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Clapp JT, Kruser JM, Schwarze ML, Hadler RA. Language in Bioethics: Beyond the Representational View. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2024:1-13. [PMID: 38626326 DOI: 10.1080/15265161.2024.2337394] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/18/2024]
Abstract
Though assumptions about language underlie all bioethical work, the field has rarely partaken of theories of language. This article encourages a more linguistically engaged bioethics. We describe the tacit conception of language that is frequently upheld in bioethics-what we call the representational view, which sees language essentially as a means of description. We examine how this view has routed the field's theories and interventions down certain paths. We present an alternative model of language-the pragmatic view-and explore how it expands and clarifies traditional bioethical concerns. To lend concreteness, we apply the pragmatic view to a pervasive concept in bioethics and adjacent fields: decision making. We suggest that problems of the decision-making approach to bioethical issues are grounded in adherence to the representational view. Drawing on empirical work in surgery and critical care, we show how the pragmatic view productively reframes bioethical questions about how medical treatments are pursued.
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Palmer Kelly E, Rush LJ, Melnyk HL, Eramo JL, McAlearney AS, Pawlik TM. Which factors influence the approach to shared decision-making among surgeons performing complex operations? JOURNAL OF COMMUNICATION IN HEALTHCARE 2024; 17:77-83. [PMID: 37818750 DOI: 10.1080/17538068.2023.2267827] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/13/2023]
Abstract
BACKGROUND Shared decision-making (SDM) aims to create a context in which patients and surgeons work together to explore treatment options and goals of care. The objective of the current study was to characterize demographic factors, behaviors, and perceptions of patient involvement among surgeons relative to SDM. METHODS Using a cross-sectional survey methodology, surgeon demographics, behaviors, and perceptions of patient involvement were assessed. Surgeon approaches to SDM were measured using a 100-point scale ranging from 'patient-led' (0) to 'surgeon-led' (100). RESULTS Among 241 respondents, most were male (n = 123, 67.2%) and White (n = 124, 69.3%); roughly one-half of surgeons had been in practice ≥10 years (n = 120, 52.4%). Surgeon approaches to SDM ranged from 0 to 81.0, with a median rating of 50.0 (IQR: 35.5, 62.0). Reported approaches to SDM were associated with years in practice, sharing information, and perceptions of patient involvement. Surgeons in practice 10 + years most frequently utilized a 'Shared, Patient-led' approach to SDM (27.5%), while individuals with less experience more often employed a 'Shared, Surgeon-led' approach (33.3%, p = 0.031). Surgeons with a 'Patient-led' approach perceived patient involvement as most important (M = 3.82, SD = 0.16), while respondents who had a 'Surgeon-led' approach considered this less important (M = 3.57, SD = 0.38; p < 0.001). CONCLUSION Surgeon factors including demographics, behaviors, and perceptions of patient involvement influenced SDM approaches. SDM between patients and surgeons should strive to be more dynamic and tailored to each specific patient's needs to promote optimal patient-centered care.
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Affiliation(s)
| | - Laura J Rush
- The Center for the Advancement of Team Science, Analytics, and Systems Thinking in Health Services and Implementation Science Research (CATALYST), College of Medicine, The Ohio State University, Columbus, OH, USA
| | - Halia L Melnyk
- The Center for the Advancement of Team Science, Analytics, and Systems Thinking in Health Services and Implementation Science Research (CATALYST), College of Medicine, The Ohio State University, Columbus, OH, USA
| | - Jennifer L Eramo
- The Center for the Advancement of Team Science, Analytics, and Systems Thinking in Health Services and Implementation Science Research (CATALYST), College of Medicine, The Ohio State University, Columbus, OH, USA
| | - Ann Scheck McAlearney
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Timothy M Pawlik
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
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Giannitrapani KF, Sasnal M, McCaa M, Wu A, Morris AM, Connell NB, Aslakson RA, Schenker Y, Shreve S, Lorenz KA. Strategies to Improve Perioperative Palliative Care Integration for Seriously Ill Veterans. J Pain Symptom Manage 2023; 66:621-629.e5. [PMID: 37643653 DOI: 10.1016/j.jpainsymman.2023.08.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Revised: 08/16/2023] [Accepted: 08/19/2023] [Indexed: 08/31/2023]
Abstract
CONTEXT Seriously ill patients are at higher risk for adverse surgical outcomes. Palliative care (PC) interventions for seriously ill surgical patients are associated with improved quality of patient care and patient-centered outcomes, yet, they are underutilized perioperatively. OBJECTIVES To identify strategies for improving perioperative PC integration for seriously ill Veterans from the perspectives of PC providers and surgeons. METHODS We conducted semistructured, in-depth individual and group interviews with Veteran Health Administration PC team members and surgeons between July 2020 and April 2021. Participants were purposively sampled from high- and low-collaboration sites based on the proportion of received perioperative palliative consults. We performed a team-based thematic analysis with dual coding (inter-rater reliability above 0.8). RESULTS Interviews with 20 interdisciplinary PC providers and 13 surgeons at geographically distributed Veteran Affairs sites converged on four strategies for improving palliative care integration and goals of care conversations in the perioperative period: 1) develop and maintain collaborative, trusting relationships between palliative care providers and surgeons; 2) establish risk assessment processes to identify patients who may benefit from a PC consult; 3) involve both PC providers and surgeons at the appropriate time in the perioperative workflow; 4) provide sufficient resources to allow for an interdisciplinary sharing of care. CONCLUSION The study demonstrates that individual, programmatic, and organizational efforts could facilitate interservice collaboration between PC clinicians and surgeons.
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Affiliation(s)
- Karleen F Giannitrapani
- Department of Veterans Affairs (K.F.G., M.S., M.M., A.W., K.A.L.), Menlo Park, California; Primary Care and Population Health (K.F.G., K.A.L.), Stanford School of Medicine, Stanford, California.
| | - Marzena Sasnal
- Department of Veterans Affairs (K.F.G., M.S., M.M., A.W., K.A.L.), Menlo Park, California; Department of Surgery (M.S., A.M.M.), S-SPIRE Center, Stanford School of Medicine, Stanford, California
| | - Matthew McCaa
- Department of Veterans Affairs (K.F.G., M.S., M.M., A.W., K.A.L.), Menlo Park, California
| | - Adela Wu
- Department of Veterans Affairs (K.F.G., M.S., M.M., A.W., K.A.L.), Menlo Park, California; Department of Neurosurgery (A.W.), Stanford School of Medicine, Stanford, California
| | - Arden M Morris
- Department of Surgery (M.S., A.M.M.), S-SPIRE Center, Stanford School of Medicine, Stanford, California
| | | | - Rebecca A Aslakson
- Department of Anesthesiology (R.A.A.), University of Vermont, Burlington, Vermont
| | - Yael Schenker
- Section of Palliative Care and Medical Ethics (Y.S.), Palliative Research Center (PaRC), University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Scott Shreve
- Department of Veterans Affairs (S.S.), VA Palliative Care, Lebanon, Pennsylvania
| | - Karl A Lorenz
- Department of Veterans Affairs (K.F.G., M.S., M.M., A.W., K.A.L.), Menlo Park, California; Primary Care and Population Health (K.F.G., K.A.L.), Stanford School of Medicine, Stanford, California
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Barrett TA, MacEwan SR, Volney J, Singer J, Di Tosto G, Melnyk HL, Shiu-Yee K, Rush LJ, Benza R, McAlearney AS. The Role of Palliative Care in Heart Failure, Part 4: A Framework for Collaboration in Advance Care Planning. J Palliat Med 2023; 26:1691-1697. [PMID: 37878340 DOI: 10.1089/jpm.2022.0599] [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] [Indexed: 10/26/2023] Open
Abstract
Background: Palliative care integration into cardiology is growing, allowing primary cardiology care teams increasing opportunities to utilize palliative care to support processes such as advance care planning (ACP). Objective: The aim of the study is to understand perspectives of cardiac care team members about the involvement and impact of palliative care on ACP in heart failure. Design: A qualitative study using a semistructured interview guide was performed. Settings/Subjects: Interviews were conducted with cardiac care team members, including cardiologists, cardiac surgeons, and nurse practitioners, at a large academic medical center in the United States with an integrated cardiac palliative care team. Measurements: Deductive and inductive thematic analysis of interview transcripts enabled characterization of themes around the role of palliative care in ACP. Results: Two themes were identified with regard to providers' perspectives about ACP: (1) different levels of comfort with initiating and conducting ACP conversations and (2) different opinions about the desired role of palliative care in the ACP process. In exploring these themes, we characterized four distinct approaches to ACP with palliative care as a novel framework for planning consultation. Conclusions: The different approaches to ACP and the implications for how cardiac providers interact with the palliative care team present an important opportunity to guide ACP consultation in practice. Adoption of this framework may help cardiac providers enhance the process of care delivery and ACP in important ways that improve care for their patients.
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Affiliation(s)
- Todd A Barrett
- Division of Palliative Medicine, Richard M. Ross Heart Hospital, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
- The Center for the Advancement of Team Science, Analytics, and Systems Thinking (CATALYST), College of Medicine, The Ohio State University, Columbus, Ohio, USA
| | - Sarah R MacEwan
- The Center for the Advancement of Team Science, Analytics, and Systems Thinking (CATALYST), College of Medicine, The Ohio State University, Columbus, Ohio, USA
- Division of General Internal Medicine, College of Medicine, The Ohio State University, Columbus, Ohio, USA
| | - Jaclyn Volney
- The Center for the Advancement of Team Science, Analytics, and Systems Thinking (CATALYST), College of Medicine, The Ohio State University, Columbus, Ohio, USA
| | - Jonathan Singer
- Department of Psychological Science, The Ohio State University, Columbus, Ohio, USA
| | - Gennaro Di Tosto
- The Center for the Advancement of Team Science, Analytics, and Systems Thinking (CATALYST), College of Medicine, The Ohio State University, Columbus, Ohio, USA
| | - Halia L Melnyk
- The Center for the Advancement of Team Science, Analytics, and Systems Thinking (CATALYST), College of Medicine, The Ohio State University, Columbus, Ohio, USA
| | - Karen Shiu-Yee
- The Center for the Advancement of Team Science, Analytics, and Systems Thinking (CATALYST), College of Medicine, The Ohio State University, Columbus, Ohio, USA
| | - Laura J Rush
- The Center for the Advancement of Team Science, Analytics, and Systems Thinking (CATALYST), College of Medicine, The Ohio State University, Columbus, Ohio, USA
| | - Raymond Benza
- Division of Cardiology, Heart and Vascular Institute/Richard M. Ross Heart Hospital, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Ann Scheck McAlearney
- The Center for the Advancement of Team Science, Analytics, and Systems Thinking (CATALYST), College of Medicine, The Ohio State University, Columbus, Ohio, USA
- Department of Family and Community Medicine, College of Medicine, The Ohio State University, Columbus, Ohio, USA
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Carlisle EM, Shinkunas LA, Lieberman MT, Hoffman RM, Reisinger HS. Evaluation of a Novel Question Prompt List in Pediatric Surgical Oncology. J Surg Res 2023; 292:44-52. [PMID: 37579715 PMCID: PMC10592310 DOI: 10.1016/j.jss.2023.07.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 05/25/2023] [Accepted: 07/12/2023] [Indexed: 08/16/2023]
Abstract
INTRODUCTION Parents of children with cancer describe interactions with clinicians as emotionally distressing. Patient engagement in treatment discussions decreases decisional conflict and improves decision quality which may limit such distress. We have shown that parents prefer to engage surgeons by asking questions, but parents may not know what to ask. Question Prompt Lists (QPLs), structured lists of questions designed to help patients ask important questions, have not been studied in pediatric surgery. We developed a QPL designed to empower parents to ask meaningful questions during pediatric surgical oncology discussions. We conducted a mixed methods analysis to assess the acceptability, appropriateness, and feasibility of using the QPL. METHODS Key stakeholders at an academic children's hospital participated in focus groups to discuss the QPL. Focus groups were recorded and transcribed. Participants were surveyed regarding QPL acceptability, appropriateness, and feasibility. Thematic content analysis of transcripts was performed. RESULTS Four parents, five nurses, five nurse practitioners, five oncologists, and four surgeons participated. Seven key themes were identified: (1) QPL as a tool of empowerment; (2) stick to the surgical details; (3) QPLs can impact discussion quality; (4) time consuming, but not overly disruptive; (5) parental emotion may impact QPL use; (6) provide QPLs prior to surgical consultation in both print and digital formats; and (7) expansion of QPLs to other disciplines. Over 70% of participants agreed that the QPL was acceptable, appropriate, and feasible. CONCLUSIONS Our novel QPL is acceptable, appropriate, and feasible to use with parents of pediatric surgical oncology patients.
