
- Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - Katherine Lee
- Department of Surgery, University of California San Diego, San Diego, CA
- Center for Surgery and Public Health, Brigham & Women's Hospital, Boston, MA
| | - Motaz Qadan
- Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - Keith D Lillemoe
- Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - David Chang
- Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - Charlotta Lindvall
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA
- Division of Palliative Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, MA
| | - Zara Cooper
- Center for Surgery and Public Health, Brigham & Women's Hospital, Boston, MA
- Department of Surgery, Brigham and Women's Hospital, Boston, MA
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17
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Sokas C, Yeh IM, Coogan K, Bernacki R, Mitchell S, Bader A, Ladin K, Palmer JA, Tulsky JA, Cooper Z. Older Adult Perspectives on Medical Decision Making and Emergency General Surgery: "It had to be Done.". J Pain Symptom Manage 2021; 61:948-954. [PMID: 33038427 PMCID: PMC8024409 DOI: 10.1016/j.jpainsymman.2020.09.039] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Revised: 09/21/2020] [Accepted: 09/28/2020] [Indexed: 11/28/2022]
Abstract
CONTEXT Optimal surgical care for older adults with life-threatening conditions, with high risk of poor perioperative outcomes and morality in the months after surgery, should incorporate an understanding of the patient's treatment goals and preferences. However, little research has explored the patient perspective of decision making and advanced care planning during an emergency surgery episode. OBJECTIVES We sought to better understand older patients' lived experience making decisions to undergo emergency general surgery (EGS) and perceptions of perioperative advance care planning (ACP). METHODS Adults aged 65 and older who underwent one of seven common EGS procedures with lengths of stay more than five days at three Boston-area hospitals were included. Semistructured phone interviews were conducted three months postdischarge. Transcripts were reviewed and coded independently by surgeons and palliative care physicians to identify themes. RESULTS About 31 patients were interviewed. Patients viewed the decision for surgery as a choice of life over death and valued prolonging life. They felt there was no choice but to proceed with surgery but reported that participation in decision making was limited because of severe symptoms, time constraints, and confused thinking. Despite recently surviving a life-threatening illness, patients had not reconsidered their wishes for the future and preferred to avoid future ACP. CONCLUSION Older patients who survived a life-threatening illness and EGS report receiving goal-concordant care in the moment that relieved symptoms and prolonged life but had not considered future care. Interventions to facilitate postoperative ACP should be targeted to this vulnerable group of older adults.
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Affiliation(s)
- Claire Sokas
- Brigham and Woman's Hospital, Center for Surgery and Public Health, Boston, Massachusetts, USA
| | - Irene M Yeh
- Division of Palliative Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA; Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Kathleen Coogan
- Brigham and Woman's Hospital, Center for Surgery and Public Health, Boston, Massachusetts, USA
| | - Rachelle Bernacki
- Division of Palliative Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA; Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Susan Mitchell
- Hebrew SeniorLife Arthur and Hinda Marcus Institute for Aging Research, Boston, Massachusetts, USA
| | - Angela Bader
- Brigham and Woman's Hospital, Center for Surgery and Public Health, Boston, Massachusetts, USA; Department of Anesthesia, Brigham and Woman's Hospital, Boston, Massachusetts, USA
| | - Keren Ladin
- Departments of Occupational Therapy and Community Health, Tufts University, Medford, Massachusetts, USA
| | - Jennifer A Palmer
- VA Boston Healthcare System, Center for Healthcare Organization and Implementation Research, Boston, Massachusetts, USA; Section of General Internal Medicine, Boston University School of Medicine, Boston, Massachusetts, USA
| | - James A Tulsky
- Division of Palliative Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA; Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Zara Cooper
- Brigham and Woman's Hospital, Center for Surgery and Public Health, Boston, Massachusetts, USA; Department of Surgery, Brigham and Woman's Hospital, Boston, Massachusetts, USA.
