Palliative Care in Surgery: Defining the Research Priorities

Stage-Dependent Levels of Brain-Derived Neurotrophic Factor and Matrix Metalloproteinase 9 in the Prognosis of Colorectal Cancer

PURPOSE

The development of sensitive and non-invasive biomarkers for the early detection of CRC and determination of their role in the individual stages of CRC.

METHODS

MMP-9 expression in serum and tissue, and BDNF expression in plasma were detected using the ELISA method. MMP-9 and BDNF in the tissue were also determined by immunohistochemical staining.

RESULTS

To assess the balance between changes in survival and tumor progression, we compared BDNF/MMP-9 ratios in tissues of living and deceased individuals. The tissue BDNF/MMP-9 ratio (evaluated immunohistochemically) decreased significantly with the progression of the disease in living patients. The BDNF/MMP-9 ratio was statistically significantly reduced in stages II and III compared to the benign group. However, in deceased individuals, the ratio showed an opposite tendency.

CONCLUSION

The determination of the tissue BDNF/MMP9 ratio can be used as a prognostic biomarker of CRC.

Was It Worth It? Critical Evaluation of a Novel Outcomes Measure in Oncologic Palliative Surgery

BACKGROUND

Patient selection for palliative surgery is complex, and appropriate outcomes measures are incompletely defined. We explored the usefulness of a specific outcomes measure "was it worth it" in patients after palliative-intent operations for advanced malignancy.

STUDY DESIGN

A retrospective review of a comprehensive longitudinal palliative surgery database was performed at an academic tertiary care center. All patients who underwent palliative-intent operation for advanced cancer from 2003 to 2022 were included. Patient satisfaction ("was it worth it") was reported within 30 days of operation after palliative-intent surgery.

RESULTS

A total of 180 patients were identified, and 81.7% self-reported that their palliative surgery was "worth it." Patients who reported that their surgery was "not worth it" were significantly older and were more likely to have recurrent symptoms and to need reoperation. There was no significant difference in overall, recurrence-free, and reoperation-free survival for patients when comparing "worth it" with "not worth it." Initial symptom improvement was not significantly different between groups. Age older than 65 years (hazard ratio 0.25, 95% CI 0.07 to 0.80, p = 0.03), family engagement (hazard ratio 6.71, 95% CI 1.49 to 31.8, p = 0.01), and need for reoperation (hazard ratio 0.042, 95% CI 0.01 to 0.16, p < 0.0001) were all independently associated with patients reporting that their operation was "worth it."

CONCLUSIONS

Here we demonstrate that simply asking a patient "was it worth it" after a palliative-intent operation identifies a distinct cohort of patients that traditional outcomes measures fail to distinguish. Family engagement and durability of an intervention are critical factors in determining patient satisfaction after palliative intervention. These data highlight the need for highly individualized care with special attention paid to patients self-reporting that their operation was "not worth it."

Patient Perspectives on Perioperative Supportive Care Needs Surrounding Major Abdominal Operations for Cancer

PURPOSE

The development of supportive care interventions delivered by surgeons for their patients is a major research priority. Designing such interventions requires understanding patients' supportive care needs for major operations. This qualitative analysis aimed to determine the supportive care needs of patients undergoing major abdominal operations for cancer.

METHODS

We conducted semi-structured interviews with a subset of participants in a randomized, controlled trial of a specialist palliative care intervention for patients undergoing abdominal resections for cancer (NCT03436290). Sampling was designed to balance the population by sex, age (older vs. younger than 65 years), and treatment group assignment (intervention vs. control). The interview guide was developed to elicit patient perceptions of their supportive care needs from diagnosis to the time of interview, about 1 month after their operation. Two coders used an iterative, inductive method to identify recurring themes in the interviews.

RESULTS

Analysis of interview transcripts revealed five primary themes: preoperative preparation, postoperative recovery, expectation setting, coordination of care, and provider characteristics. Cutting across these themes were patients' focus on time, timeliness, and timelines, as well as their desires for information both from their surgeons and other sources. Surgeons inspired trust through the quality of their communication and their responsiveness to questions. Patients were sensitive to perceived deviations from their expectations and spoke of the need to develop patience and to expect the unexpected.

CONCLUSIONS

Patients expressed several needs for supportive care that surgical teams can potentially address to improve the experience of major cancer surgery.

Shared Decision Making in the Geriatric Surgery Verification Program: Assessing Baseline Performance

CONTEXT

As part of the launch of the Geriatric Surgery Verification program in 2019, the American College of Surgeons issued care standards for older patients, including requirements for preoperative documentation of patients' goals. Hospital performance on these standards prior to the Geriatric Surgery Verification program is unknown.

OBJECTIVES

To assess baseline performance of the Geriatric Surgery Verification (GSV) standard for documentation of preoperative goals for older patients, and to determine factors associated with standard adherence.

METHODS

Using natural language processing, this study examines the electronic health records of patients aged 65 years or older who underwent coronary artery bypass grafts (CABG) or colectomies in 2017 or 2018 at three hospitals. The primary outcome was adherence to at least one of the three components of GSV Standard 5.1, which requires preoperative documentation of overall health goals, treatment goals, and patient-centered outcomes.

RESULTS

A total of 2630 operations and 2563 patients were included. At least one component of the standard was met in 307 (11.7%) operations and all three components were met in 5 (0.2%). Higher likelihood of meeting the standard was demonstrated for patients who were female (odds ratio [OR] 1.30; 95% CI 1.00-1.68), undergoing colectomy (OR 2.82; 95% CI 2.15-3.72), or with more comorbidities (Charlson scores >3 [OR 1.55; 95% CI 1.14-2.09]).