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Affiliation(s)
- Erica M Carlisle
- Division of Pediatric Surgery, Department of Surgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa; Program in Bioethics and Humanities, University of Iowa Carver College of Medicine, Iowa City, Iowa.
| | - Laura A Shinkunas
- Program in Bioethics and Humanities, University of Iowa Carver College of Medicine, Iowa City, Iowa
| | | | - Richard M Hoffman
- Department of Internal Medicine, University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | - Heather Schacht Reisinger
- Program in Bioethics and Humanities, University of Iowa Carver College of Medicine, Iowa City, Iowa; Department of Internal Medicine, University of Iowa Hospitals and Clinics, Iowa City, Iowa; Institute for Clinical and Translational Science, University of Iowa, Iowa City, Iowa
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6
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Connal S. Opportunities for shared decision-making about major surgery with high-risk patients: the switch from 'fixing the problem' to undertaking shared decision-making. Comment on Br J Anaesth 2023; 131: 56-66. Br J Anaesth 2023; 131:e152-e153. [PMID: 37739905 DOI: 10.1016/j.bja.2023.08.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Revised: 08/17/2023] [Accepted: 08/19/2023] [Indexed: 09/24/2023] Open
Affiliation(s)
- Stuart Connal
- University College London Hospitals NHS Foundation Trust, London, 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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Zaza SI, Arnold RM, Schwarze ML. Innovations in Surgical Communication 4-Present the Downsides of Surgery, Not Just Risks. JAMA Surg 2023; 158:998-1000. [PMID: 37610756 DOI: 10.1001/jamasurg.2023.3650] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/24/2023]
Abstract
This Viewpoint is the last of a 4-part series discussing ways to improve communication between surgeons and patients.
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Affiliation(s)
- Sarah I Zaza
- Department of Surgery, University of Wisconsin, Madison
| | - Robert M Arnold
- Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
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9
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Ferreira A, Wang A, Grant-Kels JM. Balancing hope and realism: Ethical challenges when surrogate and health care prognostic outlooks clash. J Am Acad Dermatol 2023:S0190-9622(23)02627-0. [PMID: 37633465 DOI: 10.1016/j.jaad.2023.08.049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Revised: 08/10/2023] [Accepted: 08/17/2023] [Indexed: 08/28/2023]
Affiliation(s)
- Alana Ferreira
- Department of Dermatology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Ally Wang
- Department of Dermatology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jane M Grant-Kels
- Department of Dermatology, University of Connecticut Health Center, Farmington, Connecticut; Department of Dermatology, University of Florida, Gainesville, Florida.
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Shaw SE, Hughes G, Pearse R, Avagliano E, Day JR, Edsell ME, Edwards JA, Everest L, Stephens TJ. Opportunities for shared decision-making about major surgery with high-risk patients: a multi-method qualitative study. Br J Anaesth 2023; 131:56-66. [PMID: 37117099 PMCID: PMC10308437 DOI: 10.1016/j.bja.2023.03.022] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Revised: 03/27/2023] [Accepted: 03/28/2023] [Indexed: 04/30/2023] Open
Abstract
BACKGROUND Little is known about the opportunities for shared decision-making when older high-risk patients are offered major surgery. This study examines how, when, and why clinicians and patients can share decision-making about major surgery. METHODS This was a multi-method qualitative study, combining video recordings of preoperative consultations, interviews, and focus groups (33 patients, 19 relatives, 36 clinicians), with observations and documentary analysis in clinics in five hospitals in the UK undertaking major orthopaedic, colorectal, and/or cardiac surgery. RESULTS Three opportunities for shared decision-making about major surgery were identified. Resolution-focused consultations (cardiac/colorectal) resulted in a single agreed preferred option related to a potentially life-threatening problem, with limited opportunities for shared decision-making. Evaluative and deliberative consultations offered more opportunity. The former focused on assessing the likelihood of benefits of surgery for a presenting problem that was not a threat to life for the patient (e.g., orthopaedic consultations) and the latter (largely colorectal) involved discussion of a range of options while also considering significant comorbidities and patient preferences. The extent to which opportunities for shared decision-making were available, and taken up by surgeons, was influenced by the nature of the presenting problem, clinical pathway, and patient trajectory. CONCLUSIONS Decisions about major surgery were not always shared between patients and doctors. The nature of the presenting problem, comorbidities, clinical pathways, and patient trajectories all informed the type of consultation and opportunities for sharing decision-making. Our findings have implications for clinicians, with shared decision-making about major surgery most feasible when the focus is on life-enhancing treatment.
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Affiliation(s)
- Sara E Shaw
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK.
| | - Gemma Hughes
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Rupert Pearse
- Faculty of Medicine & Dentistry, Queen Mary University of London, London, UK
| | - Ester Avagliano
- Hammersmith Hospital Imperial College Healthcare NHS Trust London, London, UK
| | - James R Day
- Department of Anaesthesia, Oxford University Hospitals Foundation Trust, Oxford, UK
| | - Mark E Edsell
- Department of Anaesthesia, The Royal Brompton & Harefield Hospitals, London, UK
| | | | | | - Timothy J Stephens
- Faculty of Medicine & Dentistry, Queen Mary University of London, London, UK
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Aslakson RA, Rickerson E, Fahy B, Waterman B, Siden R, Colborn K, Smith S, Verano M, Lira I, Hollahan C, Siddiqi A, Johnson K, Chandrashekaran S, Harris E, Nudotor R, Baker J, Heidari SN, Poultsides G, Conca-Cheng AM, Cook Chapman A, Lessios AS, Holdsworth LM, Gustin J, Ejaz A, Pawlik T, Miller J, Morris AM, Tulsky JA, Lorenz K, Temel JS, Smith TJ, Johnston F. Effect of Perioperative Palliative Care on Health-Related Quality of Life Among Patients Undergoing Surgery for Cancer: A Randomized Clinical Trial. JAMA Netw Open 2023; 6:e2314660. [PMID: 37256623 PMCID: PMC10233417 DOI: 10.1001/jamanetworkopen.2023.14660] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Accepted: 03/31/2023] [Indexed: 06/01/2023] Open
Abstract
Importance Involvement of palliative care specialists in the care of medical oncology patients has been repeatedly observed to improve patient-reported outcomes, but there is no analogous research in surgical oncology populations. Objective To determine whether surgeon-palliative care team comanagement, compared with surgeon team alone management, improves patient-reported perioperative outcomes among patients pursuing curative-intent surgery for high morbidity and mortality upper gastrointestinal (GI) cancers. Design, Setting, and Participants From October 20, 2018, to March 31, 2022, a patient-randomized clinical trial was conducted with patients and clinicians nonblinded but the analysis team blinded to allocation. The trial was conducted in 5 geographically diverse academic medical centers in the US. Individuals pursuing curative-intent surgery for an upper GI cancer who had received no previous specialist palliative care were eligible. Surgeons were encouraged to offer participation to all eligible patients. Intervention Surgeon-palliative care comanagement patients met with palliative care either in person or via telephone before surgery, 1 week after surgery, and 1, 2, and 3 months after surgery. For patients in the surgeon-alone group, surgeons were encouraged to follow National Comprehensive Cancer Network-recommended triggers for palliative care consultation. Main Outcomes and Measures The primary outcome of the trial was patient-reported health-related quality of life at 3 months following the operation. Secondary outcomes were patient-reported mental and physical distress. Intention-to-treat analysis was performed. Results In total, 359 patients (175 [48.7%] men; mean [SD] age, 64.6 [10.7] years) were randomized to surgeon-alone (n = 177) or surgeon-palliative care comanagement (n = 182), with most patients (206 [57.4%]) undergoing pancreatic cancer surgery. No adverse events were associated with the intervention, and 11% of patients in the surgeon-alone and 90% in the surgeon-palliative care comanagement groups received palliative care consultation. There was no significant difference between study arms in outcomes at 3 months following the operation in patient-reported health-related quality of life (mean [SD], 138.54 [28.28] vs 136.90 [28.96]; P = .62), mental health (mean [SD], -0.07 [0.87] vs -0.07 [0.84]; P = .98), or overall number of deaths (6 [3.7%] vs 7 [4.1%]; P > .99). Conclusions and Relevance To date, this is the first multisite randomized clinical trial to evaluate perioperative palliative care and the earliest integration of palliative care into cancer care. Unlike in medical oncology practice, the data from this trial do not suggest palliative care-associated improvements in patient-reported outcomes among patients pursuing curative-intent surgeries for upper GI cancers. Trial Registration ClinicalTrials.gov Identifier: NCT03611309.
