Efficacy of an Online Curriculum for Perioperative Goals of Care and Code Status Discussions: A Randomized Controlled Trial

Top Ten Tips Palliative Care Clinicians Should Know Before Their Patient Undergoes Surgery

Many seriously ill patients undergo surgical interventions. Palliative care clinicians may not be familiar with the nuances involved in perioperative care, however they can play a valuable role in enabling the delivery of patient-centered and goal-concordant perioperative care. The interval of time surrounding a surgical intervention is fraught with medical, psychosocial, and relational risks, many of which palliative care clinicians may be well-positioned to navigate. A perioperative palliative care consult may involve exploring gaps between clinician and patient expectations, facilitating continuity of symptom management or helping patients to designate a surrogate decision-maker before undergoing anesthesia. Palliative care clinicians may also be called upon to direct discussions around perioperative management of modified code status orders and to engage around the goal-concordance of proposed interventions. This article, written by a team of surgeons and anesthesiologists, many with subspecialty training in palliative medicine and/or ethics, offers ten tips to support palliative care clinicians and facilitate comprehensive discussion as they engage with patients and clinicians considering surgical interventions.

Anesthesiological Preoperative Interview with a Palliative Care Patient: A Simulation-Based Experiment Using Standardized Patients

Background and Objectives: Anesthesiologists come into contact with patients under palliative care in different clinical settings. They also routinely encounter these patients in their primary field of work, the operating room. Patients receiving palliative care who are scheduled for surgery will pose unique challenges in perioperative management, often presenting with advanced disease and with different psychosocial and ethical issues. This study aims to evaluate whether anesthesiologists without specialty training in palliative medicine will spot perioperative challenges presented by patients under palliative care and address them adequately. Materials and Methods: In this study, we simulated a preoperative anesthesiological interview using standardized patients and anesthesiologists (specialists as well as trainees). The standardized patients were asked to represent a patient under palliative care in need of surgery because of a mechanical ileus. We conducted 32 interviews, dividing the anesthesiologists into two groups. In one group, the standardized patients were instructed to address four problems, i.e., use of a port catheter for anesthesia, nausea and vomiting, pain medication, and an advance directive including a limitation of treatment (DNR-order). In the other group, these problems were also present, but were not actively addressed by the standardized patients if not asked for. The interviews were recorded, transcribed, and then analyzed. Results: In most cases, the medical problems were spontaneously identified and discussed. In only a few cases, however, was a therapy recommendation made for improved symptom control. The advance directive was spontaneously discussed by only 3 of the 32 (9%) anesthesiologists. In another 16 cases, the advance directive was discussed at the request of the standardized patients. The limitation of treatment stayed in place in all cases, and the discussion of the advance directives remained short, with an average duration of just over 5 min. Conclusions: In this study, the complex problems of patients under palliative care are not sufficiently taken into account in a preoperative anesthesiological interview. To improve treatment of the medical problems, therapists who have palliative medicine expertise, should be involved in the perioperative medical care, ideally as a multi-professional team. The discussion about perioperative limitations of treatment should be held beforehand, for example, as part of a structured advanced care planning discussion.

Assessing the educational quality of shared decision-making interventions for residents: A systematic review

OBJECTIVES

Many studies on educational interventions to enhance residents' shared decision-making (SDM) skills show limited improvement in SDM skills and clinical outcomes. One plausible explanation for these suboptimal results is the insufficient emphasis on the educational quality of training interventions.

METHODS

This review evaluates interventions' educational quality using an evaluation framework based on a previous study on effective skills transfer and a well-known SDM model. A systematic review was conducted, searching three databases until December 13, 2022. We assessed study quality by calculating MERSQI scores, examined the levels of study effects based on Kirkpatrick's model, and applied our evaluation framework to assess the interventions' educational quality. Given the heterogeneity among the studies, a meta-analysis was not feasible.

RESULTS

Twenty-six studies were included. Role-play and feedback were common training characteristics (65% and 54% of interventions). Only four studies (15%) met our framework's high educational quality threshold. No correlation was found between MERSQI scores and educational quality.

CONCLUSIONS

This review is a valuable attempt to assess the educational quality of SDM interventions beyond measuring study outcomes.

PRACTICE IMPLICATIONS

Future evaluation frameworks should consider study results, training characteristics, and training content. Our framework offers a sound basis for such an evaluation framework.

Video tools in pediatric goals of care communication: A systematic review

•Goals of Care resources are primarily in written format and for adult patients.•Video tools can support families of pediatric patients facing prognostic uncertainty.•Videos represent an effective but underutilized Goals of Care communication tool.

Digital Educational Interventions for the Development of Advanced Care Planning Skills for Medical Practitioners: A Scoping Review

BACKGROUND

Medical practitioners are important facilitators of advanced care planning but are often reluctant to engage in these conversations with patients and their families. Barriers to participation can be addressed through medical education for medical practitioners.

INTRODUCTION

The primary objective was to examine the extent to which digital educational interventions are used to foster advanced care planning skills. Secondary objectives include understanding the acceptability of these interventions and whether electronic health records can be used to personalize learning.

METHODS

Online databases were used to identify relevant articles published from 2008 to 2021. Nine articles which evaluated the impact of digital learning for medical practitioners were selected. Studies eligible for inclusion in the review assessed changes in knowledge, attitudes, and practice regarding skills used in advanced care planning.

RESULTS

All publications used a pre-post study design with education delivered solely online. Only three studies focused on completing advance care plans or directives (33%). All but two studies recorded improvements in knowledge and/or attitudes toward planning (78%) while three studies recorded improvements in clinical practice (33%). The review suggests prior clinical or personal experiences could be used to personalize education.

DISCUSSION

The literature revealed that using digital education to develop advanced care planning skills is relatively unexplored despite the ability of this type of learning to improve professional knowledge and confidence. Digital devices can also improve access to relevant information at the point-of-care. Personalized interventions that incorporate prior clinical experiences, potentially extracted from health records, could be used to optimize outcomes.

Addressing comorbidities in the perioperative setting and optimizing perioperative medicine education

PURPOSE OF REVIEW

Preoperative clinics and patient optimization are examples of collaborative, multidisciplinary care pathways that create value. This article reviews current literature to demonstrate the importance of preoperative enhancement of patients' cognitive and functional status. This article underscores the importance of formal training in multidisciplinary topics, such as frailty, brain health, and shared decision-making for anesthesiology house staff.

RECENT FINDINGS

Preoperative cognitive screening of older patients is a valuable metric for risk stratification and detection of patients at risk of postoperative delirium. Frailty is another syndrome that can be identified and optimized preoperatively. Sarcopenia has been shown to correlate with frailty; this shows promise as a method to detect frailty preoperatively.

SUMMARY

Anesthesiologists as perioperative physicians are in a unique position to lead and coordinate interdisciplinary conversations that incorporate patient goal concordant care and realistic assessment of perioperative complications. Formal house staff training in early recognition and management of patients at risk of adverse outcomes in the short and long term postoperatively improves patient outcomes and decreases healthcare spending.