CONCLUSION

Before GSV program implementation, clinicians for two major operations almost never met the GSV standard for preoperative discussion of patient goals. Interdisciplinary teams will need to adjust clinical practice to meet best-practice communication standards for older patients.

Surgical Intervention in Patients Receiving Pediatric Palliative Care Services

BACKGROUND AND OBJECTIVES

Many patients receiving pediatric palliative care (PPC) present with surgically treatable problems. The role of surgery in the care of these patients, however, has not yet been defined. We conducted a cohort study of children receiving PPC to assess the incidence, type, and likely purpose of surgical interventions performed after the initiation of PPC.

METHODS

We performed a cohort analysis of surgical interventions performed on children enrolled in an ongoing, multicenter, prospective cohort study. Patients aged <30 years receiving PPC services were eligible for inclusion in the study. Analyses included descriptive and comparative statistics, as well as logistic regression models.

RESULTS

After initiation of PPC, 81.1% (n = 488) of patients had undergone at least 1 surgical intervention (range, 1-71) with a median of 4 interventions (interquartile range, 1-9). The most frequent surgical interventions were feeding tubes, endoscopic biopsy, tracheostomy, bone marrow biopsy, tunneled catheters, bronchoscopy, and chest tube placement, followed by sternum closure, abdominal closure, atrial and ventricular septal defect repairs, and heart transplantation. Children who underwent surgical interventions were statistically less likely to die while receiving PPC (29% vs 40%, P < .03).

CONCLUSIONS

Most children receiving PPC services undergo at least 1 surgical intervention, and many undergo numerous interventions. Undergoing intervention is not futile because surgical intervention is associated with longer survival. Various patient populations that are more likely, as well as less likely, to undergo surgical intervention warrant specific focus.

Acute mesenteric ischemia: updated guidelines of the World Society of Emergency Surgery

Acute mesenteric ischemia (AMI) is a group of diseases characterized by an interruption of the blood supply to varying portions of the intestine, leading to ischemia and secondary inflammatory changes. If untreated, this process may progress to life-threatening intestinal necrosis. The incidence is low, estimated at 0.09-0.2% of all acute surgical admissions, but increases with age. Although the entity is an uncommon cause of abdominal pain, diligence is required because if untreated, mortality remains in the range of 50%. Early diagnosis and timely surgical intervention are the cornerstones of modern treatment to reduce the high mortality associated with this entity. The advent of endovascular approaches in parallel with modern imaging techniques is evolving and provides new treatment options. Lastly, a focused multidisciplinary approach based on early diagnosis and individualized treatment is essential. Thus, we believe that updated guidelines from World Society of Emergency Surgery are warranted, in order to provide the most recent and practical recommendations for diagnosis and treatment of AMI.

Failure and Rescue in Surgery-Surgical Covenant, Palliative Care, and Reimagining Quality

This Viewpoint discusses the pitfalls of failure-to-rescue metrics and importance of palliative care within surgical care.

Characteristics and Procedures Among Adults Discharged to Hospice After Gastrointestinal Tract Surgery in California

IMPORTANCE

Hospice care is associated with improved quality of life and goal-concordant care. Limited data suggest that provision of hospice services after surgery is suboptimal; however, literature in this domain is in its nascency, leaving gaps in our understanding of patients who enroll in hospice after surgery.

OBJECTIVE

To characterize the transition to hospice after gastrointestinal tract surgery and identify areas that warrant further attention and intervention.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cohort study included patients discharged to hospice after a surgical hospitalization for a digestive disorder in California-licensed hospitals between January 1, 2015, and December 31, 2019. Data were analyzed from August 1 to November 30, 2021.

EXPOSURES

Patient age, race and ethnicity, principal language, payer, and Distressed Community Index (DCI).

MAIN OUTCOMES AND MEASURES

Admission type and most common diagnoses and procedures for surgical hospitalizations that resulted in discharge to hospice, annual hospitalization trend for 3 years preceding hospice enrollment, and most common diagnoses for patients who were readmitted after hospice enrollment were summarized. Age, race and ethnicity, principal language, payer, and DCI were compared between patients who were readmitted after hospice enrollment and those who were not.

RESULTS

Of 2688 patients with surgical hospitalizations resulting in discharge to hospice (mean [SD] age, 73.2 [14.7] years; 1459 women [54.3%]), 2389 (88.9%) had urgent or emergent discharges. The most common diagnoses were cancer (primary and metastatic; 1541 [57.3%]) and bowel obstruction (563 [20.9%]). The most common procedures were bowel resection, fecal diversion, inferior vena cava filter, gastric bypass, and paracentesis. In the 3 years preceding hospice enrollment, this cohort had a mean (SD) of 2.21 (2.77) hospitalizations per patient (1537 of 5953 surgical [25.8%]). Of these, 3594 of 5953 total (60.4%) and 840 of 1537 surgical (54.7%) hospitalizations were within 1 year of hospice enrollment. Three hundred and sixty-eight patients (13.7%) were readmitted after hospice enrollment, with infection being the most common readmission diagnosis. Readmitted patients were more likely to be younger (mean [SD] age, 69.7 [16.4] vs 73.8 [14.3] years; P < .001), to speak a principal language other than English (62 of 368 [16.8%] vs 292 of 2320 [12.6%]; P = .02), to be insured through Medicaid (70 of 368 [19.0%] vs 223 of 2320 [9.6%]; P < .001), and to be from a community with higher DCI (198 of 360 [55.0%] vs 1117 of 2269 [49.2%]; P = .04) and were less likely to be White (195 of 368 [53.0%] vs 1479 of 2320 [63.8%]; P < .001).