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Affiliation(s)
- Rebecca A. Aslakson
- Department of Anesthesiology, Lerner College of Medicine at the University of Vermont, Burlington
| | - Elizabeth Rickerson
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Bridget Fahy
- Department of Surgery, Divisions of Surgical Oncology and Palliative Medicine, University of New Mexico, Albuquerque
| | - Brittany Waterman
- Department of Internal Medicine, Division of Palliative Medicine, Ohio State University Wexner Medical Center, Columbus
| | - Rachel Siden
- Division of Primary Care and Population Health, Department of Medicine, Stanford School of Medicine, Stanford, California
| | - Kathryn Colborn
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora
- Department of Biostatistics and Informatics, Colorado School of Public Health, Aurora
| | - Shelby Smith
- Department of Biostatistics and Informatics, Colorado School of Public Health, Aurora
| | - Mae Verano
- Division of Primary Care and Population Health, Department of Medicine, Stanford School of Medicine, Stanford, California
| | - Isaac Lira
- Clinical Research Department, University of New Mexico Comprehensive Cancer Center, Albuquerque
| | - Caroline Hollahan
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Amn Siddiqi
- Department of Surgery, Johns Hopkins Medical Institutions Campus, Baltimore, Maryland
| | - Kemba Johnson
- Clinical Research Center, Ohio State University Wexner Medical Center, Columbus
| | | | - Elizabeth Harris
- Harvard Medical School, Boston, Massachusetts
- Veterans Affairs Boston Healthcare System, Boston, Massachusetts
| | - Richard Nudotor
- Department of Surgery, Johns Hopkins Medical Institutions Campus, Baltimore, Maryland
| | - Joshua Baker
- Clinical Research Department, University of New Mexico Comprehensive Cancer Center, Albuquerque
| | - Shireen N. Heidari
- Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - George Poultsides
- Department of Surgery, Stanford University School of Medicine, Stanford, California
| | | | | | - Anna Sophia Lessios
- Division of Primary Care and Population Health, Department of Medicine, Stanford School of Medicine, Stanford, California
| | - Laura M. Holdsworth
- Division of Primary Care and Population Health, Department of Medicine, Stanford School of Medicine, Stanford, California
| | - Jillian Gustin
- Department of Internal Medicine, Division of Palliative Medicine, Ohio State University Wexner Medical Center, Columbus
| | - Aslam Ejaz
- Department of Surgery, Division of Surgical Oncology, Ohio State University Wexner Medical Center, Columbus
| | - Timothy Pawlik
- Department of Surgery, Division of Surgical Oncology, Ohio State University Wexner Medical Center, Columbus
| | - Judi Miller
- Patient Family Advocate, Baltimore, Maryland
| | - Arden M. Morris
- Department of Surgery, Stanford University School of Medicine, Stanford, California
| | - James A. Tulsky
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts
- Division of Palliative Medicine, Department of Medicine, Brigham & Women’s Hospital, Boston, Massachusetts
| | - Karl Lorenz
- Division of Primary Care and Population Health, Department of Medicine, Stanford School of Medicine, Stanford, California
- VA Palo Alto Healthcare System, Palo Alto, California
| | - Jennifer S. Temel
- Department of Medicine, Division of Hematology/Oncology, MGH, Boston, Massachusetts
| | - Thomas J. Smith
- Departments of Medicine and Oncology, Johns Hopkins Medical Institutions Campus, Baltimore, Maryland
| | - Fabian Johnston
- Department of Surgery, Johns Hopkins Medical Institutions Campus, Baltimore, Maryland
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12
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Carlisle EM, Shinkunas LA, Lieberman MT, Hoffman RM, Reisinger HS. "Reading the room:" A qualitative analysis of pediatric surgeons' approach to clinical counseling. J Pediatr Surg 2023; 58:503-509. [PMID: 35973862 PMCID: PMC11108180 DOI: 10.1016/j.jpedsurg.2022.08.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Revised: 06/30/2022] [Accepted: 08/03/2022] [Indexed: 11/18/2022]
Abstract
BACKGROUND In our prior analysis of parental preferences for discussions with pediatric surgeons, we identified that parents prefer more guidance from surgeons when discussing cancer surgery, emergency surgery, or surgery for infants, and they prefer to engage surgeons by asking questions. In this study, we investigate surgeon preferences for decision making discussions in pediatric surgery. METHODS We conducted a thematic content analysis of interviews of pediatric surgeons regarding their preferences for discussing surgery with parents. Board certified/board eligible pediatric surgeons who had been in practice for at least one year and spoke English were eligible. Fifteen surgeons were invited, and twelve 30-minute semi-structured interviews were completed (80%). Interviews were recorded and transcribed. Thematic content analysis was performed using deductive and inductive methods. RESULTS Data saturation was achieved after 12 interviews [6 women (50%), median years in practice 6.25, 10 in academic practice (83%), 8 from Midwest (67%)]. 5 themes emerged: (1) Collaboration to promote parental engagement; (2) "Cancer is distinct but not unique;" (3) "Read the room:" tailoring discussions to specific parental needs; (4) Perceived role of the surgeon; (5) Limited experience with decision support tools in pediatric surgery. CONCLUSIONS Pediatric surgeons prefer a collaborative approach to counseling that engages parents through education. They prioritize tailoring discussions to meet parental needs. Few have utilized decision support tools, however most expressed interest. Insight gained from our work will guide development of a decision support tool that empowers parental participation in counseling for pediatric surgery. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Erica M Carlisle
- University of Iowa Hospitals and Clinics, Department of Surgery, Division of Pediatric Surgery, Iowa City, IA, USA; University of Iowa Carver College of Medicine, Program in Bioethics and Humanities, Iowa City, IA, USA.
| | - Laura A Shinkunas
- University of Iowa Carver College of Medicine, Program in Bioethics and Humanities, Iowa City, IA, USA
| | | | - Richard M Hoffman
- University of Iowa Hospitals and Clinics, Iowa City, IA, Department of Internal Medicine, USA
| | - Heather Schacht Reisinger
- University of Iowa Carver College of Medicine, Program in Bioethics and Humanities, Iowa City, IA, USA; University of Iowa Hospitals and Clinics, Iowa City, IA, Department of Internal Medicine, USA; University of Original article Iowa, Institute for Clinical and Translational Science, Iowa City, IA, USA
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Melucci AD, Erlick MR, Loria A, Russell MM, Temple LK, Poles GC. Surgical Informed Consent: A Scoping Review of Physician-facing Decision Support Tools. ANNALS OF SURGERY OPEN 2023; 4:e259. [PMID: 37600865 PMCID: PMC10431347 DOI: 10.1097/as9.0000000000000259] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Accepted: 01/09/2023] [Indexed: 01/31/2023] Open
Abstract
Objectives Physician-facing decision support tools facilitate shared decision-making (SDM) during informed consent, but it is unclear whether they are comprehensive in the domains they measure. In this scoping review, we aimed to (1) identify the physician-facing tools used during SDM; (2) assess the patient-centered domains measured by these tools; (3) determine whether tools are available for older adults and for use in various settings (elective vs. emergent); and (4) characterize domains future tools should measure. Methods Using the Preferred Reporting Items for Systematic Reviews and Meta-analyses extension for Scoping Reviews, Embase, Medline, and Web of Science were queried for articles published between January 2000 and September 2022. Articles meeting inclusion criteria underwent title and abstract review. Eligible studies underwent data abstraction by two reviewers. Results Of 4365 articles identified, 160 were eligible. Tools to aid in surgical SDM focus on elective procedures (79%) and the outpatient setting (71%). Few tools are designed for older adults (5%) or for nonelective procedures (9%). Risk calculators were most common, followed by risk indices, prognostic nomograms, and communication tools. Of the domains measured, prognosis was more commonly measured (85%), followed by alternatives (28%), patient goals (36%), and expectations (46%). Most tools represented only one domain (prognosis, 33.1%) and only 6.7% represented all four domains. Conclusions and Implications Tools to aid in the surgical SDM process measure short-term prognosis more often than patient-centered domains such as long-term prognosis, patient goals, and expectations. Further research should focus on communication tools, the needs of older patients, and use in diverse settings.
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Affiliation(s)
- Alexa D. Melucci
- From the Department of Surgery, University of Rochester Medical Center, Rochester, NY
| | - Mariah R. Erlick
- University of Rochester School of Medicine and Dentistry, Rochester, NY
| | - Anthony Loria
- From the Department of Surgery, University of Rochester Medical Center, Rochester, NY
| | - Marcia M. Russell
- Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA
- Department of Surgery, VA Greater Los Angeles Healthcare System, Los Angeles, CA
| | - Larissa K. Temple
- From the Department of Surgery, University of Rochester Medical Center, Rochester, NY
| | - Gabriela C. Poles
- From the Department of Surgery, University of Rochester Medical Center, Rochester, NY
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14
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Cannon ST, Gabbard J, Walsh RC, Statler TM, Browne JD, Marterre B. Concordant palliative care delivery in advanced head and neck cancer. Am J Otolaryngol 2023; 44:103675. [PMID: 36302326 PMCID: PMC9743959 DOI: 10.1016/j.amjoto.2022.103675] [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: 09/02/2022] [Accepted: 10/16/2022] [Indexed: 11/27/2022]
Abstract
OBJECTIVES To describe the palliative care consultation practices in an academic head and neck surgery practice. METHODS This is a retrospective review of a palliative care database and the health record for all palliative care consultations of patients suffering from advanced stage head and neck cancer within a 21-month period. RESULTS Ten head and neck cancer patients received palliative care consults while on the otolaryngology service. One consultation occurred preoperatively; nine occurred postoperatively, on a median of hospital day 9. At the time of referral, seven patients were in the ICU and three were on a surgical floor. Code status de-escalation occurred in six patients and psycho-socio-spiritual suffering was supported in all consultations. Nine patients died within six months, with a median post-consultation survival of 35 days. Of these, two died in an ICU, five were discharged to hospice, one to a SNF, and one to a LTACH. CONCLUSION Palliative care consultation in this advanced head and neck cancer cohort was commonly late, however, significant suffering was mitigated following most consults. Palliative care specialists are experts at eliciting patient values, determining acceptable tradeoffs and suffering limitations by employing a shared decision-making process that ends with a patient-centered value-congruent treatment recommendation. Oftentimes, this embraces curative-intent or palliative surgery, along with contingency plans for unacceptable value-incongruent postoperative outcomes. Enhanced awareness of the benefits of embracing concordant palliative care in advanced head and neck cancer patients may help overcome the significant barriers to involving palliative care experts earlier.
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Affiliation(s)
- Sydney T. Cannon
- Department of Otolaryngology-Head and Neck Surgery, Wake Forest School of Medicine and Atrium Health-Wake Forest Baptist, Winston-Salem, NC, United States of America
| | - Jennifer Gabbard
- Department of Internal Medicine, Section on Palliative Care, Wake Forest School of Medicine and Atrium Health-Wake Forest Baptist, Winston-Salem, NC, United States of America
| | - Rebecca C. Walsh
- Department of Otolaryngology-Head and Neck Surgery, Wake Forest School of Medicine and Atrium Health-Wake Forest Baptist, Winston-Salem, NC, United States of America
| | - Tiffany M. Statler
- Department of Internal Medicine, Section on Palliative Care, Wake Forest School of Medicine and Atrium Health-Wake Forest Baptist, Winston-Salem, NC, United States of America
| | - J. Dale Browne
- Department of Otolaryngology-Head and Neck Surgery, Wake Forest School of Medicine and Atrium Health-Wake Forest Baptist, Winston-Salem, NC, United States of America,Corresponding author at: 1 Medical Center Blvd, Winston-Salem, NC 27157, United States of America. (J.D. Browne)
| | - Buddy Marterre
- Department of Internal Medicine, Section on Palliative Care, Wake Forest School of Medicine and Atrium Health-Wake Forest Baptist, Winston-Salem, NC, United States of America,Department of General Surgery, Wake Forest School of Medicine and Atrium Health-Wake Forest Baptist, Winston-Salem, NC, United States of America
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15
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Carlisle EM, Shinkunas LA, Ruba E, Klipowicz CJ, Lieberman MT, Hoffman RM, Reisinger HS. A valued voice: A qualitative analysis of parental decision-making preferences in emergent paediatric surgery. Health Expect 2022; 26:531-541. [PMID: 36482826 PMCID: PMC9854285 DOI: 10.1111/hex.13686] [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: 07/01/2022] [Revised: 10/21/2022] [Accepted: 11/23/2022] [Indexed: 12/14/2022] Open
Abstract
INTRODUCTION Shared decision-making, with an emphasis on patient autonomy, is often advised in healthcare decision-making. However, this may be difficult to implement in emergent settings. We have previously demonstrated that when considering emergent operations for their children, parents prefer surgeon guidance as opposed to shared decision-making. Here, we interviewed parents of paediatric patients who had undergone emergent operations to better understand parental decision-making preferences. METHODS Parents of paediatric patients who underwent surgery over the past 5 years at a University-based, tertiary children's hospital for cancer, an emergent operation while in the neonatal intensive care unit (NICU) or extracorporeal membrane oxygenation (ECMO) were invited to complete a 60-min semi-structured interview. Interviews were digitally recorded and transcribed verbatim. Thematic content analysis was performed via deductive and inductive analysis. An iterative approach to thematic sampling/data analysis was used. RESULTS Thematic saturation was achieved after 12 interviews (4 cancer, 5 NICU and 3 ECMO). Five common themes were identified: (1) recommendations from surgeons are valuable; (2) 'lifesaving mode': parents felt there were no decisions to be made; (3) effective ways of obtaining information about treatment; (4) shared decision-making as a 'dialogue' or 'discussion' and (5) parents as a 'valued voice' to advocate for their children. CONCLUSIONS When engaging in decision-making regarding emergent surgical procedures for their children, parents value a surgeon's recommendation. Parents felt that discussion or dialogue with surgeons defined shared decision-making, and they believed that the opportunity to ask questions gave them a 'valued voice', even when they felt there were no decisions to be made. PATIENT OR PUBLIC CONTRIBUTION For this study, we interviewed parents of paediatric patients who had undergone emergent operations to better understand parental decision-making preferences. Parents thus provided all the data for the study.