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18
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Cunningham HB, Scielzo SA, Nakonezny PA, Bruns BR, Brasel KJ, Inaba K, Brakenridge SC, Kerby JD, Joseph BA, Mohler MJ, Cuschieri J, Paulk ME, Ekeh AP, Madni TD, Taveras LR, Imran JB, Wolf SE, Phelan HA. Burn Surgeon and Palliative Care Physician Attitudes Regarding Goals of Care Delineation for Burned Geriatric Patients. J Burn Care Res 2020; 39:1000-1005. [PMID: 29771351 DOI: 10.1093/jbcr/iry027] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Palliative care specialists (PCS) and burn surgeons (BS) were surveyed regarding: 1) importance of goals of care (GoC) conversations for burned seniors; 2) confidence in their own specialty's ability to conduct these conversations; and 3) confidence in the ability of the other specialty to do so. A 13-item survey was developed by the steering committee of a multicenter consortium dedicated to palliative care in the injured geriatric patient and beta-tested by BS and PCS unaffiliated with the consortium. The finalized instrument was electronically circulated to active physician members of the American Burn Association and American Academy for Hospice and Palliative Medicine. Forty-five BS (7.3%) and 244 PCS (5.7%) responded. Palliative physicians rated being more familiar with GoC, were more comfortable having a discussion with laypeople, were more likely to have reported high-quality training in performing conversations, believed more palliative specialists were needed in intensive care units, and had more interest in conducting conversations relative to BS. Both groups believed themselves to perform GoC discussions better than the other specialty perceived them to do so. BS favored leading team discussions, whereas palliative specialists preferred jointly led discussions. Both groups agreed that discussions should occur within 72 hours of admission. Both groups believe themselves to conduct GoC discussions for burned seniors better than the other specialty perceived them to do so, which led to disparate views on perceptions for the optimal leadership of these discussions.
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Affiliation(s)
- Holly B Cunningham
- Department of Surgery, University of Texas Southwestern, Dallas, TX, USA
| | - Shannon A Scielzo
- Department of Internal Medicine, University of Texas Southwestern, Dallas, TX, USA
| | - Paul A Nakonezny
- Department of Clinical Science and Psychiatry, University of Texas Southwestern, Dallas, TX, USA
| | - Brandon R Bruns
- Department of Surgery, University of Maryland, Baltimore, MD, USA
| | - Karen J Brasel
- Division of Trauma, Critical Care and Acute Care Surgery, Oregon Health Science University, Portland, OR, USA
| | - Kenji Inaba
- Division of Acute Care Surgery and Critical Care, University of Southern California, Los Angeles, CA, USA
| | | | - Jeffrey D Kerby
- Division of Acute Care Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Bellal A Joseph
- Department of Surgery, University of Arizona Health Sciences, Tucson, AZ, USA
| | - M J Mohler
- Department of Surgery, University of Arizona Health Sciences, Tucson, AZ, USA
| | - Joseph Cuschieri
- Department of Surgery, University of Washington Medical Center, Seattle, WA, USA
| | - Mary E Paulk
- Department of Internal Medicine, University of Texas Southwestern, Dallas, TX, USA
| | - Akpofure P Ekeh
- Department of Surgery, Wright State University, Dayton, OH, USA
| | - Tarik D Madni
- Department of Surgery, University of Texas Southwestern, Dallas, TX, USA
| | - Luis R Taveras
- Department of Surgery, University of Texas Southwestern, Dallas, TX, USA
| | - Jonathan B Imran
- Department of Surgery, University of Texas Southwestern, Dallas, TX, USA
| | - Steven E Wolf
- Department of Surgery, University of Texas Medical Branch, Galveston, TX, USA
| | - Herb A Phelan
- Department of Surgery, University of Texas Southwestern, Dallas, TX, USA
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19
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Chamberlain C, Blazeby JM. A good surgical death. Br J Surg 2019; 106:1427-1428. [DOI: 10.1002/bjs.11360] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Accepted: 08/14/2019] [Indexed: 01/20/2023]
Affiliation(s)
- C Chamberlain
- Population Health Sciences, Bristol Medical School, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS, UK
| | - J M Blazeby
- Bristol Centre for Surgical Research, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- University Hospitals Bristol NHS Foundation Trust, Bristol, UK
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20