CONCLUSIONS AND RELEVANCE

These findings suggest multiple opportunities for advance care planning in this surgical cohort, with a particular focus on emergent care. Further study is needed to understand the reasons for rehospitalization after hospice discharge and identify ways to improve communication and decision-making support for patients who choose to enroll in hospice care. Given the frequent antecedent interactions with the health care system among this population, longitudinal and tailored approaches may be beneficial to promote equitable end-of-life care; however, further research is needed to clarify barriers and understand differing patient needs.

Palliative Care Consultation is Associated with Decreased Rates of In-Hospital Mortality Among Patients Undergoing Major Amputation

OBJECTIVE

Despite advancements in medical care and surgical techniques, major amputation continues to be associated with risks for morbidity and mortality. Palliative care programs may help alleviate symptoms and align patients' goals and the care they receive with their treatment plan. Access to specialty Palliative medicine among vascular surgery patients is limited . Here, we aim to describe utilization and impact of formal palliative care consultation for patients receiving major amputations.

METHODS

This is a retrospective, secondary data analysis project examining the records of patients who received major amputations by the vascular surgery team between 2016 and 2021. Demographics, operative, and postoperative outcomes were recorded. The primary outcome variable was palliative care consultation during index admission (the admission in which the patient received their first major amputation). Secondary outcomes were in-hospital mortality as well as code status at time of death, if death occurred during the index admission, location of death, and discharge destination RESULTS: The cohort comprised of 292 patients (39% female, 53% Black, mean age 63) who received a lower extremity major amputation. Most patients (65%) underwent amputation for limb ischemia. One-year mortality after first major amputation was 29%. Average length of stay was 20 days. Thirty-five (12%) patients received a palliative care consultation during the hospitalization in which they received their first major amputation. On multivariable analysis, patients were more likely to receive a palliative care consult during their index admission if they had undergone a through knee amputation (OR = 2.89, p = 0.039) or acute limb ischemia (OR = 4.25, p = 0.005). A formal palliative care consult was associated with lower likelihood of in-hospital death and increased likelihood of discharge to hospice (OR = 0.248, p = 0.0167, OR1.283, p < 0.001).There were not statistically significant differences in the code status of patients who received a palliative care consultation.

CONCLUSIONS

In a large academic medical center, palliative medicine consultation was associated with lower in-hospital mortality among patients with advanced vascular disease and major limb amputation. These data will hopefully stimulate much needed prospective research to develop and test tools to identify patients in need and derive evidence about the impact of palliative care services.

Improving Serious Illness Care for Surgical Patients: Quality Indicators for Surgical Palliative Care

OBJECTIVE

Develop quality indicators that measure access to and the quality of primary PC delivered to seriously ill surgical patients.

SUMMARY OF BACKGROUND DATA

PC for seriously ill surgical patients, including aligning treatments with patients' goals and managing symptoms, is associated with improved patient-oriented outcomes and decreased healthcare utilization. However, efforts to integrate PC alongside restorative surgical care are limited by a lack of surgical quality indicators to evaluate primary PC delivery.

METHODS

We developed a set of 27 preliminary indicators that measured palliative processes of care across the surgical episode, including goals of care, decision-making, symptom assessment, and issues related to palliative surgery. Then using the RAND-UCLA Appropriateness method, a 12-member expert advisory panel rated the validity (primary outcome) and feasibility of each indicator twice: (1) remotely and (2) after an in-person moderated discussion.

RESULTS

After 2 rounds of rating, 24 indicators were rated as valid, covering the preoperative evaluation (9 indicators), immediate preoperative readiness (2 indicators), intraoperative (1 indicator), postoperative (8 indicators), and end of life (4 indicators) phases of surgical care.

CONCLUSIONS

This set of quality indicators provides a comprehensive set of process measures that possess the potential to measure high quality PC for seriously ill surgical patients throughout the surgical episode.

Palliative Care Interventions for Peripheral Artery Disease: A Systematic Review and Narrative Synthesis

Background: Peripheral artery disease (PAD) encompasses conditions with poor outcome and severe suffering, both mentally and physically, yet utilization and research into palliative care interventions remain sparse. Objective: The purpose of this study is to identify existing evidence on palliative care intervention for chronic limb threatening ischaemia (CLTI) and abdominal aortic aneurysm (AAA). Design: We conducted a PROSPERO-registered systematic review of studies published between 1991 and 2020 in which people with PAD received palliative care interventions and at least one patient outcome was recorded. For the purpose of this study, a palliative care intervention was defined as one which aims primarily to reduce negative impact of PAD on patients' and/or caregivers' physical, emotional, psychological, social, or spiritual condition. Results: A total of 8 studies involving 87,024 patients met the inclusion criteria (4 cohort studies and 4 cross-sectional studies). Methodological quality ranged from low to moderate. The small number of studies and study heterogeneity precluded meta-analysis. Regarding our primary outcomes, only two articles recorded patient-reported outcomes. Five articles found an association between palliative care and reduction in health care utilization, a secondary outcome of the study. Most of the studies reported that palliative care was likely underused. Only two of the studies included non-hospital patients. Conclusion: Despite high mortality and morbidity associated with PAD, evidence of the effectiveness of palliative care in this group of patients is lacking. There are only a handful of articles on palliative care for people with PAD, and the majority are small, methodologically flawed and lack meaningful patient-reported outcomes. High-quality research of palliative care interventions in patients with PAD is urgently needed to better understand the impact of palliative care on quality of end of life and to develop and evaluate service-level interventions.