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Affiliation(s)
- Erica M. Carlisle
- Department of Surgery, Division of Pediatric SurgeryUniversity of Iowa Hospitals and ClinicsIowa CityIowaUSA,College of Medicine, Program in Bioethics and HumanitiesUniversity of Iowa Carver College of MedicineIowa CityIowaUSA
| | - Laura A. Shinkunas
- College of Medicine, Program in Bioethics and HumanitiesUniversity of Iowa Carver College of MedicineIowa CityIowaUSA
| | - Emily Ruba
- College of MedicineUniversity of Iowa Carver College of MedicineIowa CityIowaUSA
| | | | | | - Richard M. Hoffman
- Department of Internal MedicineUniversity of Iowa Hospitals and ClinicsIowa CityIowaUSA
| | - Heather S. Reisinger
- College of Medicine, Program in Bioethics and HumanitiesUniversity of Iowa Carver College of MedicineIowa CityIowaUSA,Department of Internal MedicineUniversity of Iowa Hospitals and ClinicsIowa CityIowaUSA,Institute for Clinical and Translational ScienceUniversity of IowaIowa CityIowaUSA
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16
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Visual Preoperative Risk Depiction Tools for Shared Decision-making: A Pilot Study from the Surgeon's Perspective. Plast Reconstr Surg Glob Open 2022; 10:e4690. [PMID: 36467117 PMCID: PMC9708169 DOI: 10.1097/gox.0000000000004690] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Accepted: 10/04/2022] [Indexed: 01/25/2023]
Abstract
UNLABELLED Shared decision-making (SDM) and effective risk communication improve patient satisfaction, adherence to treatment, and understanding of perioperative care pathways. Available risk calculators are less relevant for low-risk operations. The aim of this pilot study was to develop graphical risk visualization tools to enhance surgical SDM discussions preoperatively. METHODS Complications for reduction mammoplasty and skin grafting in a burns setting were sourced from the American College of Surgeons National Surgical Quality Improvement Program Surgical Risk Calculator, the American Society of Plastic Surgeons website, peer-reviewed literature, and available clinical data. Pre- and postoperative patient satisfaction data were collected from the published literature on Breast-Q patient-reported outcomes for reduction mammoplasty. Everyday risk comparisons were collected from a general online database search. Three distinct risk depiction tools (spiral, tile, and scatter plot) were developed in the Microsoft Office Suite. Anonymous REDCap surveys were sent to healthcare practitioners for feedback. RESULTS Twenty-six survey results were collected. Twenty-four respondents (92%) agreed these graphics would be useful for SDM discussions. Nineteen respondents (73%) either agreed or strongly agreed that these graphics depicted risk in a meaningful way. Fifteen respondents (58%) indicated they would use these graphics in daily practice. The majority of respondents preferred the spiral design (58%). Areas for improvement included design simplification and written explanations to accompany graphics. Feedback from the survey was incorporated into the spiral design. CONCLUSIONS Risk visualization tools meaningfully depict surgical risks to improve communication in SDM. This study proposes a tool that can be adapted for many surgical procedures.
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17
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Stephens TJ, Pearse RM. The limitations of shared decision-making in surgery. Br J Surg 2022; 109:1051-1052. [DOI: 10.1093/bjs/znac292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Accepted: 07/28/2022] [Indexed: 11/13/2022]
Affiliation(s)
- Timothy J Stephens
- Faculty of Medicine and Dentistry, Queen Mary, University of London , London , UK
- Adult Critical Care Unit, The Royal London Hospital, Barts Health NHS Trust , London , UK
| | - Rupert M Pearse
- Faculty of Medicine and Dentistry, Queen Mary, University of London , London , UK
- Adult Critical Care Unit, The Royal London Hospital, Barts Health NHS Trust , London , UK
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18
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Abstract
BACKGROUND & AIMS The emotional underpinnings that facilitate and complicate the practice of ethical principles like respect warrant sustained interdisciplinary attention. In this article, I suggest that shame is a requisite component of the emotional repertoire than makes respect for persons possible. MATERIALS & METHODS I use person-centered interview data from a sample of 54 physicians (including 35 surgeons), 60% of whom are women, to examine the emergence and endurance of shame as a mood with moral significance. Drawing on anthropologist Throop's concept of a moral mood, I explore physicians' first-person narratives of the endurance of shame experiences. RESULTS Narratives demonstrate that shame inheres in biomedical contexts that reinforce the physician's responsibilization and culpability for events beyond their control. As a persistent cognitive and affective state, mooded shame is a recursive and compulsory motive force for a physician's dynamic evolution as a moral actor. DISCUSSION Variably distressing, looming and commonplace, mooded shame becomes an atmospheric and imaginative mode through which physicians contemplate their responsibilities and connections to patients. Sometimes in a hypercognized manner that conceals its emotional roots, physicians link the mood of shame to their incessant efforts to fulfill responsibilities to each unique patient. CONCLUSION I suggest that through reflection made possible within mooded shame, physicians develop a sense of being both accountable to and alongside patients, and I explore the ties between this position and philosophical concepts of respect.
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Affiliation(s)
- Elizabeth Bromley
- Departments of Psychiatry and Biobehavioral Sciences and Anthropology, Center for Health Services and Society, University of California, Los Angeles, Los Angeles, California, USA
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19
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Weill SR, Layden AJ, Nabozny MJ, Leahy J, Claxton R, Zelenski AB, Zimmermann C, Childers J, Arnold R, Hall DE. Applying VitalTalk TM Techniques to Best Case/Worst Case Training to Increase Scalability and Improve Surgeon Confidence in Shared Decision-making. JOURNAL OF SURGICAL EDUCATION 2022; 79:983-992. [PMID: 35246401 DOI: 10.1016/j.jsurg.2022.01.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Revised: 01/03/2022] [Accepted: 01/22/2022] [Indexed: 06/14/2023]
Abstract
OBJECTIVE Best Case/Worst Case (BC/WC) is a communication tool designed to promote shared decision-making for high-risk procedures near the end of life. This study aimed to increase scalability of a BC/WC training program and measure its impact on surgeon confidence in and perceived importance of the methodology. DESIGN A prospective cohort pre-post study; December 2018 to January 2019. SETTING Multi-center tertiary care teaching hospital. PARTICIPANTS Forty-eight resident surgeons from general surgery and otolaryngology. RESULTS Learners were 24 to 37 years old with 52% in post graduate year 1 to 2. Although learners encountered high-stakes communication (HSC) frequently (3.6 [0.7] on 5-point Likert scale), most reported no HSC training in medical school (74.5%) or residency (87.5%). BC/WC training was accomplished with an instructor to learner ratio of 1-to-5.3. After training, learner confidence improved on all measured communication skills on a 5-point scale (e.g., exploring patient's values increased from 3.6 [0.8] to 4.1 [0.6], p = <0.0001); average within-person improvement was 0.72 (0.6) points across all skills. Perceived importance improved across all skills (e.g., basing a recommendation on patient's values increased from 4.4 [0.8] to 4.8 [0.5], p = 0.0009); average within-person improvement was 0.46 (0.5) points across all skills. Learners reported this training would likely help them in future interactions (4.4 [0.73] on 5-point scale) and 95.2% recommended it be offered to resident physicians in other residency programs and to attending surgeons. CONCLUSIONS Formal training in BC/WC increases learners' perception of both the importance of HSC skills and their confidence in exercising those skills in clinical practice. VitalTalkTM methodology permitted scaling training to 5.3 learners per instructor and was highly recommended for other surgeons. Ongoing training, such as this, may support more patient-centered decision-making and care.
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Affiliation(s)
- Sydney R Weill
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania; Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.
| | - Alexander J Layden
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania; Department of Epidemiology, University of Pittsburgh, Pittsburgh, Pennsylvania
| | | | - Janet Leahy
- Department of General Medicine, Section of Palliative Care and Medical Ethics, UPMC, Pittsburgh, Pennsylvania
| | - Rene Claxton
- Department of General Medicine, Section of Palliative Care and Medical Ethics, UPMC, Pittsburgh, Pennsylvania
| | - Amy B Zelenski
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Chris Zimmermann
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Julie Childers
- Department of General Medicine, Section of Palliative Care and Medical Ethics, UPMC, Pittsburgh, Pennsylvania
| | - Robert Arnold
- Department of General Medicine, Section of Palliative Care and Medical Ethics, UPMC, Pittsburgh, Pennsylvania
| | - Daniel E Hall
- Department of Surgery, University of Pittsburgh Medical Center (UPMC), Pittsburgh, Pennsylvania; The Wolff Center at UPMC, Pittsburgh, Pennsylvania; Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania; Geriatric Research Educational and Clinical Center, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
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20
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Murthy S, Clapp JT, Burson RC, Fleisher LA, Neuman MD. Physicians' perspectives of prognosis and goals of care discussions after hip fracture. J Am Geriatr Soc 2022; 70:1487-1494. [PMID: 34990017 PMCID: PMC9106823 DOI: 10.1111/jgs.17642] [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: 08/11/2021] [Revised: 12/10/2021] [Accepted: 12/17/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Hip fracture often represents a major transition in patients' health, with a 1-year mortality rate between 25% and 30% and a challenging recovery course. Caring for hip fracture patients presents opportunities for goals of care discussions that include prognostic information and guidance about functional dependence. METHODS We conducted qualitative, semi-structured interviews with 23 attending physicians involved with the care of hip fracture patients, including orthopedic surgeons, anesthesiologists, internists, and geriatricians, across 13 health systems in the United States and Canada. Questions addressed knowledge and interpretation of prognosis, discussing prognosis and goals of care, and timing and prioritization of surgery. Interviews were analyzed using a constructivist grounded theory approach to identify themes and develop a coding taxonomy. RESULTS Physicians agreed that hip fracture had a considerable 1-year mortality, felt that it was important to discuss prognostic outcomes and the recovery process, wanted to elucidate patients' priorities, and often promoted timely surgery. Physicians perceived challenges when discussing mortality data with new patients in an acute setting. They more easily discussed outcomes related to functional dependence and quality of life. Some physicians used iterative communication as a strategy to have in-depth conversations in a busy perioperative setting. CONCLUSION Providing timely, compassionate care for hip fracture patients is challenging. There are opportunities to study iterative communication to encourage dialogue at key points of patient care to better discuss prognosis and recovery and bolster coordinated multidisciplinary care that focuses on patients' goals and values.
