1
|
Colley A, Broering J, Lee K, Lin JA, Pierce L, Finlayson E, Sudore RL, Wick EC. "It Gives Me Peace of Mind So I Can Focus on Healing": Views on Advance Care Planning for Older Surgical Patients. J Palliat Med 2024; 27:667-674. [PMID: 38386513 PMCID: PMC11238830 DOI: 10.1089/jpm.2023.0589] [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] [Accepted: 01/22/2024] [Indexed: 02/24/2024] Open
Abstract
Introduction: The period of time before an elective operation may be an opportune time to engage older adults in advance care planning (ACP). Past interventions have not been readily incorporated into surgical workflows leaving a need for ACP tools that are generalizable, easy to implement, and effective. Design: This is a qualitative study. Setting and Subjects: Older adults with a history of cancer and a recent major operation were recruited through their surgical oncologist at a tertiary medical center in the United States. Interviews were conducted to determine how to adapt the validated PrepareForYourCare.org ACP program with electronic health record prompts for the perioperative setting and openness to introducing ACP during a presurgical visit. We used qualitative content analysis to determine themes. Results: Eight themes were identified: (1) ACP as static and private, (2) people expected a prompt, (3) family trusted to do the "right" thing, (4) lack of relationship or comfort with providers, (5) a team-based approach can be helpful, (6) surgeon's expertise (e.g., prognosis and surgical risk), (7) ACP belongs on the surgical checklist, and (8) patients would welcome a conversation starter. Discussion: Older surgical patients are interested in engaging with ACP, particularly if prompted, and believe it has a place on the preoperative "checklist." Conclusions: To effectively engage patients with ACP, a combination of routine prompts by the health care team and patient-centered follow-up may be required.
Collapse
Affiliation(s)
- Alexis Colley
- Department of Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Jeannette Broering
- Department of Urology, University of California, San Francisco, San Francisco, California, USA
| | - Katherine Lee
- Division of Palliative Medicine, University of California, San Francisco, California, USA
| | - Joseph A. Lin
- Department of Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Logan Pierce
- Department of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Emily Finlayson
- Department of Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Rebecca L. Sudore
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Elizabeth C. Wick
- Department of Surgery, University of California, San Francisco, San Francisco, California, USA
| |
Collapse
|
2
|
Lin JA, Colley A, Pierce L, Finlayson E, Sudore RL, Wick EC. Clinician Review of Advanced Care Planning for Older Surgical Patients Requiring Intensive Care. Jt Comm J Qual Patient Saf 2024; 50:154-156. [PMID: 37926671 PMCID: PMC10890795 DOI: 10.1016/j.jcjq.2023.09.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Revised: 09/21/2023] [Accepted: 09/29/2023] [Indexed: 11/07/2023]
|
3
|
Blank J, Shiroff AM, Kaplan LJ. Surgical Emergencies in Patients with Significant Comorbid Diseases. Surg Clin North Am 2023; 103:1231-1251. [PMID: 37838465 DOI: 10.1016/j.suc.2023.06.003] [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: 10/16/2023]
Abstract
Emergency surgery in patients with significant comorbidities benefits from a structured approach to preoperative evaluation, intra-operative intervention, and postoperative management. Providing goal concordant care is ideal using shared decision-making. When operation cannot achieve the patient's goal, non-operative therapy including Comfort Care is appropriate. When surgical therapy is offered, preoperative physiology-improving interventions are far fewer than in other phases. Reevaluation of clinical care progress helps define trajectory and inform goals of care. Palliative Care Medicine may be critical in supporting loved ones during a patient's critical illness. Outcome evaluation defines successful strategies and outline opportunities for improvement.
Collapse
Affiliation(s)
- Jacqueline Blank
- Department of Surgery, Division of Trauma, Surgical Critical Care, and Emergency Surgery, Perelman School of Medicine, University of Pennsylvania, 51 North 39th Street, MOB 1, Suite 120, Philadelphia, PA 19104, USA
| | - Adam M Shiroff
- Department of Surgery, Division of Trauma, Surgical Critical Care, and Emergency Surgery, Perelman School of Medicine, University of Pennsylvania, 51 North 39th Street, MOB 1, Suite 120, Philadelphia, PA 19104, USA; Surgical Services, Section of Surgical Critical Care and Emergency General Surgery, Corporal Michael J. Crescenz VA Medical Center, 3900 Woodland Avenue, Philadelphia, PA 19104, USA
| | - Lewis J Kaplan
- Department of Surgery, Division of Trauma, Surgical Critical Care, and Emergency Surgery, Perelman School of Medicine, University of Pennsylvania, 51 North 39th Street, MOB 1, Suite 120, Philadelphia, PA 19104, USA; Surgical Services, Section of Surgical Critical Care and Emergency General Surgery, Corporal Michael J. Crescenz VA Medical Center, 3900 Woodland Avenue, Philadelphia, PA 19104, USA.