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Udelsman BV, Lilley EJ, Qadan M, Chang DC, Lillemoe KD, Lindvall C, Cooper Z. Deficits in the Palliative Care Process Measures in Patients with Advanced Pancreatic Cancer Undergoing Operative and Invasive Nonoperative Palliative Procedures. Ann Surg Oncol 2019; 26:4204-4212. [DOI: 10.1245/s10434-019-07757-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Indexed: 01/19/2023]
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21
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Bonanno AM, Kiraly LN, Siegel TR, Brasel KJ, Cook MR. Surgical palliative care training in general surgery residency: An educational needs assessment. Am J Surg 2019; 217:928-931. [DOI: 10.1016/j.amjsurg.2019.01.008] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2018] [Revised: 01/03/2019] [Accepted: 01/13/2019] [Indexed: 12/15/2022]
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22
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Cunningham HB, Scielzo SA, Nakonezny PA, Bruns BR, Brasel KJ, Inaba K, Brakenridge SC, Kerby JD, Joseph BA, Mohler MJ, Cuschieri J, Paulk ME, Ekeh AP, Madni TD, Taveras LR, Imran JB, Wolf SE, Phelan HA. Trauma Surgeon and Palliative Care Physician Attitudes Regarding Goals-of-Care Delineation for Injured Geriatric Patients. Am J Hosp Palliat Care 2019; 36:669-674. [DOI: 10.1177/1049909118823182] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background: The value of defining goals of care (GoC) for geriatric patients is well known to the palliative care community but is a newer concept for many trauma surgeons. Palliative care specialists and trauma surgeons were surveyed to elicit the specialties’ attitudes regarding (1) importance of GoC conversations for injured seniors; (2) confidence in their own specialty’s ability to conduct these conversations; and (3) confidence in the ability of the other specialty to do so. Methods: A 13-item survey was developed by the steering committee of a multicenter, palliative care-focused consortium and beta-tested by trauma surgeons and palliative care specialists unaffiliated with the consortium. The finalized instrument was electronically circulated to active physician members of the American Association for the Surgery of Trauma and American Academy for Hospice and Palliative Medicine. Results: Respondents included 118 trauma surgeons (8.8%) and 244 palliative care specialists (5.7%). Palliative physicians rated being more familiar with GoC, were more likely to report high-quality training in performing conversations, believed more palliative specialists were needed in intensive care units, and had more interest in conducting conversations relative to trauma surgeons. Both groups believed themselves to perform GoC discussions better than the other specialty perceived them to do so and favored their own specialty leading team discussions. Conclusions: Both groups believe themselves to conduct GoC discussions for injured seniors better than the other specialty perceived them to do so, which led to disparate views on the optimal leadership of these discussions.
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Affiliation(s)
| | - Shannon A. Scielzo
- Department of Internal Medicine, University of Texas Southwestern, Dallas, TX, USA
| | - Paul A. Nakonezny
- Department of Psychiatry, University of Texas Southwestern, Dallas, TX, USA
| | - Brandon R. Bruns
- Department of Surgery, University of Maryland, College Park, MD, USA
| | - Karen J. Brasel
- Department of Surgery, Oregon Health Science University, Portland, OR, USA
| | - Kenji Inaba
- Department of Surgery, University of Southern California, Los Angeles, CA, USA
| | | | - Jeffrey D. Kerby
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Bellal A. Joseph
- Department of Surgery, University of Arizona Health Sciences, Tucson, AZ, USA
| | - M. J. Mohler
- Department of Surgery, University of Arizona Health Sciences, Tucson, AZ, USA
| | - Joseph Cuschieri
- Department of Surgery, University of Washington Medical Center, Seattle, WA, USA
| | - Mary E. Paulk
- Department of Internal Medicine, University of Texas Southwestern, Dallas, TX, USA
| | | | - Tarik D. Madni
- Department of Surgery, University of Texas Southwestern, Dallas, TX, USA
| | - Luis R. Taveras
- Department of Surgery, University of Texas Southwestern, Dallas, TX, USA
| | - Jonathan B. Imran
- Department of Surgery, University of Texas Southwestern, Dallas, TX, USA
| | - Steven E. Wolf
- Department of Surgery, University of Texas Medical Branch, Galveston, TX, USA
| | - Herb A. Phelan
- Department of Surgery, University of Texas Southwestern, Dallas, TX, USA
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23
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Heller DR, Jean RA, Chiu AS, Feder SI, Kurbatov V, Cha C, Khan SA. Regional Differences in Palliative Care Utilization Among Geriatric Colorectal Cancer Patients Needing Emergent Surgery. J Gastrointest Surg 2019; 23:153-162. [PMID: 30328071 PMCID: PMC6751557 DOI: 10.1007/s11605-018-3929-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Accepted: 08/10/2018] [Indexed: 01/31/2023]