Quality Indicators in Surgical Palliative Care: A Systematic Review

CONTEXT

Defining high quality palliative care in seriously ill surgical patients is essential to provide patient-centered surgical care. Quality indicators specifically for seriously ill surgical patients are necessary in order to integrate palliative care into existing surgical quality improvement programs.

OBJECTIVES

To identify existing quality indicators that measure palliative care delivery in seriously ill surgical patients, characterize their development, and assess their methodological quality.

METHODS

A PRISMA-guided systematic review included studies that reported on the development process and characteristics of palliative care quality indicators and guidelines in adult surgical patients. Relevant measures were categorized into the previously defined National Consensus Project domains of palliative care and the Donabedian quality framework, and assessed for methodological quality.

RESULTS

There were 263 unique measures identified from 26 studies, of which 70% were process measures. Indicators addressing Care of the Patient Near the End of Life (31.5%) and Physical Aspects of Care (20.8%) were the most common. Indicators addressing Spiritual (2.6%) and Cultural Aspects of Care (1.2%) were the least common. Methodological quality varied widely across studies. Although most studies defined a purpose for the indicators and used scientific evidence, many studies lacked input from target populations and few had discussed the practical application of indicators.

CONCLUSION

This review was a key step that informed efforts to develop quality indicators for seriously ill surgical patients. Few indicators addressed non-physical aspects of suffering and no indicators were identified addressing palliative surgery. Future attention is needed toward the development and practical application of palliative care quality indicators in surgical patients.

Preoperative Frailty Status and Intensity of End-of-Life Care Among Older Adults After Emergency Surgery

CONTEXT

Emergency general surgery (EGS) is common and highly morbid for older adults, particularly for those who are frail. However, there are little data on the quality of end-of-life care (EOLC) for this population.

OBJECTIVES

We sought to examine the association of frailty with intensity of EOLC for older adults with and without frailty who undergo EGS but die within one year.

METHODS

This retrospective cohort study included 100% Medicare fee-for-service beneficiaries, ≥66 years, who underwent one of five EGS procedures with the highest mortality (partial colectomy, small bowel resection, peptic ulcer disease repair, adhesiolysis, or laparotomy) between 2008 and 2014 and died within one year. A validated claims-based frailty index (CFI) identified patients who were not frail (CFI < 0.15), prefrail (0.15 ≤ CFI < 0.25), mildly frail (0.25 ≤ CFI < 0.35), and moderately to severe frail (CFI ≥ 0.35). Multivariable adjusted logistic or Poisson regression compared post-discharge and EOL healthcare utilization.

RESULTS

Among 138,916 older EGS adults who died within one year, 32.2% were not frail, 31.7% were prefrail, 29.8% had mild frailty and 6.3% had moderate-to-severe frailty. Decedents with any degree of frailty experienced high-intensity EOLC (P < 0.01), low rates of hospice use (P < 0.01), and fewer days at home. Of those who survived the index hospitalization but died within one year, moderate-to-severely frail decedents had the highest odds of visiting an emergency department (odds ratio [OR] = 1.19, CI = 1.13-1.27), rehospitalization (OR = 1.23, CI = 1.16-1.31), or an intensive care unit admission (OR = 1.22, CI = 1.13-1.30) in the last 30 days of life compared to nonfrail decedents.

CONCLUSION

While all older patients undergoing EGS have poor end-of-life outcomes, frail EGS patients receive the highest intensity EOLC and represent a vulnerable population for whom targeted interventions could limit burdensome treatment.

Perioperative cardiovascular outcomes among older adults undergoing in-hospital noncardiac surgery

BACKGROUND

Older adults undergoing noncardiac surgery have a high risk of major adverse cardiovascular events (MACE). This study aims to estimate the magnitude of increased perioperative risk, and examine national trends in perioperative MACE following in-hospital noncardiac surgery in older adults compared to middle-aged adults.

DESIGN

Time-series analysis of retrospective longitudinal data.

SETTING

The United States Agency for Healthcare Research and Quality National Inpatient Sample (NIS).

PARTICIPANTS

Hospitalizations for major noncardiac surgery among adults age ≥45 years between January 2004 and December 2014.

MEASUREMENTS

Inpatient perioperative MACE was defined as a composite of in-hospital death, myocardial infarction (MI), and ischemic stroke. In hospital death was determined from the NIS discharge disposition. MI and ischemic stroke were defined by International Classification of Diseases, Ninth Revision codes.

RESULTS

Of an estimated 55,349,978 surgical hospitalizations, 26,423,039 (47.7%) were for adults age 45-64, 14,231,386 (25.7%) age 65-74, 10,621,029 (19.2%) age 75-84 years, and 4,074,523 (7.4%) age ≥85 years. MACE occurred in 1,601,022 surgical hospitalizations (2.9%). Adults 65-74 (2.8%; aOR 1.16, 95% CI 1.14-1.17), 75-84 years (4.5%; aOR 1.30, 95% CI 1.28-1.32), and ≥85 years (6.9%; aOR 1.55, 95% CI 1.52-1.57) had greater risk of MACE than those 45-64 years (1.7%). From 2004 to 2014, MACE declined among adults 65-74 (3.1-2.5%, p < 0.001), 75-85 years (4.9-3.9%, p < 0.001), and ≥85 years (7.7-6.1%, p < 0.001), but was unchanged for adults age 45-64. Declines in MACE were driven by decreased MI and mortality despite increased stroke.