| |
Collapse
|
4
|
Devin CL, Shaffer VO. Advanced care planning: A step in the right direction. Surgery 2023; 174:1276. [PMID: 37574331 DOI: 10.1016/j.surg.2023.06.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Revised: 05/28/2023] [Accepted: 06/18/2023] [Indexed: 08/15/2023]
Affiliation(s)
- Courtney L Devin
- Department of Surgery, Emory University School of Medicine, Atlanta, GA. https://twitter.com/voshaffer
| | - Virginia O Shaffer
- Department of Surgery, Emory University School of Medicine, Atlanta, GA.
| |
Collapse
|
5
|
Colley A, Lin J, Pierce L, Johnson C, Bongiovanni T, Finlayson E, Sudore R, Wick EC. Experiences with targeting inpatient advance care planning for emergency general surgery patients: A resident-led quality improvement project. Surgery 2023; 174:844-850. [PMID: 37183132 PMCID: PMC10526751 DOI: 10.1016/j.surg.2023.04.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Revised: 03/09/2023] [Accepted: 04/09/2023] [Indexed: 05/16/2023]
Abstract
BACKGROUND For patients who may permanently or temporarily lose their ability to communicate preferences, advance care planning is a critical mechanism to guide medical decision-making but is currently underused among surgical patients. METHODS A resident-led quality improvement project, including education and performance measurement, was conducted on an emergency general surgery service to increase the completion of inpatient advance care planning notes using a specialized template in the electronic health record. Advance care planning documentation was defined as either preadmission advance care planning documentation (eg, advance directive) or inpatient advance care planning (use of the electronic health record template). Data from patients admitted to the emergency general surgery service for 12+ hours were analyzed, and baseline data (July 2020 to June 2021) were compared with data from the intervention period (July 2021 to June 2022). The chart review evaluated the content of the inpatient advance care planning documentation from the intervention period. RESULTS The frequency of inpatient advance care planning documentation increased (9.3%, n = 56 to 16.6%, n = 92, P < .001) with a greater contribution of inpatient advance care planning notes by the surgery team (16.7% to 55.4%) in the intervention period. Content analysis indicated that 79.0% of inpatient advance care planning notes listed preferences for life-sustaining therapy, 78.3% listed surrogacy, 57.3% listed overall health goals, and 50.3% listed treatment goals specific to the surgical encounter. CONCLUSION Although a resident-led quality improvement project contributed to greater adoption of standardized inpatient advance care planning documentation on an emergency general surgery service, progress was slow, and integration into standard work was not achieved. Future efforts are needed to better understand the integration of essential advance care planning elements into workflows and to establish inclusive educational programming to prepare all team members for conducting and documenting advance care planning conversations.
Collapse
Affiliation(s)
- Alexis Colley
- Department of Surgery, University of California-San Francisco, CA. http://www.twitter.com/Alexis_ColleyMD
| | - Joseph Lin
- Department of Surgery, University of California-San Francisco, CA
| | - Logan Pierce
- Department of Medicine, University of California-San Francisco, CA
| | | | | | - Emily Finlayson
- Department of Surgery, University of California-San Francisco, CA
| | - Rebecca Sudore
- Division of Geriatrics, Department of Medicine, University of California-San Francisco, CA
| | - Elizabeth C Wick
- Department of Surgery, University of California-San Francisco, CA.
| |
Collapse
|
6
|
Hao S, Reis HL, Wercholuk AN, Snyder RA, Parikh AA. Prehabilitation for Older Adults Undergoing Liver Resection: Getting Patients and Surgeons Up to Speed. J Am Med Dir Assoc 2022; 23:547-554. [PMID: 35247359 DOI: 10.1016/j.jamda.2022.01.077] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Revised: 01/19/2022] [Accepted: 01/27/2022] [Indexed: 12/13/2022]
Abstract
OBJECTIVES Morbidity rates following liver resection are high, especially among older adult patients. This review aims to evaluate the evidence surrounding prehabilitation in older patients anticipating liver resection and to describe how prehabilitation may be implemented. DESIGN Problem-based narrative review with case-based discussion. SETTING AND PARTICIPANTS All older adults anticipating liver resection inclusive of benign and malignant etiologies in the United States. METHODS Literature search was performed using MeSH terms and keywords in MEDLINE via PubMed, followed by a manual second search for relevant references within selected articles. Articles were excluded if not available in the English language or did not include patients undergoing hepatectomy. RESULTS Prehabilitation includes a range of activities including exercise, nutrition/dietary changes, and psychosocial interventions that may occur from several weeks to days preceding a surgical operation. Older adult patients who participate in prehabilitation may experience improvement in preoperative candidacy as well as improved postoperative quality of life and faster return to baseline; however, evidence supporting a reduction in postoperative length of stay and perioperative morbidity and mortality is conflicting. A variety of modalities are available for prehabilitation but lack consensus and standardization. For a provider desiring to prescribe prehabilitation, multidisciplinary assessments including geriatric, cardiopulmonary, and future remnant liver function can help determine individual patient needs and select appropriate interventions. CONCLUSIONS AND IMPLICATIONS In the older adult patient undergoing liver resection, the current body of literature suggests promising benefits of prehabilitation programs inclusive of functional assessment as well as multimodal interventions. Additional research is needed to determine best practices.