Abstract
BACKGROUND The benefits of palliative care (PC) in critical illness are validated across a range of diseases, yet it remains underutilized in surgical patients. This study analyzed patient and hospital factors predictive of PC utilization for elderly patients with colorectal cancer (CRC) requiring emergent surgery. METHODS The National Inpatient Sample was queried for patients aged ≥ 65 years admitted emergently with CRC from 2009 to 2014. Patients undergoing colectomy, enterectomy, or ostomy formation were included and stratified according to documentation of PC consultation during admission. Chi-squared testing identified unadjusted group differences, and multivariable logistic regression identified predictors of PC. RESULTS Of 86,573 discharges meeting inclusion criteria, only 3598 (4.2%) had PC consultation. Colectomy (86.6%) and ostomy formation (30.4%) accounted for the operative majority. PC frequency increased over time (2.9% in 2009 to 6.2% in 2014, P < 0.001) and was nearly twice as likely to occur in the West compared with the Northeast (5.7 vs. 3.3%, P < 0.001) and in not-for-profit compared with proprietary hospitals (4.5 vs. 2.3%, P < 0.001). PC patients were more likely to have metastases (60.1 vs. 39.9%, P < 0.001) and die during admission (41.5 vs. 6.4%, P < 0.001). On multivariable logistic regression, PC predictors (P < 0.05) included region outside the Northeast, increasing age, more recent year, and metastatic disease. CONCLUSIONS In the USA, PC consultation for geriatric patients with surgically managed complicated CRC is low. Regional variation appears to play an important role. With mounting evidence that PC improves quality of life and outcomes, understanding the barriers associated with its provision to surgical patients is paramount.
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Affiliation(s)
- Danielle R Heller
- Department of Surgery, Yale School of Medicine, P.O. Box 208062, New Haven, CT, 06520-8062, USA
| | - Raymond A Jean
- Department of Surgery, Yale School of Medicine, P.O. Box 208062, New Haven, CT, 06520-8062, USA
- National Clinician Scholars Program, Department of Internal Medicine, Yale School of Medicine, P.O. Box 208088, New Haven, CT, 06520-8088, USA
| | - Alexander S Chiu
- Department of Surgery, Yale School of Medicine, P.O. Box 208062, New Haven, CT, 06520-8062, USA
| | - Shelli I Feder
- National Clinician Scholars Program, Department of Internal Medicine, Yale School of Medicine, P.O. Box 208088, New Haven, CT, 06520-8088, USA
- US Department of Veterans Affairs, 950 Campbell Ave, West Haven, CT, 06516, USA
| | - Vadim Kurbatov
- Department of Surgery, Yale School of Medicine, P.O. Box 208062, New Haven, CT, 06520-8062, USA
| | - Charles Cha
- Section of Surgical Oncology, Department of Surgery, Yale School of Medicine, PO Box 208062, New Haven, CT, 06520-8062, USA
| | - Sajid A Khan
- Section of Surgical Oncology, Department of Surgery, Yale School of Medicine, PO Box 208062, New Haven, CT, 06520-8062, USA.
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24
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Sroka R, Gabriel EM, Al-Hadidi D, Nurkin SJ, Urman RD, Quinn TD. A novel anesthesiologist-led multidisciplinary model for evaluating high-risk surgical patients at a comprehensive cancer center. J Healthc Risk Manag 2019; 38:12-23. [PMID: 30033650 DOI: 10.1002/jhrm.21326] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
The objective of this retrospective analysis was to describe the development and implementation of an anesthesiologist-led multidisciplinary committee to evaluate high-risk surgical patients in order to improve surgical appropriateness. The study was conducted in an anesthesia preoperative evaluation clinic at an academic comprehensive cancer center. One hundred sixty-seven high-risk surgical patients with cancer-related diagnoses were evaluated and discussed at a High-Risk Committee (HRC) meeting to determine surgical appropriateness and optimize perioperative care. The HRC is an anesthesiologist-led model for multidisciplinary review of high-risk patients developed at Roswell Park Comprehensive Cancer Center. The group of high-risk patients in which surgery was not performed had, on average, a greater percentage of hypertension, smoking history, dyspnea, heart failure, chronic obstructive pulmonary disease, diabetes, renal failure, and sleep apnea than the group in whom surgery was performed. Only one of 107 high-risk patients who had surgery died within the first 30 days after surgery. A smaller percentage of patients died in the group that had surgery versus the group in which surgery was canceled. For all patients discussed by the HRC, the mortality was less than 2% within the first 30 days after the HRC.