CONCLUSION

Older adults accounted for half of hospitalizations, but experienced the majority of MACE. Older adults had greater adjusted odds of MACE than younger individuals. The proportion of perioperative MACE declined over time, despite increases in ischemic stroke. These data highlight risks of noncardiac surgery in older adults that warrant increased attention to improve perioperative outcomes.

Palliative Care for Extracorporeal Life Support: Insights From the National Inpatient Sample

BACKGROUND

Providing temporary cardiopulmonary support, extracorporeal membrane oxygenation (ECMO) carries a high risk of mortality. Palliative care (PC) may facilitate a patient-centered approach to end-of-life care in order to aid symptom management and provide psychosocial support to families. The present study aimed to identify factors associated with PC consultation and its impact on resource utilization in ECMO.

STUDY DESIGN

All adults placed on ECMO at a PC capable center were identified in the 2006-2017 National Inpatient Sample. Indications for ECMO were identified using diagnosis codes and classified into postcardiotomy syndrome, respiratory failure, cardiogenic shock, mixed cardiopulmonary failure, and transplant related.

RESULTS

Of 41 122 patients undergoing ECMO, 20 514 (49.9%) died in the same hospitalization. Of those, 3951 (19.3%) received a PC consult. Use of PC consults increased significantly from 5.5% in 2006 to 22.8% in 2017 (nptrend<.001). After multivariable risk adjustment, PC consults did not affect costs (β: -$7341, 95% CI: -22 572 to +7888) or duration of hospitalizations (β: -.37 days, 95% CI: -2.76 to +2.02).

CONCLUSION

Utilization of PC does not appear to negatively influence resource utilization among non-survivors of ECMO. Increased adaptation of PC in ECMO may improve end-of-life care, a factor that deserves future study.

Chemotherapy After Diagnosis of Malignant Bowel Obstruction is Associated with Superior Survival for Medicare Patients with Advanced Malignancy

Background

Although malignant bowel obstruction (MBO) often is a terminal event, systemic therapies are advocated for select patients to extend survival. This study aimed to evaluate factors associated with receipt of chemotherapy after MBO and to determine whether chemotherapy after MBO is associated with survival.

Methods

This retrospective cohort study investigated patients 65 years of age or older with metastatic gastrointestinal, gynecologic, or genitourinary cancers who were hospitalized with MBO from 2008 to 2012 using the Surveillance, Epidemiology, and End Results (SEER)-Medicare database. Fine and Gray models were used to identify factors associated with receipt of chemotherapy accounting for the competing risk of death. Cox models identified factors associated with overall survival.

Results

Of the 2983 MBO patients, 39% (n = 1169) were treated with chemotherapy after MBO. No differences in receipt of chemotherapy between the surgical and medical patients were found in the univariable analysis (subdistribution hazard ratio [SHR], 0.96; 95% confidence interval [CI], 0.86–1.07; p = 0.47) or multivariable analysis (SHR, 1.12; 95% CI, 1.00–1.26; p = 0.06). Older age, African American race, medical comorbidities, non-colorectal and non-ovarian cancer diagnoses, sepsis, ascites, and intensive care unit stays were inversely associated with receipt of chemotherapy after MBO (p < 0.05). Chemotherapy with surgery was associated with longer survival than surgery (adjusted hazard ratio [aHR], 2.97; 95% CI, 2.65–3.34; p < 0.01) or medical management without chemotherapy (aHR, 4.56; 95% CI, 4.04–5.14; p < 0.01). Subgroup analyses of biologically diverse cancers (colorectal, pancreatic, and ovarian) showed similar results, with greater survival related to chemotherapy (p < 0.05).

Conclusions

Chemotherapy plays an integral role in maximizing oncologic outcome for select patients with MBO. The data from this study are critical to optimizing multimodality care for these complex patients.

Supplementary Information

The online version contains supplementary material available at 10.1245/s10434-021-09831-0.

High-intensity end-of-life care among Medicare beneficiaries with bladder cancer

OBJECTIVES

To quantify the proportion of patients receiving high-intensity end-of-life care, identify associated risk factors, and assess how receipt of palliative care impact end-of-life care; as the delivery of such care, and how it relates to palliative care, has not been reported in bladder cancer SUBJECTS AND METHODS: We conducted a retrospective cohort study of patients with bladder cancer who died within 1 year of diagnosis using Surveillance, Epidemiology, and End Results linked Medicare data. The primary outcome was a composite measure of high-intensity end-of-life care (>1 hospital admission, >1 ED visit, or ≥1 ICU admission within the last month of life; receipt of chemotherapy within the last 2 weeks of life; or acute care in-hospital death). Secondary outcomes included the use of such care over time and any association with the use of palliative care. A generalized linear mixed model assessed for independent determinants.

RESULTS

Overall, 45% of patients received high-intensity end-of-life care. This proportion decreased over time. Patients receiving high-intensity care had higher rates of comorbidities, advanced bladder cancer, and nonbladder cancer cause of death. These patients more often received palliative care but, compared to those not receiving high-intensity care, this occurred farther removed from bladder cancer diagnosis and closer to death.

CONCLUSIONS

Nearly half of Medicare beneficiaries with bladder cancer who die within 1 year of diagnosis receive high-intensity care at the end of life. Palliative care was seldom used and only very near the time of death.