Collapse
Affiliation(s)
- Scarlett Hao
- Division of Surgical Oncology, Department of Surgery, Brody School of Medicine at East Carolina University, Greenville, NC, USA
| | - Heidi L Reis
- Health Sciences Library, Brody School of Medicine at East Carolina University, Greenville, NC, USA
| | - Ashley N Wercholuk
- Division of Surgical Oncology, Department of Surgery, Brody School of Medicine at East Carolina University, Greenville, NC, USA
| | - Rebecca A Snyder
- Division of Surgical Oncology, Department of Surgery, Brody School of Medicine at East Carolina University, Greenville, NC, USA; Department of Public Health, Brody School of Medicine at East Carolina University, Greenville, NC, USA
| | - Alexander A Parikh
- Division of Surgical Oncology, Department of Surgery, Brody School of Medicine at East Carolina University, Greenville, NC, USA.
| |
Collapse
|
7
|
Pennarola BW, Fry A, Prichett L, Beri AE, Shah NN, Wiener L. Mapping the Landscape of Advance Care Planning in Adolescents and Young Adults Receiving Allogeneic Hematopoietic Stem Cell Transplantation: A 5-Year Retrospective Review. Transplant Cell Ther 2022; 28:164.e1-164.e8. [PMID: 34936929 PMCID: PMC8923987 DOI: 10.1016/j.jtct.2021.12.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Revised: 12/03/2021] [Accepted: 12/05/2021] [Indexed: 12/17/2022]
Abstract
Allogeneic hematopoietic stem cell transplantation (HSCT) carries significant risks of morbidity and mortality. Participation in advance care planning (ACP) is crucial to promote patient-centered care and has been shown to have positive impacts on patients, caregivers, and providers. Historically, both HSCT recipients and adolescents and young adults (AYAs) are significantly less likely to engage in ACP. We sought to characterize ACP utilization in AYAs undergoing HSCT by evaluating the frequency of different types of ACP documentation over time and identifying demographic and clinical factors associated with documentation of each type of ACP. We conducted a single-center retrospective review of the electronic health record (EHR) of AYAs (age 15 to 39 years) who underwent allogeneic HSCT between 2015 and 2020. EHR documents were screened for 3 predefined categories of ACP: (1) advance directives (ADs) or medical orders (MOs), which included proof of signed paper directives, expressions of preferred code status, and identification of a healthcare proxy; (2) goals of care (GOC) conversations, which included discussions of medical care in a specific situation informed by patients' priorities; and (3) other ACP conversations, which included more general discussions of patients' values regarding their care or legacy wishes. Documents were coded by 2 researchers, and discrepant categorizations were reviewed by a third researcher. Patients age <18 years on the day of transplantation were excluded in the analyses of AD/MO documentation. Univariate and multivariate logistic regression were used to test for associations between patient factors and documentation of each type of ACP. For deceased patients, Kaplan-Meier curves were created to illustrate the time-to-event relationship between days before death and documentation of each type of ACP. Sixty-eight thousand documents associated with 219 patients were reviewed, and 666 ACP documents associated with 190 patients were identified. Few of the 219 patients had documented GOC (n = 29; 13%) or other ACP conversations (n = 81; 37%). A subset of patients (n = 28; 13%) had no documented ACP. Most of the 201 patients age ≥18 years had a documented AD/MO (n = 172; 86%). No tested factors were significantly associated with documentation of ADs/MOs. GOC and other ACP conversations were more likely to occur in patients with a palliative care consult, and patients with a malignant diagnosis were also more likely to engage in GOC conversations. More than 50% of the documentation occurred in the subset of 39 deceased patients, with one-half of AD/MO documentation in the last 67 days of life, one-half of other ACP documentation in the last 20 days of life, and one-half of GOC documentation in the final 2 days of life. Although the majority of AYA patients receiving HSCT did have documentation of ADs/MOs, few patients had documented GOC or other ACP conversations. The bulk of all ACP conversations occurred in patients that ultimately died and who were very close to the end of life. Our results support ongoing efforts to improve the implementation of ACP in this vulnerable population, particularly for those undergoing HSCT for nonmalignant conditions.
Collapse
Affiliation(s)
- Brian W Pennarola
- Pediatric Oncology Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, Maryland; Department of Pediatric Oncology, Johns Hopkins Hospital, Baltimore, Maryland.
| | - Abigail Fry
- Pediatric Oncology Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - Laura Prichett
- Johns Hopkins School of Medicine, Department of Pediatrics, Biostatistics, Epidemiology, and Data Management Core, Baltimore, Maryland
| | - Andrea E Beri
- National Institutes of Health Biomedical Translational Research Information System, Bethesda, Maryland
| | - Nirali N Shah
- Pediatric Oncology Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - Lori Wiener
- Pediatric Oncology Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| |
Collapse
|