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Affiliation(s)
- Raymond Sroka
- Roswell Park Comprehensive Cancer Center, Buffalo, NY
- Jacobs School of Medicine and Biomedical Sciences, Department of Anesthesiology, State University of New York at Buffalo, Buffalo, NY
| | | | - Danna Al-Hadidi
- Jacobs School of Medicine and Biomedical Sciences, Department of Anesthesiology, State University of New York at Buffalo, Buffalo, NY
| | | | - Richard D Urman
- Brigham and Women's Hospital, Boston, MA
- Harvard Medical School, Boston, MA
| | - Timothy D Quinn
- Roswell Park Comprehensive Cancer Center, Buffalo, NY
- Jacobs School of Medicine and Biomedical Sciences, Department of Anesthesiology, State University of New York at Buffalo, Buffalo, NY
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Outcomes of emergency abdominal surgery in octogenarians: A single-center analysis. Am J Surg 2018; 218:248-254. [PMID: 30509459 DOI: 10.1016/j.amjsurg.2018.11.023] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Revised: 10/17/2018] [Accepted: 11/15/2018] [Indexed: 11/22/2022]
Abstract
BACKGROUND The aim of this study was to assess outcomes of octogenarians undergoing emergency abdominal surgery (EAS). METHODS Octogenarians undergoing EAS 12/2011-12/2016 were retrospectively analysed. The outcomes were assessed by univariable and multivariable regression analysis. RESULTS One-hundred-forty patients with a median age of 83.9 years were included. EAS was performed for cholecystitis (27.1%), ileus (22.1%), hollow viscus perforation (16.4%), diverticulitis (12.9%), mesenteric ischemia (10.0%), incarcerated hernia (9.3%), and appendicitis (2.1%). The overall and early (within 7 days from surgery) mortality rate was 16.4% and 10.0%, respectively. Multivariable analysis revealed age (OR 1.24,CI95% 1.04-1.47,p = 0.015), ASA scores≥4 (OR 11.15,CI95% 2.39-52.02,p = 0.002), mesenteric ischemia (OR 52.60,CI95% 8.93-309.94,p < 0.001) and ICU admission (OR 9.23,CI95% 1.74-49.04,p = 0.009) as independent predictors for mortality. Postoperative withdrawal of care accounted for 36% of early mortalities. CONCLUSIONS One third of early mortality in octogenarians was due to postoperative withdrawal of care. An interdisciplinary decision-making including patients' and relatives' wishes may avoid ethically questionable interventions in octogenarians.
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Lee KC, Cooper Z. Ethical considerations about emergent surgical hospitalizations in patients with advanced cancer. Cancer 2018; 124:4432-4434. [PMID: 30427534 DOI: 10.1002/cncr.31684] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2018] [Accepted: 06/27/2018] [Indexed: 11/08/2022]
Affiliation(s)
- Katherine C Lee
- The Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts.,Department of Surgery, University of California, San Diego, La Jolla, California
| | - Zara Cooper
- The Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts.,Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts
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Suwanabol PA, Kanters AE, Reichstein AC, Wancata LM, Dossett LA, Rivet EB, Silveira MJ, Morris AM. Characterizing the Role of U.S. Surgeons in the Provision of Palliative Care: A Systematic Review and Mixed-Methods Meta-Synthesis. J Pain Symptom Manage 2018; 55:1196-1215.e5. [PMID: 29221845 DOI: 10.1016/j.jpainsymman.2017.11.031] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2017] [Revised: 11/27/2017] [Accepted: 11/28/2017] [Indexed: 12/25/2022]
Abstract
CONTEXT The provision of palliative care varies appropriately by clinical factors such as patient age and severity of disease and also varies by provider practice and specialty. Surgical patients are persistently less likely to receive palliative care than their medical counterparts for reasons that are not clear. OBJECTIVES We sought to characterize surgeon-specific determinants of palliative care in seriously ill and dying patients. METHODS We performed a systematic review of the literature focused on surgery and palliative care within PubMed, CINAHL, EMBASE, Scopus, and Ovid Medline databases from January 1, 2000 through December 31, 2016 according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Quantitative and qualitative studies with primary data evaluating surgeons' attitudes, knowledge, and behaviors or experiences in care for seriously ill and dying patients were selected for full review by at least two study team members based on predefined inclusion criteria. Data were extracted based on a predetermined instrument and compared across studies using thematic analysis in a