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Affiliation(s)
- Sushila Murthy
- Department of Anesthesiology and Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Center for Perioperative Outcomes Research and Transformation, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Justin T Clapp
- Department of Anesthesiology and Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Center for Perioperative Outcomes Research and Transformation, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Randall C Burson
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Lee A Fleisher
- Department of Anesthesiology and Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Center for Clinical Standards and Quality, Centers for Medicare and Medicaid Services, Baltimore, Maryland, USA
| | - Mark D Neuman
- Department of Anesthesiology and Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Center for Perioperative Outcomes Research and Transformation, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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21
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22
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Role of Palliative Care. Perioper Med (Lond) 2022. [DOI: 10.1016/b978-0-323-56724-4.00043-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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23
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Bader A. The Value of Preoperative Assessment. Perioper Med (Lond) 2022. [DOI: 10.1016/b978-0-323-56724-4.00004-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Demyan L, Wu G, Moumin D, Blumenthaler AN, Deutsch GB, Nealon W, Herman JM, Weiss MJ, Burns EA, DePeralta DK. Advance care planning in patients undergoing surgery to resect pancreatic adenocarcinoma: Underlying tension between balancing hope and realism. Surgery 2021; 171:459-466. [PMID: 34563351 DOI: 10.1016/j.surg.2021.08.033] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Revised: 08/01/2021] [Accepted: 08/16/2021] [Indexed: 12/21/2022]
Abstract
BACKGROUND The timing and the dose of Advanced Care Planning in patients with pancreatic ductal adenocarcinoma undergoing curative-intent resection are generally dictated by the surgeon performing the operation. METHODS A qualitative investigation using 1:1 interviews with 40 open-ended questions was conducted with a convenience sample of 10 high-volume pancreatic surgeons from across the country. The grounded theory approach was used for data analysis. RESULTS A total of 10 interviews were conducted with expert pancreatic surgeons-6 males and 4 females. During preoperative counseling, all surgeons attempt to motivate patients by emphasizing hope, optimism, and the fact that surgery offers the only opportunity for cure. All surgeons discuss the possibility of recurrence as well as postoperative complications; however, a majority perceived that patients do not fully appreciate the likelihood of recurrence or postoperative complications. All surgeons acknowledged the importance of end-of-life conversations when death is imminent. Seventy percent of surgeons had mixed opinions regarding benefits of preoperative Advanced Care Planning in the preoperative setting, while 20% felt it was definitely beneficial, particularly that delivery of care aligned with patient goals. All surgeons emphasized that Advanced Care Planning should be led by a physician who both knows the patient well and understands the nuances of pancreatic ductal adenocarcinoma management. Most common barriers to in-depth Advanced Care Planning discussion reported by surgeons include taking away hope, lack of time, and concern for sending "mixed messages." CONCLUSION We identified that surgeons experience a fundamental tension between promoting realistic long-term goals and expectations versus focusing on hope and enabling an overly optimistic perception of prognosis.
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Affiliation(s)
- Lyudmyla Demyan
- Department of Surgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY.
| | - Grace Wu
- Zucker School of Medicine at Hofstra, New Hyde Park, NY
| | - Dina Moumin
- Zucker School of Medicine at Hofstra, New Hyde Park, NY
| | | | - Gary B Deutsch
- Department of Surgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY; Zucker School of Medicine at Hofstra, New Hyde Park, NY
| | - William Nealon
- Department of Surgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY; Zucker School of Medicine at Hofstra, New Hyde Park, NY
| | - Joseph M Herman
- Department of Surgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY; Zucker School of Medicine at Hofstra, New Hyde Park, NY
| | - Matthew J Weiss
- Department of Surgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY; Zucker School of Medicine at Hofstra, New Hyde Park, NY
| | - Edith A Burns
- Department of Surgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY; Department of Internal Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY
| | - Danielle K DePeralta
- Department of Surgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY; Zucker School of Medicine at Hofstra, New Hyde Park, NY
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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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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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Schwarze ML, Buffington A, Tucholka JL, Hanlon B, Rathouz PJ, Marka N, Taylor LJ, Zimmermann CJ, Kata A, Baggett ND, Fox DA, Schmick AE, Berlin A, Glass NE, Mosenthal AC, Finlayson E, Cooper Z, Brasel KJ. Effectiveness of a Question Prompt List Intervention for Older Patients Considering Major Surgery: A Multisite Randomized Clinical Trial. JAMA Surg 2021; 155:6-13. [PMID: 31664452 DOI: 10.1001/jamasurg.2019.3778] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Poor preoperative communication can have serious consequences, including unwanted treatment and postoperative conflict. Objective To compare the effectiveness of a question prompt list (QPL) intervention vs usual care on patient engagement and well-being among older patients considering major surgery. Design, Setting, and Participants This randomized clinical trial used a stepped-wedge design to randomly assign patients to a QPL intervention (n = 223) or usual care (n = 223) based on the timing of their visit with 1 of 40 surgeons at 5 US study sites. Patients were 60 years or older with at least 1 comorbidity and an oncologic or vascular (cardiac, neurosurgical, or peripheral vascular) problem that could be treated with major surgery. Family members were also enrolled (n = 263). The study dates were June 2016 to November 2018. Data analysis was by intent-to-treat. Interventions A brochure of 11 questions to ask a surgeon developed by patient and family stakeholders plus an endorsement letter from the surgeon were sent to patients before their outpatient visit. Main Outcomes and Measures Primary patient engagement outcomes included the number and type of questions asked during the surgical visit and patient-reported Perceived Efficacy in Patient-Physician Interactions scale assessed after the surgical visit. Primary well-being outcomes included (1) the difference between patient's Measure Yourself Concerns and Well-being (MYCaW) scores reported after surgery and scores reported after the surgical visit and (2) treatment-associated regret at 6 to 8 weeks after surgery. Results Of 1319 patients eligible for participation, 223 were randomized to the QPL intervention and 223 to usual care. Among 446 patients, the mean (SD) age was 71.8 (7.1) years, and 249 (55.8%) were male. On intent-to-treat analysis, there was no significant difference between the QPL intervention and usual care for all patient-reported primary outcomes. The difference in MYCaW scores for family members was greater in usual care (effect estimate, 1.51; 95% CI, 0.28-2.74; P = .008). When the QPL intervention group was restricted to patients with clear evidence they reviewed the QPL, a nonsignificant increase in the effect size was observed for questions about options (odds ratio, 1.88; 95% CI, 0.81-4.35; P = .16), expectations (odds ratio, 1.59; 95% CI, 0.67-3.80; P = .29), and risks (odds ratio, 2.41; 95% CI, 1.04-5.59; P = .04) (nominal α = .01). Conclusions and Relevance The results of this study were null related to primary patient engagement and well-being outcomes. Changing patient-physician communication may be difficult without addressing clinician communication directly. Trial Registration ClinicalTrials.gov identifier: NCT02623335.
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Affiliation(s)
| | - Anne Buffington
- Department of Surgery, University of Wisconsin-Madison, Madison
| | | | - Bret Hanlon
- Department of Biostatistics & Medical Informatics, University of Wisconsin-Madison, Madison
| | - Paul J Rathouz
- Department of Population Health, The University of Texas at Austin, Austin
| | - Nicholas Marka
- Department of Surgery, University of Wisconsin-Madison, Madison
| | - Lauren J Taylor
- Department of Surgery, University of Wisconsin-Madison, Madison
| | | | - Anna Kata
- Division of Geriatrics, Department of Medicine, University of California, San Francisco
| | | | - Daniel A Fox
- School of Medicine, Northwestern University, Evanston, Illinois
| | - Andrea E Schmick
- Department of Medicine, University of Wisconsin-Madison, Madison
| | - Ana Berlin
- Division of General Surgery, Department of Surgery, Columbia University Medical Center, New York, New York.,Adult Palliative Medicine Service, Division of Hematology/Oncology, Department of Medicine, Columbia University Medical Center, New York, New York
| | - Nina E Glass
- Department of Surgery, Rutgers New Jersey Medical School, Newark
| | - Anne C Mosenthal
- Department of Surgery, Rutgers New Jersey Medical School, Newark
| | - Emily Finlayson
- Department of Surgery, University of California, San Francisco
| | - Zara Cooper
- Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Karen J Brasel
- Department of Surgery, Oregon Health and Science University, Portland
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Long KL, Ingraham AM, Wendt EM, Saucke MC, Balentine C, Orne J, Pitt SC. Informed Consent and Informed Decision-Making in High-Risk Surgery: A Quantitative Analysis. J Am Coll Surg 2021; 233:337-345. [PMID: 34102279 DOI: 10.1016/j.jamcollsurg.2021.05.029] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Revised: 05/19/2021] [Accepted: 05/19/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Informed consent is an ethical and legal requirement that differs from informed decision-making-a collaborative process that fosters participation and provides information to help patients reach treatment decisions. The objective of this study was to measure informed consent and informed decision-making before major surgery. STUDY DESIGN We audio-recorded 90 preoperative patient-surgeon conversations before major cardiothoracic, vascular, oncologic, and neurosurgical procedures at 3 centers in the US and Canada. Transcripts were scored for 11 elements of informed consent based on the American College of Surgeons' definition and 9 elements of informed decision-making using Braddock's validated scale. Uni- and bivariate analyses tested associations between decision outcomes as well as patient, consultation, and surgeon characteristics. RESULTS Overall, surgeons discussed more elements of informed consent than informed decision-making. They most frequently described the nature of the illness, the operation, and potential complications, but were less likely to assess patient understanding. When a final treatment decision was deferred, surgeons were more likely to discuss elements of informed decision-making focusing on uncertainty (50% vs 15%, p = 0.006) and treatment alternatives (63% vs 27%, p = 0.02). Conversely, when surgery was scheduled, surgeons completed more elements of informed consent. These results were not associated with the presence of family, history of previous surgery, location, or surgeon specialty. CONCLUSIONS Surgeons routinely discuss components of informed consent with patients before high-risk surgery. However, surgeons often fail to review elements unique to informed decision-making, such as the patients' role in the decision, their daily life, uncertainty, understanding, or patient preference.
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Affiliation(s)
- Kristin L Long
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI.
| | - Angela M Ingraham
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Elizabeth M Wendt
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Megan C Saucke
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Courtney Balentine
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Jason Orne
- Qualitative Health Research Consultants, Madison, WI
| | - Susan C Pitt
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
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Cushman T, Waisel DB, Treggiari MM. The Role of Anesthesiologists in Perioperative Limitation of Potentially Life-Sustaining Medical Treatments: A Narrative Review and Perspective. Anesth Analg 2021; 133:663-675. [PMID: 34014183 DOI: 10.1213/ane.0000000000005559] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
No patient arrives at the hospital to undergo general anesthesia for its own sake. Anesthesiology is a symbiont specialty, with the primary mission of preventing physical and psychological pain, easing anxiety, and shepherding physiologic homeostasis so that other care may safely progress. For most elective surgeries, the patient-anesthesiologist relationship begins shortly before and ends after the immediate perioperative period. While this may tempt anesthesiologists to defer goals of care discussions to our surgical or primary care colleagues, we have both an ethical and a practical imperative to share this responsibility. Since the early 1990s, the American College of Surgeons (ACS), the American Society of Anesthesiologists (ASA), and the Association of Perioperative Registered Nurses (AORN) have mandated a "required reconsideration" of do-not-resuscitate (DNR) orders. Key ethical considerations and guiding principles informing this "required reconsideration" have been extensively discussed in the literature and include respect for patient autonomy, beneficence, and nonmaleficence. In this article, we address how well these principles and guidelines are translated into daily clinical practice and how often anesthesiologists actually discuss goals of care or potential limitations to life-sustaining medical treatments (LSMTs) before administering anesthesia or sedation. Having done so, we review how often providers implement goal-concordant care, that is, care that reflects and adheres to the stated patient wishes. We conclude with describing several key gaps in the literature on goal-concordance of perioperative care for patients with limitations on LSMT and summarize novel strategies and promising efforts described in recent literature to improve goal-concordance of perioperative care.