Interpretive description: A flexible qualitative methodology for medical education research

BACKGROUND

Qualitative research approaches are increasingly integrated into medical education research to answer relevant questions that quantitative methodologies cannot accommodate. However, researchers have found that traditional qualitative methodological approaches reflect the foundations and objectives of disciplines whose aims are recognizably different from the medical education domain of inquiry (Thorne, 2016, Interpretive description. New York, NY: Routledge). Interpretive description (ID), a widely used qualitative research method within nursing, offers an accessible and theoretically flexible approach to analysing qualitative data within medical education research. ID is an appropriate methodological alternative for medical education research, as it can address complex experiential questions while producing practical outcomes. It allows for the advancement of knowledge surrounding educational experience without sacrificing methodological integrity that long-established qualitative approaches provide.

PURPOSE

In this paper, we present interpretive description as a useful research methodology for qualitative approaches within medical education. We then provide a toolkit for medical education researchers interested in incorporating interpretive description into their study design. We propose a coherent set of strategies for identifying analytical frameworks, sampling, data collection, analysis, rigour and the limitations of ID for medical education research. We conclude by advocating for the interpretive description approach as a viable and flexible methodology for medical education research.

Socially conscious surgical care must prioritize older adults

TOPIC

A commentary on social justice issues in geriatric surgery FUTURE DIRECTIONS: Recognizing social determinants of health and racism as a contributing mechanism for inequities in the care of older adult surgical patients KNOWLEDGE GAPS: Identifying the role of the surgeon in achieving health equity for older adults PURPOSE: Increase recognition of opportunities for antiracist care in everyday surgical practice, including shared decision-making and palliative care STATE OF THE ART: Patient treatment goals documented in their own words. Social needs screening in older adult surgical patients TECHNOLOGY GAPS: Platform for clear documentation of surgical treatments offered and patient treatment goals, social determinants of health and social risk factors, and collaborative treatment and discharge plans discussed across multidisciplinary, elder-friendly teams.

Improving quality in colon and rectal surgery through palliative care

Palliative care is a medical discipline that emphasizes quality of life and can be provided in parallel with recovery-directed treatments in colon and rectal surgery. Palliative care is receiving increasing attention and investigation for its potential to improve quality and outcomes for a wide spectrum of patients by benefiting symptom management, supporting complex health care decision making and facilitating care transitions. Primary palliative care refers to the application of palliative care principles by clinicians of all disciplines whereas specialty palliative care is a multidisciplinary approach and includes a clinician with advanced training and experience.

Improving the value of palliative surgery by optimizing patient selection: The role of long-term survival on high impact palliative intent operations

BACKGROUND

In order to better characterize outcomes of palliative surgery (PS), we evaluated patients that experienced top quartile survival to elucidate predictors of high impact PS.

METHODS

All PS performed on advanced cancer patients from 2003 to 2017 were identified from a PS database.

RESULTS

167 patients were identified. Multivariate analysis demonstrated the ability to rise from a chair was independently associated with top quartile survival (HR 7.61, 95% CI 2.12-48.82, p=0.008) as was the need for re-operation (HR 2.81, 95% CI 1.26-6.30, p=0.0012). Patients who were able to rise from a chair had significantly prolonged overall survival (320 vs 87 days, p < 0.001).

CONCLUSIONS

Although not the primary goal, long-term survival can be achieved following PS and is associated with re-operation and the ability to rise from a chair. These patients experience the benefits of PS for a longer period of time, which in turn maximizes value and positive impact.

SUMMARY

Long-term survival and symptom control can be achieved in highly selected advanced cancer patients following palliative surgery. The ability of the patient to independently rise from a chair and the provider to offer a re-operation when indicated are associated with long-term survival following a palliative operation.

Defining Serious Illness Among Adult Surgical Patients

CONTEXT

Palliative care (PC) for seriously ill surgical patients, including aligning treatments with patients' goals and managing symptoms, is associated with improved patient-oriented outcomes and decreased health care utilization. However, efforts to integrate PC alongside restorative surgical care are limited by the lack of a consensus definition for serious illness in the perioperative context.

OBJECTIVES

The objectives of this study were to develop a serious illness definition for surgical patients and identify a denominator for quality measurement efforts.

METHODS

We developed a preliminary definition including a set of criteria for 11 conditions and health states. Using the RAND-UCLA Appropriateness Method, a 12-member expert advisory panel rated the criteria for each condition and health state twice, once after an in-person moderated discussion, for validity (primary outcome) and feasibility of measurement.

RESULTS

All panelists completed both rounds of rating. All 11 conditions and health states defining serious illness for surgical patients were rated as valid. During the in-person discussion, panelists refined and narrowed criteria for two conditions (vulnerable elder, heart failure). The final definition included the following 11 conditions and health states: vulnerable elder, heart failure, advanced cancer, oxygen-dependent pulmonary disease, cirrhosis, end-stage renal disease, dementia, critical trauma, frailty, nursing home residency, and American Society of Anesthesiology Risk Score IV-V.

CONCLUSION

We identified a consensus definition for serious illness in surgery. Opportunities remain in measuring the prevalence, identifying health trajectories, and developing screening criteria to integrate PC with restorative surgical care.