meta-synthesis of qualitative and quantitative findings. RESULTS A total of 2589 abstracts were identified and screened, and 35 articles (26 quantitative and nine qualitative) fulfilled criteria for full review. Among these, 17 articles explored practice and attitudes of surgeons regarding palliative and end-of-life care, 11 articles assessed training in palliative care, five characterized surgical decision making, one described behaviors of surgeons caring for seriously ill and dying patients, and one explicitly identified barriers to use of palliative care. Four major themes across studies affected receipt of palliative care for surgical patients: 1) surgeons' experience and knowledge, 2) surgeons' attitudes, 3) surgeons' preferences and decision making for treatment, and 4) perceived barriers. CONCLUSIONS Among the articles reviewed, surgeons overall demonstrated insight into the benefits of palliative care but reported limited knowledge and comfort as well as a multitude of challenges to introducing palliative care to their patients. These findings indicate a need for wider implementation of strategies that allow optimal integration of palliative care with surgical decision making.
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Affiliation(s)
| | - Arielle E Kanters
- Department of Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Ari C Reichstein
- Department of Surgery, Allegheny Health Network, Pittsburgh, Pennsylvania, USA
| | - Lauren M Wancata
- Department of Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Lesly A Dossett
- Department of Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Emily B Rivet
- Department of Surgery and Division of Hematology, Oncology and Palliative Care, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Maria J Silveira
- Department of Surgery, Division of Geriatric and Palliative Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Arden M Morris
- S-SPIRE Center and Department of Surgery, Stanford University, Stanford, California, USA
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Suwanabol PA, Reichstein AC, Suzer-Gurtekin ZT, Forman J, Silveira MJ, Mody L, Morris AM. Surgeons' Perceived Barriers to Palliative and End-of-Life Care: A Mixed Methods Study of a Surgical Society. J Palliat Med 2018; 21:780-788. [PMID: 29649396 DOI: 10.1089/jpm.2017.0470] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Nearly 20% of colorectal cancer (CRC) patients present with potentially incurable (Stage IV) disease, yet their physicians do not integrate cancer treatment with palliative care. Compared with patients treated by primary providers, surgical patients with terminal diseases are significantly less likely to receive palliative or end-of-life care. OBJECTIVE To describe surgeon perspectives on palliative and end-of-life care for patients with Stage IV CRCs. DESIGN This is a convergent mixed methods study using a validated survey instrument from the Critical Care Peer Workgroup of the Robert Wood Johnson Foundation's Promoting Excellence in End-of-Life Care Project with additional qualitative questions. SETTINGS Participants were all current, nonretired members of the American Society of Colon and Rectal Surgeons. MAIN OUTCOME MEASURES Surgeon-perceived barriers to palliative and end-of-life care for patients with Stage IV CRCs were identified. RESULTS Among 131 Internet survey respondents (response rate 16.5%), 76.1% reported no formal education in palliative care, and specifically noted inadequate training in techniques to forgo life-sustaining measures (37.9%) and communication (42.7%). Over half (61.8%) of surgeons cited unrealistic expectations among patients and families as a barrier to care, which also limited discussion of palliation. At the system level, absence of documentation, appropriate processes, and culture hindered the initiation of palliative care. Thematic analysis of open-ended questions confirmed and extended these findings through the following major barriers to palliative and end-of-life care: (1) surgeon knowledge and training; (2) communication challenges; (3) difficulty with prognostication; (4) patient and family factors encompassing unrealistic expectations and discordant preferences; and (5) systemic issues including culture and lack of documentation and appropriate resources. LIMITATIONS Generalizability is limited by the small sample size inherent to Internet surveys, which may contribute to selection bias. CONCLUSIONS Surgeons valued palliative and end-of-life care but reported multilevel barriers to its provision. These data will inform strategies to reduce these perceived barriers.