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Affiliation(s)
- Tera Cushman
- From the Department of Anesthesiology and Perioperative Medicine, Oregon Health & Science University, Portland, Oregon
| | - David B Waisel
- Department of Anesthesiology, Yale University, New Haven, Connecticut
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31
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Ovaitt AK, Hughley BB, McCammon S. Ethical Considerations for Elderly Patients with Cutaneous Malignancy. Otolaryngol Clin North Am 2021; 54:415-423. [PMID: 33743889 DOI: 10.1016/j.otc.2020.11.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Discussions of ethics in surgery generally focus on the principles of beneficence, nonmalfeasance, autonomy, and justice. Caring for elderly patients with advanced cutaneous malignancies often requires the added consideration of narrative ethics to account for the expanded circle of care, complex medical conditions, and different goals of treatment often seen in this population. By focusing on the patient's illness narrative and relying on the collective experiences of the patient and surgeon, compassionate and appropriate care can be provided for these often-devastating disease processes.
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Affiliation(s)
- Alyssa K Ovaitt
- Department of Otolaryngology-Head and Neck Surgery, University of Alabama at Birmingham, FOT 1155, 1720 2nd Avenue South, Birmingham, AL 35294-3412, USA
| | - Brian B Hughley
- Department of Otolaryngology-Head and Neck Surgery, University of Florida, 1345 Center Drive, Box #100264, Gainesville, FL 32610, USA
| | - Susan McCammon
- Department of Otolaryngology-Head and Neck Surgery, The University of Alabama at Birmingham, Faculty Office Tower 1155, 1720 2nd Avenue South, Birmingham, AL 35294-3412, USA; Department of Internal Medicine, Division of Gerontology, Geriatrics and Palliative Care, The University of Alabama at Birmingham, 1720 2nd Avenue South, Birmingham, AL 35294-3412, USA.
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32
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De Roo AC, Vitous CA, Rivard SJ, Bamdad MC, Jafri SM, Byrnes ME, Suwanabol PA. High-risk surgery among older adults: Not-quite shared decision-making. Surgery 2021; 170:756-763. [PMID: 33712309 DOI: 10.1016/j.surg.2021.02.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Revised: 01/27/2021] [Accepted: 02/01/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Shared decision-making is critical to optimal patient-centered care. For elective operations, when there is sufficient time for deliberate discussion, little is known about how surgeons navigate decision-making and how surgeons align care with patient preferences. In this context, we sought to explore surgeons' approaches to decision-making for adults ≥65 years at high-risk of postoperative complications or death. METHODS We conducted semistructured in-depth interviews with 46 practicing surgeons across Michigan. Transcripts were iteratively analyzed through steps informed by inductive thematic analysis. RESULTS Four major themes emerged characterizing how surgeons approach high-risk surgical decision-making for older adults: (1) risk assessment was defined as the process used by surgeons to identify and analyze factors that may negatively impact outcome; (2) expectations and goals described the process of surgeons engaging with patients and families to discuss potential outcomes and desired objectives; (3) external and internal motivating factors outlined extrinsic dynamics (eg, quality metrics, referrals) and intrinsic drivers (eg, surgeons' personal experiences) that influenced high-risk decision-making; and (4) decision-making approaches and challenges encompassed the roles of patients and surgeons and obstacles to engaging in a true shared decision-making process. CONCLUSION Although shared decision-making is strongly recommended, we found that surgeons who perform high-risk operations among older adults predominantly focused on assessing risk and setting expectations with patients and families rather than inviting them to actively participate in the decision-making process. Surgeons also reported influences on decision-making from quality metrics, referrals, and personal experiences. Patient involvement, however, was seldom discussed suggesting that surgeons may not be engaging in true shared decision-making when benefits should be weighed against a high likelihood of harm.
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Affiliation(s)
- Ana C De Roo
- Center for Healthcare Outcomes and Policy, Department of Surgery, University of Michigan, Ann Arbor, MI.
| | - Crystal Ann Vitous
- Center for Healthcare Outcomes and Policy, Department of Surgery, University of Michigan, Ann Arbor, MI
| | - Samantha J Rivard
- Center for Healthcare Outcomes and Policy, Department of Surgery, University of Michigan, Ann Arbor, MI. https://twitter.com/rivardsj
| | - Michaela C Bamdad
- Center for Healthcare Outcomes and Policy, Department of Surgery, University of Michigan, Ann Arbor, MI. https://twitter.com/michaelabamdad
| | - Sara M Jafri
- Center for Healthcare Outcomes and Policy, Department of Surgery, University of Michigan, Ann Arbor, MI. https://twitter.com/sara_jafri1
| | - Mary E Byrnes
- Center for Healthcare Outcomes and Policy, Department of Surgery, University of Michigan, Ann Arbor, MI. https://twitter.com/sociologymary
| | - Pasithorn A Suwanabol
- Center for Healthcare Outcomes and Policy, Department of Surgery, University of Michigan, Ann Arbor, MI. https://twitter.com/amysuwanabol
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Ethics Consultation in Surgical Specialties. HEC Forum 2021; 34:89-102. [PMID: 33674985 PMCID: PMC7934986 DOI: 10.1007/s10730-021-09447-7] [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] [Accepted: 02/10/2021] [Indexed: 11/24/2022]
Abstract
Multiple studies have been performed to identify the most common ethical dilemmas encountered by ethics consultation services. However, limited data exists comparing the content of ethics consultations requested by specific hospital specialties. It remains unclear whether the scope of ethical dilemmas prompting an ethics consultation differ between specialties and if there are types of ethics consultations that are more or less frequently called based on the specialty initiating the ethics consult. This study retrospectively assessed the incidence and content of ethics consultations called by surgical vs. non-surgical specialties between January 1, 2013 to December 31, 2018 using our RedCap Database and information collected through the EMR via our Clinical and Translational Science Center. 548 total ethics consultations were analyzed (surgical n = 135, non-surgical n = 413). Our results demonstrate that more surgical consults originated from the ICU, as opposed to lower acuity units (45.9% vs. 14.3%, p ≤ 0.001), and surgical patients were more likely to have a DNR in place (37.5% vs. 22.2%, p = 0.002). Surgical specialties were more likely to call about issues relating to withholding/withdrawing life-sustaining treatment (p ≤ 0.001), while non-surgical specialties were more likely to call about issues related to discharge planning (p = 0.001). There appear to be morally relevant differences between consults classified as the “same” that are not entirely captured by the usual ethics consultations classification system. In conclusion, this study highlights the unique ethical issues experienced by surgical vs. non-surgical specialties. Ultimately, our data can help ethics consultation services determine how best to educate various hospital specialties to approach ethical issues commonly experienced within their field.
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Abstract
Thoracoabdominal aortic aneurysms, although rare, continue to be associated with high morbidity and mortality in the modern era of vascular surgery, and knowledge of this disease is essential for those in clinical practice. Given the clinically silent nature of the disease, it is difficult to determine disease incidence, with most epidemiologic recommendations not made based on evidence regarding those diagnosed with the disease, but extrapolated from data on surgical outcomes. It appears that although men are more likely to develop thoracoabdominal aortic aneurysms, the distribution is not as skewed as in abdominal aortic aneurysms. Current evidence suggests that Black and Hispanic patients continue to have disproportionately poor disease outcomes, mostly attributed to later presentation and undergoing interventions at lower-volume centers. Although select patients meet criteria for disease screening based on personal or family history of aneurysmal disease, general population screening has not been recommended by any professional organization to date. Vascular surgeons need to continue to be at the forefront of thoracoabdominal aortic aneurysm management, especially as care becomes centered around comprehensive "aortic care centers" and as more endovascular therapies become available.
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Affiliation(s)
- Jordan B Stoecker
- Department of Surgery, Hospital of the University of Pennsylvania, 3400 Spruce Street, Maloney 4th Floor, Philadelphia, PA 19104.
| | - Grace J Wang
- Division of Vascular Surgery and Endovascular Therapy, Hospital of the University of Pennsylvania, 3400 Spruce Street, Maloney 4th Floor, Philadelphia, PA 19104.
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Hugar LA, Wulff-Burchfield EM, Winzelberg GS, Jacobs BL, Davies BJ. Incorporating palliative care principles to improve patient care and quality of life in urologic oncology. Nat Rev Urol 2021; 18:623-635. [PMID: 34312530 PMCID: PMC8312356 DOI: 10.1038/s41585-021-00491-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/07/2021] [Indexed: 02/07/2023]
Abstract
Palliative care - specialized healthcare focused on improving quality of life for patients with serious illnesses - can help urologists to care for patients with unmet symptom, coping and communication needs. Society guidelines from the American Society of Clinical Oncology and the National Comprehensive Cancer Network recommend incorporating palliative care into standard oncological care, based on multiple randomized trials demonstrating that it significantly improves physical well-being, patient satisfaction and goal concordant care. Misconceptions regarding the objective and ideal timing of palliative care are common; a key concept is that palliative care and treatments seeking to cure or prolong life are not mutually exclusive. Urologists are well positioned to champion the integration of palliative care into surgical urologic oncology and should be aware of palliative care guidelines, indications for palliative care use and how the field of urologic oncology can adopt best practices.
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Affiliation(s)
- Lee A. Hugar
- grid.468198.a0000 0000 9891 5233Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center, Tampa, FL USA
| | - Elizabeth M. Wulff-Burchfield
- grid.412016.00000 0001 2177 6375Medical Oncology Division and Palliative Care Division, Department of Internal Medicine, University of Kansas Medical Center, Westwood, KS USA
| | - Gary S. Winzelberg
- grid.10698.360000000122483208UNC Palliative Care Program, Division of Geriatric Medicine, Department of Medicine, University of North Carolina Chapel Hill School of Medicine, Chapel Hill, NC USA
| | - Bruce L. Jacobs
- grid.21925.3d0000 0004 1936 9000Department of Urology, University of Pittsburgh School of Medicine, Pittsburgh, PA USA
| | - Benjamin J. Davies
- grid.21925.3d0000 0004 1936 9000Department of Urology, University of Pittsburgh School of Medicine, Pittsburgh, PA USA
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Yefimova M, Aslakson RA. Preoperative Conversations About Postoperative Risks, Outcomes, and Quality of Life-Time to Start Thinking Outside the Box. JAMA Netw Open 2020; 3:e2024048. [PMID: 33180125 DOI: 10.1001/jamanetworkopen.2020.24048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Maria Yefimova
- Office of Research, Patient Care Services, Stanford Healthcare, Stanford, California
- Department of Medicine and Division of Primary Care and Population Health, Section of Palliative Care, Stanford University, Stanford, California
| | - Rebecca A Aslakson
- Department of Medicine and Division of Primary Care and Population Health, Section of Palliative Care, Stanford University, Stanford, California
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University, Stanford, California
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Tylee MJ, Rubenfeld GD, Wijeysundera D, Sklar MC, Hussain S, Adhikari NKJ. Anesthesiologist to Patient Communication: A Systematic Review. JAMA Netw Open 2020; 3:e2023503. [PMID: 33180130 PMCID: PMC7662141 DOI: 10.1001/jamanetworkopen.2020.23503] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
IMPORTANCE Many patients are admitted to the intensive care unit following surgery, and some of them will experience incomplete recovery. For patients in this situation, preoperative discussions regarding patient values and preferences may direct care decisions. Existing literature shows that it is uncommon for surgeons to have these conversations preoperatively; it is unclear whether anesthesia professionals engage with patients on this topic prior to surgery. OBJECTIVE To review the literature on communication between patients and anesthesia professionals, with a focus on discussions related to postoperative critical care. EVIDENCE REVIEW MEDLINE and Web of Science were searched using specific search criteria from January 1980 to April 2020. Studies describing encounters between patients and anesthesia professionals were selected, and data regarding study objectives, study design, methodology, measures, outcomes, patient characteristics, and clinical setting were extracted and collated. The Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guideline was followed. FINDINGS A total of 12 studies including 1284 individual patient encounters were eligible for inclusion in the review. These studies demonstrated that communication between patients and anesthesia professionals related to postoperative care is rare: only 2 studies reported communication regarding adverse postoperative events, and this communication behavior was reported in only 46 of 1284 consultations (3.6%) across all studies. Additional findings were that communication during these encounters is dominated by anesthetic planning and perioperative logistics, with variable discussion of perioperative risks vs benefits and infrequent elicitation of patient values and preferences. Some data suggest that patients wish to be involved in perioperative decision-making but are often limited by an incomplete understanding of risks and benefits. CONCLUSIONS AND RELEVANCE This systematic review found that communication in anesthesia is dominated by anesthetic planning and discussion of preoperative logistics, whereas postoperative critical care is rarely discussed. Most patients who are admitted to an intensive care unit after a major operation will not have had a discussion regarding goals of care specific to protracted recovery or prolonged intensive care with their anesthesiologist.