Integrating Advance Care Planning Videos into Surgical Oncologic Care: A Randomized Clinical Trial

Background: Preoperative advance care planning (ACP) may benefit patients undergoing major surgery. Objective: To evaluate feasibility, safety, and early effectiveness of video-based ACP in a surgical population. Design: Randomized controlled trial with two study arms. Setting: Single, academic, inner-city tertiary care hospital. Subjects: Patients undergoing major cancer surgery were recruited from nine surgical clinics. Of 106 consecutive potential participants, 103 were eligible and 92 enrolled. Interventions: In the intervention arm, patients viewed an ACP video developed by patients, surgeons, palliative care clinicians, and other stakeholders. In the control arm, patients viewed an informational video about the hospital's surgical program. Measurements: Primary Outcomes-ACP content and patient-centeredness in patient-surgeon preoperative conversation. Secondary outcomes-patient Hospital Anxiety and Depression Scale (HADS) score; patient goals of care; patient and surgeon satisfaction; video helpfulness; and medical decision maker designation. Results: Ninety-two patients (target enrollment: 90) were enrolled. The ACP video was successfully integrated with no harm noted. Patient-centeredness was unchanged (incidence rate ratio [IRR] = 1.06, confidence interval [0.87-1.3], p = 0.545), although there were more ACP discussions in the intervention arm (23% intervention vs. 10% control, p = 0.18). While slightly underpowered, study results did not signal that further enrollment would have yielded statistical significance. There were no differences in secondary outcomes other than the intervention video was more helpful (p = 0.007). Conclusions: The ACP video was successfully integrated into surgical care without harm and was thought to be helpful, although video content did not significantly change the ACP content or patient-surgeon communication. Future studies could increase the ACP dose through modifying video content and/or who presents ACP. Trial Registration: clinicaltrials.gov Identifier NCT02489799.

High Burden of Palliative Care Needs of Older Adults During Emergency Major Abdominal Surgery

OBJECTIVES

To quantify preoperative illness burden in older adults undergoing emergency major abdominal surgery (EMAS), to examine the association between illness burden and postoperative outcomes, and to describe end-of-life care in the year after discharge.

DESIGN

Retrospective study using data from Health and Retirement Study interviews linked to Medicare claims (2000-2012).

SETTING

National population-based dataset.

PARTICIPANTS

Medicare beneficiaries who underwent EMAS.

MEASUREMENTS

High illness burden, defined as ≥2 of the following vulnerabilities: functional dependence, dementia, use of helpers, multimorbidity, poor prognosis, high healthcare utilization. In-hospital outcomes were complications and mortality. Postdischarge outcomes included emergency department (ED) visits, hospitalization, intensive care unit (ICU) stay, and 365-day mortality. For individuals discharged alive who died within 365 days of surgery, outcomes included hospice use, hospitalization, ICU use, and ED use in the last 30 days of life. Multivariable regression was used to determine the association between illness burden and outcomes.

RESULTS

Of 411 participants, 57% had high illness burden. More individuals with high illness burden had complications (45% vs 28% p=0.00) and in-hospital death (20% vs 9%, p=0.00) than those without. After discharge (n=349), individuals with high illness burden experienced more ED visits (57% vs 46%, P=.04) and were more likely to die (35% vs 13%, p=0.00). Of those who died after discharge (n=86), 75% had high illness burden, median survival was 67 days (range 21-141 days), 48% enrolled in hospice, 32% died in the hospital, 23% were in the ICU in the last 30 days of life and 37% had an ED visit in the last 30 days of life.

CONCLUSION

Most older adults undergoing EMAS have preexisting high illness burden and experience high mortality and healthcare use in the year after surgery, particularly near the end of life. Concurrent surgical and palliative care may improve quality of life and end-of-life care in these people. J Am Geriatr Soc 66:2072-2078, 2018.

The ethics of interventional procedures for patients too ill for surgery

PURPOSE OF REVIEW

Minimally invasive interventional procedures are increasingly popular options for patients who are high-risk candidates for open surgical procedures. It is unclear how to proceed in the rare circumstance of a complication during an interventional procedure, where addressing the complication would require exposing the patient to the full risk that was being avoided with the minimally invasive technique. This review provides recommendations on how to approach this paradoxical scenario.

RECENT FINDINGS

Risk stratification, communication frameworks, and advanced care planning can facilitate shared decision-making between physicians and patients. Risk stratification may include mortality predictive models, disability and frailty scores, and patient-centered outcome studies. In the event of procedural complication or failure, aggressive surgical treatment or limited repair should be guided by patient preferences to best ensure value concordant care.

SUMMARY

Interventional procedures, and emergent open surgery, should be offered as long as patients are fully informed about the benefits and risks, including the implications of potential life-sustaining treatments, and whether their respective goals of treatment are consistent with the intervention. Implementing this framework will require a cultural shift in physician attitudes to recognize that in some cases, nonintervention or less aggressive treatment may be a reasonable alternative to surgical intervention.

Training Surgeons and Anesthesiologists to Facilitate End-of-Life Conversations With Patients and Families: A Systematic Review of Existing Educational Models

OBJECTIVE

Despite caring for patients near the end-of-life (EOL), surgeons and anesthesiologists report low confidence in their ability to facilitate EOL conversations. This discrepancy exists despite competency requirements and professional medical society recommendations. The objective of this systematic review is to identify articles describing EOL communication training available to surgeons and anesthesiologists, and to assess their methodological rigor to inform future curricular design and evaluation.

METHODS

This PRISMA-concordant systematic review identified English-language articles from PubMed, EMBASE, and manual review. Eligible articles included viewpoint pieces, and observational, qualitative, or case studies that featured an educational intervention for surgeons or anesthesiologists on EOL communication skills. Data on the study objective, setting, design, participants, intervention, and results were extracted and analyzed. The Newcastle-Ottawa Scale was used to assess methodological quality.

