What Should the Surgeons Do at the Family Meeting: A Multi-Disciplinary Qualitative Description of Surgeon Participation in Palliative Care Discussions.

OBJECTIVE: National guidelines have suggested that quality surgical care should incorporate effective palliative care (PC). Numerous barriers to surgeon participation remain and the domains of optimal surgeon participation are unclear. DESIGN: Eight semi-structured and multi-professional focus groups with 34 total participants. Discussion was transcribed, and qualitative approaches were used to encode, identify, and categorize emergent themes. SETTING: Oregon Health & Science University, Portland Oregon. A tertiary care teaching hospital. PARTICIPANTS: 34 multi-disciplinary participants in eight focus groups, identified on a volunteer basis. RESULTS: Key themes defining domains of optimal surgeon/palliative practice include: (1) "primary/secondary PC" which detailed conflict between the surgeon's desire to be part of palliative discussions and competing clinical/time demands. (2) "role/responsibility" described the tension surgeons feel around a desire to provide honest and goal concordant care (3) "teamwork/conflict" detailed the approach to disagreement among multidisciplinary teams. CONCLUSIONS: In this qualitative analysis, emergent themes suggest that surgeons want to be involved in the PC of their patients but are limited by available time and competing for ethical obligations. Tension between competing communication and care obligations and PC goals is common, and discord around patient goals remains an issue. This work highlights the need for a standardized curriculum to improve the PC of surgical patients.

Supporting surgical residents learning clinical palliative care: Insights from multi-disciplinary focus groups.

BACKGROUND: A shortage of palliative care (PC) sub-specialists highlights the need for quality PC provided by treating surgeons, although no established curriculum exists to teach surgical residents PC skills. To guide curriculum development, we sought to determine what modifiable factors contribute to surgical residents successfully providing PC. METHODS: Eight focus groups with 34 participants were conducted. Semi-structured interviews were recorded, transcribed, and de-identified. Inductive thematic analysis was utilized to encode, identify, and categorize emergent themes. RESULTS: Barriers to resident involvement in PC included: Limited Knowledge/Inexperience, Communication Difficulties, Time Constraints, and Burnout. Factors supporting resident involvement included: Patient Relationship/Rapport, Expertise Guiding PC Discussions, and Institutional Support. Communication skills that support successful PC delivery include establishing rapport, managing conflicts, avoiding bias, and acknowledging personal/scientific limitations. DISCUSSION: This work identifies modifiable factors that support surgical residents providing PC. Faculty and institutional support, resident education on PC principles, and expanding clinical experience with PC may be the most modifiable from a programmatic perspective. Curriculum and process development focused on these areas will help optimize surgical resident's success delivering PC.

Teaching primary palliative care to general surgical residents: A novel pedagogical approach drawn from multi-disciplinary focus group data.

BACKGROUND: Primary palliative care (PPC) is provided by the primary team and is essential for high-quality surgical care. There is a recognized PPC clinical and research need but little work on the optimal way to teach PPC to general surgery residents. We sought to define important factors of PPC pedagogy (i.e. nature and practice of teaching). METHODS: Eight semi-structured and multi-professional focus groups (n = 34) were performed. Discussion was transcribed, and de-identified. Qualitative approaches were used to encode, identify, and categorize emergent themes. RESULTS: Emergent themes included: establishing a baseline knowledge, use of existing resources, simulation and debriefings, and emphasis on authentic clinical opportunities with graduated responsibility. A tension between resident entrustability and hesitancy of faculty to entrust was identified. CONCLUSIONS: PPC must be taught in surgical residency and the themes identified here will inform development and implementation of a PPC curriculum.

Effective Palliative Care in the Trauma Setting.

A 55-year-old man undergoes emergent exploratory laparotomy and splenectomy following a motorcycle collision. Following surgery, he is found to have a traumatic brain injury requiring decompressive craniectomy and intracranial pressure monitoring. The patient then continues to have complications throughout his hospital course. Using the American College of Surgeons Trauma Quality Improvement Program guidelines, the surgical team has early and ongoing primary palliative care discussions to foster communication and determine goals of care for the patient. As the patient deteriorates, the surgical team continues meeting with the patient's surrogate decision makers to discuss the best case and worst case scenarios regarding the patient's prognosis and expected quality of life.