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Affiliation(s)
- Michael J. Tylee
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Department of Anesthesia and Pain Management, University Health Network, Toronto General Hospital, Toronto, Ontario, Canada
- Department of Anesthesia, University of Toronto, Toronto, Ontario, Canada
| | - Gordon D. Rubenfeld
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Interdepartmental Division of Critical Care, University of Toronto, Li Ka Shing Knowledge Institute, Toronto, Ontario, Canada
| | - Duminda Wijeysundera
- Department of Anesthesia, University of Toronto, Toronto, Ontario, Canada
- Department of Anesthesia, St Michael’s Hospital, Toronto, Ontario, Canada
| | - Michael C. Sklar
- Interdepartmental Division of Critical Care, University of Toronto, Li Ka Shing Knowledge Institute, Toronto, Ontario, Canada
| | - Sajid Hussain
- Department of Intensive Care Medicine, King AbdulAziz Medical City, Riyadh, Saudi Arabia
| | - Neill K. J. Adhikari
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Interdepartmental Division of Critical Care, University of Toronto, Li Ka Shing Knowledge Institute, Toronto, Ontario, Canada
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Surgical Duration Implicated in Major Postoperative Complications in Total Hip and Total Knee Arthroplasty: A Retrospective Cohort Study. JOURNAL OF THE AMERICAN ACADEMY OF ORTHOPAEDIC SURGEONS GLOBAL RESEARCH AND REVIEWS 2020; 4:e20.00043. [PMID: 33156161 PMCID: PMC7643914 DOI: 10.5435/jaaosglobal-d-20-00043] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Total hip and knee arthroplasties are two of the most commonly performed orthopaedic surgeries and are expected to increase in incidence in the coming decades. We sought to examine whether the duration of these procedures is related to various postoperative complications using data from 2010 to 2017 from the American College of Surgeons National Surgical Quality Improvement Program database.
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The religious/spiritual beliefs and needs of cancer survivors who underwent cancer-directed surgery. Palliat Support Care 2020; 19:175-181. [DOI: 10.1017/s1478951520000772] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
AbstractObjectiveWe sought to characterize patients’ preferences for the role of religious and spiritual (R&S) beliefs and practices during cancer treatment and describe the R&S resources desired by patients during the perioperative period.MethodA cross-sectional survey was administered to individuals who underwent cancer-directed surgery. Data on demographics and R&S beliefs/preferences were collected and analyzed.ResultsAmong 236 participants, average age was 58.8 (SD = 12.10) years; the majority were female (76.2%), white (94.1%), had a significant other or spouse (60.2%), and were breast cancer survivors (43.6%). Overall, more than one-half (55.9%) of individuals identified themselves as being religious, while others identified as only spiritual (27.9%) or neither (16.2%). Patients who identified as religious wanted R&S integrated into their care more often than patients who were only spiritual or neither (p < 0.001). Nearly half of participants (49.6%) wanted R&S resources when admitted to the hospital including the opportunity to speak with an R&S leader (e.g., rabbi; 72.1%), R&S texts (64.0%), and journaling materials (54.1%). Irrespective of R&S identification, 68.0% of patients did not want their physician to engage with them about R&S topics.Significance of resultsAccess to R&S resources is important during cancer treatment, and incorporating R&S into cancer care may be especially important to patients that identify as religious. R&S needs should be addressed as part of the cancer care plan.
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Normahani P, Sounderajah V, Harrop-Griffiths W, Chukwuemeka A, Peters NS, Standfield NJ, Collins M, Jaffer U. Achieving good-quality consent: review of literature, case law and guidance. BJS Open 2020; 4:757-763. [PMID: 32475083 PMCID: PMC7528509 DOI: 10.1002/bjs5.50306] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Revised: 01/20/2020] [Accepted: 05/05/2020] [Indexed: 01/22/2023] Open
Abstract
Background Informed consent is an integral part of clinical practice. There is widespread agreement amongst health professionals that obtaining procedural consent needs to move away from a unidirectional transfer of information to a process of supporting patients in making informed, self‐determined decisions. This review aimed to identify processes and measures that warrant consideration when engaging in consent‐based discussions with competent patients undergoing elective procedures. Methods Formal written guidance from the General Medical Council and Royal College of Surgeons of England, in addition to peer‐reviewed literature and case law, was considered in the formulation of this review. Results A framework for obtaining consent is presented that is informed by the key tenets of shared decision‐making (SDM), a model that advocates the contribution of both the clinician and patient to the decision‐making process through emphasis on patient participation, analysis of empirical evidence, and effective information exchange. Moreover, areas of contention are highlighted in which further guidance and research are necessary for improved enhancement of the consent process. Conclusion This SDM‐centric framework provides structure, detail and suggestions for achieving meaningful consent.
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Affiliation(s)
- P Normahani
- Imperial Vascular Unit, London, UK.,Department of Surgery and Cancer, London, UK
| | - V Sounderajah
- Imperial Vascular Unit, London, UK.,Department of Surgery and Cancer, London, UK
| | - W Harrop-Griffiths
- Anaesthetic Department, London, UK.,Department of Surgery and Cancer, London, UK
| | - A Chukwuemeka
- Department of Cardiothoracic Surgery, London, UK.,Department of Surgery and Cancer, London, UK
| | - N S Peters
- Connected Care Bureau, Imperial College NHS Healthcare Trust, London, UK.,National Lung and Heart Institute, Imperial College London, London, UK
| | - N J Standfield
- Imperial Vascular Unit, London, UK.,Department of Surgery and Cancer, London, UK
| | - M Collins
- London Borough of Hounslow Council, London, UK
| | - U Jaffer
- Imperial Vascular Unit, London, UK.,Department of Surgery and Cancer, London, UK
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Hatchimonji JS, Huston-Paterson HH, Dortche K, Orji W, Ganta N, O'Connor N, Kaplan LJ, Martin ND. Do we know our patients' goals? Evaluating preoperative discussions in emergency surgery. Am J Surg 2020; 220:861-862. [PMID: 32560921 DOI: 10.1016/j.amjsurg.2020.05.028] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 05/18/2020] [Accepted: 05/18/2020] [Indexed: 11/15/2022]
Affiliation(s)
- Justin S Hatchimonji
- Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.
| | - Hattie H Huston-Paterson
- Department of Surgery, David Geffen School of Medicine at the University of California Los Angeles, Los Angeles, CA, USA.
| | - Kristina Dortche
- Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.
| | - Whitney Orji
- Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.
| | - Niharika Ganta
- Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.
| | - Nina O'Connor
- Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA. nina.o'
| | - Lewis J Kaplan
- Division of Traumatology, Emergency Surgery, and Surgical Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.
| | - Niels D Martin
- Division of Traumatology, Emergency Surgery, and Surgical Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.
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Lafaro KJ, Li A, Rodriguez J, Clark K, Loscalzo M, Wong FL, Melstrom LG, Warner SG. Surgeon and patient perceptions of cure in advanced gastrointestinal malignancies: Are we on the same page? J Surg Oncol 2020; 122:489-494. [PMID: 32441359 DOI: 10.1002/jso.25986] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Accepted: 05/09/2020] [Indexed: 11/06/2022]
Abstract
BACKGROUND AND OBJECTIVES Effective communication is essential to complex shared decision making and is associated with improved recovery and pain control. However, patients and surgeons often have disparate expectations of treatment efficacy and perceptions of cure for advanced malignancies. This study measures correlation of patient and surgeon expectations with perceptions of cure. METHODS Our prospective study surveying surgeon-patient dyads before and after surgical consultation was performed for advanced abdominal malignancy between July and November 2017 at a single NCI designated cancer center using electronic questionnaires. RESULTS Patients and surgeons' own opinions regarding surgical candidacy (Q1), chance at cure (Q2), and life expectancy (Q3) did not measurably change from pre- to postvisit survey as evidenced by unchanged response concordance (patients Q1 P = .82; Q2 P = .81; and Q3 P = .53; surgeon responses Q1: P = .17; Q2: P = .32; and Q3: P = .50). Patient and surgeon perception of likelihood of cure and of estimated life expectancy remained discordant in pre- and postvisit surveys (Q2: P = .006 and Q3: P = .03). CONCLUSIONS These data highlight the stark differences between patient and surgeon perceptions of cure and prognosis of gastrointestinal cancers. These results prove that a larger scale study using this electronic questionnaire is feasible and important to better understand these differences and enhance shared decision making.
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Affiliation(s)
- Kelly J Lafaro
- Department of Surgery, Johns Hopkins University, Baltimore, Maryland
| | - Arthur Li
- Department of Population Sciences, City of Hope National Medical Center, Duarte, California
| | - Jenny Rodriguez
- Department of Supportive Care Medicine, City of Hope National Medical Center, Duarte, California
| | - Karen Clark
- Department of Supportive Care Medicine, City of Hope National Medical Center, Duarte, California
| | - Matthew Loscalzo
- Department of Supportive Care Medicine, City of Hope National Medical Center, Duarte, California
| | - F Lennie Wong
- Department of Population Sciences, City of Hope National Medical Center, Duarte, California
| | - Laleh G Melstrom
- Department of Surgery, City of Hope National Medical Center, Duarte, California
| | - Susanne G Warner
- Department of Surgery, City of Hope National Medical Center, Duarte, California
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Shaw S, Hughes G, Stephens T, Pearse R, Prowle J, Ashcroft RE, Avagliano E, Day J, Edsell M, Edwards J, Everest L. Understanding decision making about major surgery: protocol for a qualitative study of shared decision making by high-risk patients and their clinical teams. BMJ Open 2020; 10:e033703. [PMID: 32376751 PMCID: PMC7223149 DOI: 10.1136/bmjopen-2019-033703] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION Surgical treatments are being offered to more patients than ever before, and increasingly to high-risk patients (typically multimorbid and over 75). Shared decision making is seen as essential practice. However, little is currently known about what 'good' shared decision making involves nor how it applies in the context of surgery for high-risk patients. This new study aims to identify how high-risk patients, their families and clinical teams negotiate decision making for major surgery. METHODS AND ANALYSIS Focusing on major joint replacement, colorectal and cardiac surgery, we use qualitative methods to explore how patients, their families and clinicians negotiate decision making (including interactional, communicative and informational aspects and the extent to which these are perceived as shared) and reflect back on the decisions they made. Phase 1 involves video recording 15 decision making encounters about major surgery between patients, their carers/families and clinicians; followed by up to 90 interviews (with the same patient, carer and clinician participants) immediately after a decision has been made and again 3-6 months later. Phase 2 involves focus groups with a wider group of (up to 90) patients and (up to 30) clinicians to test out emerging findings and inform development of shared decision making scenarios (3-5 summary descriptions of how decisions are made). ETHICS AND DISSEMINATION The study forms the first part in a 6-year programme of research, Optimising Shared decision-makIng for high-RIsk major Surgery (OSIRIS). Ethical challenges around involving patients at a challenging time in their lives will be overseen by the programme steering committee, which includes strong patient representation and a lay chair. In addition to academic outputs, we will produce a typology of decision making scenarios for major surgery to feed back to patients, professionals and service providers and inform subsequent work in the OSIRIS programme.