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Affiliation(s)
- Pasithorn A Suwanabol
- 1 Division of Colorectal Surgery, Department of Surgery, University of Michigan , Ann Arbor, Michigan
| | - Ari C Reichstein
- 2 Division of Colorectal Surgery, Department of Surgery, Allegheny Health Network , Pittsburgh, Pennsylvania
| | | | - Jane Forman
- 4 Center for Clinical Management Research , Veterans Affairs Health Services Research & Development, VA Ann Arbor Health Care System, Ann Arbor, Michigan
| | - Maria J Silveira
- 5 Division of Geriatric and Palliative Medicine, Department of Internal Medicine, University of Michigan , Ann Arbor, Michigan.,6 Geriatric Research, Education and Clinical Center (GRECC) , Veterans Affairs Health Affairs, VA Ann Arbor Health Care System, Ann Arbor, Michigan
| | - Lona Mody
- 5 Division of Geriatric and Palliative Medicine, Department of Internal Medicine, University of Michigan , Ann Arbor, Michigan.,6 Geriatric Research, Education and Clinical Center (GRECC) , Veterans Affairs Health Affairs, VA Ann Arbor Health Care System, Ann Arbor, Michigan
| | - Arden M Morris
- 7 Department of Surgery, S-SPIRE Center, Stanford University , Stanford, California
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Shared Decision-Making in Acute Surgical Illness: The Surgeon's Perspective. J Am Coll Surg 2018; 226:784-795. [PMID: 29382560 DOI: 10.1016/j.jamcollsurg.2018.01.008] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2017] [Revised: 12/31/2017] [Accepted: 01/01/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND Surgical patients increasingly have more comorbidities and are of an older age, complicating surgical decision-making in emergent situations. Little is known about surgeons' perceptions of shared decision-making in these settings. STUDY DESIGN Twenty semi-structured interviews were conducted with practicing surgeons at 2 large academic medical centers. Thirteen questions and 2 case vignettes were used to assess perceptions of decision-making, considerations when deciding whether to offer to operate, and communication patterns with patients and families. RESULTS Thematic analysis revealed 6 major themes: responsibility for the decision to operate, perceived futility, surgeon judgment, surgeon introspection, pressure to operate, and costs of the operation. Perceived futility was universally considered a contraindication to surgical intervention. However, the challenge of defining futility led participants to emphasize the importance of patients' self-determined risk-to-benefit analysis when considering surgical intervention. More experienced surgeons reported greater comfort with communicating to patients that a condition was not amenable to an operation and reserved the right to refuse to operate. CONCLUSIONS Due to external pressures and uncertainty, some providers err on the side of operative intervention, despite suspected futility. Greater experience allows surgeons to withstand external pressures, be confident in their assessments of perceived futility, and guide patients and their families away from additional interventions.
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Taylor LJ, Nabozny MJ, Steffens NM, Tucholka JL, Brasel KJ, Johnson SK, Zelenski A, Rathouz PJ, Zhao Q, Kwekkeboom KL, Campbell TC, Schwarze ML. A Framework to Improve Surgeon Communication in High-Stakes Surgical Decisions: Best Case/Worst Case. JAMA Surg 2017; 152:531-538. [PMID: 28146230 DOI: 10.1001/jamasurg.2016.5674] [Citation(s) in RCA: 148] [Impact Index Per Article: 21.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Although many older adults prefer to avoid burdensome interventions with limited ability to preserve their functional status, aggressive treatments, including surgery, are common near the end of life. Shared decision making is critical to achieve value-concordant treatment decisions and minimize unwanted care. However, communication in the acute inpatient setting is challenging. Objective To evaluate the proof of concept of an intervention to teach surgeons to use the Best Case/Worst Case framework as a strategy to change surgeon communication and promote shared decision making during high-stakes surgical decisions. Design, Setting, and Participants Our prospective pre-post study was conducted from June 2014 to August 2015, and data were analyzed using a mixed methods approach. The data were drawn from decision-making conversations between 32 older inpatients with an acute nonemergent surgical problem, 30 family members, and 25 surgeons at 1 tertiary care hospital in Madison, Wisconsin. Interventions A 2-hour training session to teach each study-enrolled surgeon to use the Best Case/Worst Case communication framework. Main Outcomes and Measures We scored conversation transcripts using OPTION 5, an observer measure of shared decision making, and used qualitative content analysis to characterize patterns in conversation structure, description of outcomes, and deliberation over treatment alternatives. Results The study participants were patients aged 68 to 95 years (n = 32), 44% of whom had 5 or more comorbid conditions; family members of patients (n = 30); and surgeons (n = 17). The median OPTION 5 score improved from 41 preintervention (interquartile range, 26-66) to 74 after Best Case/Worst Case training (interquartile range, 60-81). Before training, surgeons described the patient's problem in conjunction with an operative solution, directed deliberation over options, listed discrete procedural risks, and did not integrate preferences into a treatment recommendation. After training, surgeons using Best Case/Worst Case clearly presented a choice between treatments, described a range of postoperative trajectories including functional decline, and involved patients and families in deliberation. Conclusions and Relevance Using the Best Case/Worst Case framework changed surgeon communication by shifting the focus of decision-making conversations from an isolated surgical problem to a discussion about treatment alternatives and outcomes. This intervention can help surgeons structure challenging conversations to promote shared decision making in the acute setting.