RESULTS

Database and manual search returned 2710 articles. A total of 2268 studies were screened by title and abstract, 46 reviewed in full-text, and 16 included in the final analysis. Fifteen studies were conducted exclusively in academic hospitals. Two studies included attending surgeons as participants; all others featured residents, fellows, or a mix thereof. Fifteen studies used simulated role-playing to teach and assess EOL communication skills. Measured outcomes included knowledge, attitudes, confidence, self-rated or observer-rated communication skills, and curriculum feedback; significance of results varied widely. Most studies lacked adequate methodological quality and appropriate control groups to be confident about the significance and applicability of their results.

CONCLUSIONS

There are few quality studies evaluating EOL communication training for surgeons and anesthesiologists. These programs frequently use role-playing to teach and assess EOL communication skills. More studies are needed to evaluate the effect of these interventions on patient outcomes. However, evaluating the effectiveness of these initiatives poses methodological challenges.

Palliative Care Utilization among Patients Admitted for Gastrointestinal and Thoracic Cancers

BACKGROUND

Although a growing body of literature recommends the early initiation of palliative care (PC), the use of PC remains variable.

OBJECTIVE

The current study sought to describe the use of PC and to identify factors associated with the use of inpatient PC.

DESIGN

Retrospective, cross-sectional analysis of data from the National Inpatient Sample.

SETTING AND SUBJECTS

Patients admitted with a primary diagnosis of gastrointestinal and/or thoracic cancer from 2012 to 2013.

MEASUREMENTS

In-hospital length of stay (LOS), morbidity, mortality, and total charges.

RESULTS

A total of 282,899 patients were identified who met inclusion criteria of whom, 24,100 (8.5%) patients received a PC consultation during their inpatient admission. Patients who received PC were more likely to have a longer LOS (LOS >14 days: 5.4% vs. 9.4%) and were more likely to develop a postoperative complication (28.3% vs. 45.9%, both p < 0.001). Inpatient mortality was significantly higher among patients who had received PC than those who did not (5.4% vs. 44.1%, p < 0.001). On multivariable analysis, patient age (age ≥75 years: Odds Ratio [OR] = 2.54, 95% CI: 2.33-2.78), comorbidity (CCI >6: OR = 2.60, 95% CI: 2.48-2.74), and admission to larger hospitals (reference small: OR = 1.20, 95% CI: 1.14-1.25) were associated with greater odds of receiving PC (all p < 0.05). Patients who underwent a major operation during their inpatient admission demonstrated 79% lower odds of receiving PC (OR = 0.21, 95% CI: 0.20-0.22, p < 0.001).

CONCLUSIONS

Among patients admitted for cancer, PC services were used in 8.5% of patients during their inpatient admission with surgical patients being 79% less likely to receive a PC consultation. Further research is required to delineate the barriers to the use of PC so as to promote the use of PC among high-risk patients.

Shared Decision-Making in Acute Surgical Illness: The Surgeon's Perspective

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.

Changes in professionals' beliefs following a palliative care implementation programme at a surgical department: a qualitative evaluation

BACKGROUND

One ambition regarding palliative care is that it should be more accessible to patients and families regardless of care setting. Previous studies show many difficulties and shortcomings in the care of patients with palliative care needs in acute care facilities, but also challenges regarding efforts to implement palliative care. The aim of this study is to evaluate how the implementation of palliative care, using a combination of integration and consultation strategies, can change beliefs regarding palliative care among professionals in a surgical department.

METHOD

In order to explore professionals' experiential outcome of an educational implementation strategy, a before-after qualitative design was used. The study was based on three focus group discussions. Two discussions were conducted before introducing the implementation strategy and one was conducted after. The participants consisted of five nurses and two specialist surgeons from a surgical department in Sweden. The focus group discussions revealed a variety of different attitudes and beliefs, which were analysed using qualitative systematic text condensation.

RESULTS

Beliefs regarding palliative care were identified in seven areas; the importance of palliative care, working methods in palliative care, team collaboration in palliative care, collegial support, discussions about diagnosis, symptoms at the end of life, and families of patients in palliative care. Changes in beliefs were seen in all areas except one: team collaboration in palliative care.

CONCLUSION

It is possible to change the beliefs of health care professionals in a surgical department regarding palliative care through the implementation of palliative knowledge. Beliefs were changed from an individual to a collective development where the group initiated a shared palliative working method. The changes observed were palliative care being described as more complex and participants differentiating between surgical care and palliative care.

Acute mesenteric ischemia: guidelines of the World Society of Emergency Surgery

Acute mesenteric ischemia (AMI) is typically defined as a group of diseases characterized by an interruption of the blood supply to varying portions of the small intestine, leading to ischemia and secondary inflammatory changes. If untreated, this process will eventuate in life threatening intestinal necrosis. The incidence is low, estimated at 0.09–0.2% of all acute surgical admissions. Therefore, although the entity is an uncommon cause of abdominal pain, diligence is always required because if untreated, mortality has consistently been reported in the range of 50%. Early diagnosis and timely surgical intervention are the cornerstones of modern treatment and are essential to reduce the high mortality associated with this entity. The advent of endovascular approaches in parallel with modern imaging techniques may provide new options. Thus, we believe that a current position paper from World Society of Emergency Surgery (WSES) is warranted, in order to put forth the most recent and practical recommendations for diagnosis and treatment of AMI. This review will address the concepts of AMI with the aim of focusing on specific areas where early diagnosis and management hold the strongest potential for improving outcomes in this disease process.

Some of the key points include the prompt use of CT angiography to establish the diagnosis, evaluation of the potential for revascularization to re-establish blood flow to ischemic bowel, resection of necrotic intestine, and use of damage control techniques when appropriate to allow for re-assessment of bowel viability prior to definitive anastomosis and abdominal closure.