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Affiliation(s)
- Sara Shaw
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Gemma Hughes
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Tim Stephens
- School of Medicine & Dentistry, Queen Mary University of London, London, UK
| | - Rupert Pearse
- Barts and the London School of Medicine & Dentistry, Queen Mary University of London, London, UK
| | - John Prowle
- Barts and the London School of Medicine & Dentistry, Queen Mary University of London, London, UK
| | | | - Ester Avagliano
- Department of Anaesthesia, St. George's University Hospitals Foundation Trust, London, UK
| | - James Day
- Department of Anaesthesia, John Radcliffe Hospital, Oxford, UK
| | - Mark Edsell
- Department of Anaesthesia, St. George's University Hospitals Foundation Trust, London, UK
| | - Jennifer Edwards
- Department of Anaesthesia, Royal Alexandra Hospital, Paisley, UK
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Evidence-Based Gardening: Using Palliative Approaches to Cure Complex Wounds. Ann Plast Surg 2019; 83:S45-S49. [PMID: 31513065 DOI: 10.1097/sap.0000000000002100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Complex wounds are commonly thought to require aggressive surgical intervention to achieve healing. However, optimal healing results can often be achieved when greater emphasis is placed on optimizing patient factors prior to any surgical intervention. A retrospective review was performed of pressure ulcers and complex wound cases treated over 5 years at the Yale New Haven Wound Center. Optimal healing including clinical resolution of osteomyelitis and improved scarring was achieved when patient factors, such as glucose control and nutrition, were optimized. Surgical intervention can be more effective and even avoided entirely with the appropriate focus on optimizing patient factors.
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Marterre B, Clayville K. Navigating the Murky Waters of Hope, Fear, and Spiritual Suffering: An Expert Co-Captain's Guide. Surg Clin North Am 2019; 99:991-1018. [PMID: 31446923 DOI: 10.1016/j.suc.2019.06.013] [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: 10/26/2022]
Abstract
How can surgeons deliver compassionate, holistic care to patients who are beyond cure? Interacting emotionally and understanding hope, fear, and spiritual suffering is key. Responsibly reframing hope to underlying meanings, and away from specific outcomes, is critical. Facilitating moves from cure to comfort to a peaceful dying process requires some retooling of the surgical toolbox. Surgeons possess a unique set of skills, including imagination and an undying sense of hope. Surgeons who have the courage to delve into their emotions and sustain realistic hope for their patients, all the way to the end, will reap deep personal and professional rewards.
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Affiliation(s)
- Buddy Marterre
- Surgical Palliative Care, Department of General Surgery, Wake Forest Baptist Health, 5th Floor, Watlington Hall, Medical Center Boulevard, Winston-Salem, NC 27157, USA.
| | - Kristel Clayville
- Zygon Center for Religion and Science, MacLean Center for Clinical Medical Ethics, 1100 East 55th Street, Chicago, IL 60615, USA
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Aslakson RA, Chandrashekaran SV, Rickerson E, Fahy BN, Johnston FM, Miller JA, Conca-Cheng A, Wang S, Morris AM, Lorenz K, Temel JS, Smith TJ. A Multicenter, Randomized Controlled Trial of Perioperative Palliative Care Surrounding Cancer Surgery for Patients and Their Family Members (PERIOP-PC). J Palliat Med 2019; 22:44-57. [PMID: 31486730 PMCID: PMC7366274 DOI: 10.1089/jpm.2019.0130] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/19/2019] [Indexed: 12/19/2022] Open
Abstract
Background: Despite positive outcomes associated with specialist palliative care (PC) in diverse medical populations, little research has investigated specialist PC in surgical ones. Although cancer surgery is predominantly safe, operations can be extensive and unpredictable perioperative morbidity and mortality persist, particularly for patients with upper gastrointestinal (GI) cancers. Objectives and Hypotheses: Our objective is to complete a multicenter, randomized controlled trial comparing surgeon-PC co-management with surgeon-alone management among patients pursuing curative-intent surgery for upper GI cancers. We hypothesize that perioperative PC will improve patient postsurgical quality of life. This study and design are based on >8 years of engagement and research with patients, family members, and clinicians surrounding major cancer surgery and advance care planning/PC for surgical patients. Methods: Randomized controlled superiority trial with two study arms (surgeon-PC team co-management and surgeon-alone management) and five data collection points over six months. The principal investigator and analysts are blinded to randomization. Setting: Four, geographically diverse, academic tertiary care hospitals. Data collection began December 20, 2018 and continues to December 2020. Participants: Patients recruited from surgical oncology clinics who are undergoing curative-intent surgery for an upper GI cancer. Interventions: In the intervention arm, patients receive care from both their surgical team and a specialist PC team; the PC is provided before surgery, immediately after surgery, and at least monthly until three months postsurgery. Patients randomized to the usual care arm receive care from only the surgical team. Main Outcomes and Measures: Primary outcome: patient quality of life. Secondary outcomes: patient: symptom experience, spiritual distress, prognostic awareness, health care utilization, and mortality. Caregiver: quality of life, caregiver burden, spiritual distress, and prognostic awareness. Intent-to-treat analysis will be used. Ethics and Dissemination: This study has been approved by the institutional review boards of all study sites and is registered on clinicaltrials.gov (NCT03611309, First received: August 2, 2018).
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Affiliation(s)
- Rebecca A. Aslakson
- Division of Primary Care and Population Health, Department of Medicine, Stanford University, Stanford, California
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University, Stanford, California
| | - Shivani V. Chandrashekaran
- Division of Primary Care and Population Health, Department of Medicine, Stanford University, Stanford, California
| | - Elizabeth Rickerson
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Bridget N. Fahy
- Department of Surgery, University of New Mexico, Albuquerque, New Mexico
| | - Fabian M. Johnston
- Division of Surgical Oncology, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | | | - Alison Conca-Cheng
- The Warren Alpert Medical School, Brown University, Providence, Rhode Island
| | - Suwei Wang
- Division of Primary Care and Population Health, Department of Medicine, Stanford University, Stanford, California
| | - Arden M. Morris
- Stanford-Surgery Policy Improvement Research and Education Center, Stanford University, Stanford, California
| | - Karl Lorenz
- Division of Primary Care and Population Health, Department of Medicine, Stanford University, Stanford, California
- VA Palo Alto Health Care System, Palo Alto, California
| | - Jennifer S. Temel
- Division of Hematology and Oncology, Department of Medicine, Cancer Center, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Thomas J. Smith
- Sidney Kimmel Comprehensive Cancer Center, The Johns Hopkins University, Baltimore, Maryland
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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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Abstract
Shared decision making requires the exchange of information from the patient and the surgeon (and ideally involves the expertise of the entire multidisciplinary team) to determine the medical and/or surgical treatment that best aligns with the patient's goals and values. Should the surgical patient wish to transition to end-of-life care, the transition to comfort-focused care is within the scope of practice for surgeons. Incorporating the expertise of other health care professionals is an important consideration for whole-patient care. Integrating primary palliative care into surgical practice can help mitigate unnecessary suffering and allow a smoother transition to comfort-focused care.
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Affiliation(s)
- Christine C Toevs
- Terre Haute Regional Hospital, 3901 South 7th Street, Terre Haute, IN 47802, USA; Indiana University School of Medicine, Terre Haute, IN, USA.
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Turnbull AE, Bosslet GT, Kross EK. Aligning use of intensive care with patient values in the USA: past, present, and future. THE LANCET RESPIRATORY MEDICINE 2019; 7:626-638. [PMID: 31122892 DOI: 10.1016/s2213-2600(19)30087-6] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Revised: 03/06/2019] [Accepted: 03/06/2019] [Indexed: 10/26/2022]
Abstract
For more than three decades, both medical professionals and the public have worried that many patients receive non-beneficial care in US intensive care units during their final months of life. Some of these patients wish to avoid severe cognitive and physical impairments, and protracted deaths in the hospital setting. Recognising when intensive care will not restore a person's health, and helping patients and families embrace goals related to symptom relief, interpersonal connection, or spiritual fulfilment are central challenges of critical care practice in the USA. We review trials from the past decade of interventions designed to address these challenges, and present reasons why evaluating, comparing, and implementing these interventions have been difficult. Careful scrutiny of the design and interpretation of past trials can show why improving goal concordant care has been so elusive, and suggest new directions for the next generation of research.
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Affiliation(s)
- Alison E Turnbull
- Division of Pulmonary and Critical Care Medicine, School of Medicine, Department of Epidemiology, Bloomberg School of Public Health, and Outcomes After Critical Illness and Surgery Group, Johns Hopkins University, Baltimore, MD, USA.
| | - Gabriel T Bosslet
- Division of Pulmonary, Allergy, Critical Care, Occupational, and Sleep Medicine, and Charles Warren Fairbanks Center for Medical Ethics, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Erin K Kross
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, WA, USA
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Aslakson RA, Isenberg SR, Crossnohere NL, Conca-Cheng AM, Moore M, Bhamidipati A, Mora S, Miller J, Singh S, Swoboda SM, Pawlik TM, Weiss M, Volandes A, Smith TJ, Bridges JFP, Roter DL. Integrating Advance Care Planning Videos into Surgical Oncologic Care: A Randomized Clinical Trial. J Palliat Med 2019; 22:764-772. [PMID: 30964385 DOI: 10.1089/jpm.2018.0209] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
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.
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Affiliation(s)
- Rebecca A Aslakson
- 1 Palliative Care Section, Department of Medicine, Stanford University School of Medicine, Stanford, California.,2 Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, California.,3 Department of Health, Behavior, and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Sarina R Isenberg
- 3 Department of Health, Behavior, and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland.,4 Temmy Latner Centre for Palliative Care and Lunenfeld-Tanenbaum Research Institute, Sinai Health System, Toronto, Ontario, Canada
| | - Norah L Crossnohere
- 3 Department of Health, Behavior, and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Alison M Conca-Cheng
- 5 Department of Anesthesiology and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Madeleine Moore
- 5 Department of Anesthesiology and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Akshay Bhamidipati
- 5 Department of Anesthesiology and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Silvia Mora
- 5 Department of Anesthesiology and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Judith Miller
- 6 Patient/Family Member Co-Investigator, Ellicott City, Maryland
| | - Sarabdeep Singh
- 5 Department of Anesthesiology and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Sandra M Swoboda
- 7 Department of Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Timothy M Pawlik
- 8 Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Matthew Weiss
- 7 Department of Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Angelo Volandes
- 9 Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Thomas J Smith
- 10 Department of Oncology and Palliative Care Program, Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins University, Baltimore, Maryland
| | - John F P Bridges
- 8 Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Debra L Roter
- 3 Department of Health, Behavior, and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
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