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Affiliation(s)
| | | | - Nicole M Steffens
- Denver Public Health, Denver Health and Hospital Authority, Denver, Colorado
| | | | - Karen J Brasel
- Department of Surgery, Oregon Health and Science University, Portland
| | - Sara K Johnson
- Department of Medicine, University of Wisconsin, Madison
| | - Amy Zelenski
- Department of Medicine, University of Wisconsin, Madison
| | - Paul J Rathouz
- Department of Biostatistics and Medical Informatics, University of Wisconsin, Madison
| | - Qianqian Zhao
- Department of Biostatistics and Medical Informatics, University of Wisconsin, Madison
| | | | | | - Margaret L Schwarze
- Department of Surgery, University of Wisconsin, Madison7Department of Medical History and Bioethics, University of Wisconsin, Madison
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Broman KK, Phillips SE, Ehrenfeld JM, Patel MB, Guillamondegui OM, Sharp KW, Pierce RA, Poulose BK, Holzman MD. Identifying Futile Interfacility Surgical Transfers. Am Surg 2017. [DOI: 10.1177/000313481708300838] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Surgeons perceive that some surgical transfers are futile, but the incidence and risk factors of futile transfer are not quantified. Identifying futile interfacility transfers could save cost and undue burdens to patients and families. We sought to describe the incidence and factors associated with futile transfers. We conducted a retrospective cohort study from 2009 to 2013 including patients transferred to a tertiary referral center for general or vascular surgical care. Futile transfers were defined as resulting in death or hospice discharge within 72 hours of transfer without operative, endoscopic, or radiologic intervention. One per cent of patient transfers were futile (27/ 1696). Characteristics of futile transfers included older age, higher comorbidity burden and illness severity, vascular surgery admission, Medicare insurance, and surgeon documentation of end-stage disease as a factor in initial decision-making. Among futile transfers, 82 per cent were designated as do not resuscitate (vs 9% of nonfutile, P < 0.01), and 59 per cent received a palliative care consult (vs 7%, P < 0.01). A small but salient proportion of transferred patients undergo deliberate care de-escalation and early death or hospice discharge without intervention. Efforts to identify such patients before transfer through improved communication between referring and accepting surgeons may mitigate burdens of transfer and facilitate more comfortable deaths in patients’ local communities.
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Affiliation(s)
- Kristy Kummerow Broman
- Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
- Geriatric Research, Education, and Clinical Center (GRECC)
- Surgery Service, Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Murfreesboro, Tennessee
| | | | - Jesse M. Ehrenfeld
- Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
- Department of Anesthesiology
- Department of Bioinformatics
- Department of Health Policy
| | - Mayur B. Patel
- Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
- Geriatric Research, Education, and Clinical Center (GRECC)
- Surgery Service, Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Murfreesboro, Tennessee
- Department of Neurosurgery, and
- Department of Hearing & Speech Sciences, Vanderbilt University Medical Center, Nashville, Tennessee
| | | | - Kenneth W. Sharp
- Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Richard A. Pierce
- Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
- Surgery Service, Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Murfreesboro, Tennessee
| | - Benjamin K. Poulose
- Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Michael D. Holzman
- Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
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