Frailty and Preoperative Palliative Care in Surgical Oncology.

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.

Time is Short: Tools to Integrate Palliative Care and Communication Skills Education into Your Surgical Residency.

The need to integrate palliative care (PC) training into surgical education has been increasingly recognized. Our aim is to describe a set of PC educational strategies, with a range of requisite resources, time, and prior expertise, to provide options that surgical educators can tailor for different programs. Each of these strategies has been successfully employed individually or in some combination at our institutions, and components can be generalized to other training programs. Asynchronous and individually paced PC training can be provided using existing resources published by the American College of Surgeons and upcoming SCORE curriculum modules. A multiyear PC curriculum, with didactic components of increasing complexity for more advanced residents, can be applied based on available time in the didactic schedule and local expertise. Simulation-based training in PC skills can be developed to provide objective competency-based training. Finally, a dedicated rotation on a surgical palliative care service can provide the most immersive experience with steps toward clinical entrustment of PC skills for trainees.

Integrating Surgical Palliative Care Into the Full Spectrum of Medical Education.

We describe our institutional approach to incorporating surgical palliative care education into the Undergraduate Medical Education, Graduate Medical Education and Continuing Medical Education spaces as a model to help guide similarly interested educators. We had a well-established Ethics and Professionalism Curriculum, but an educational needs assessment revealed that both the residents and faculty felt that additional training in palliative care principles was crucial. We describe our full spectrum palliative care curriculum, which begins with the medical students on their surgical clerkship and continues with a 4 week surgical palliative care rotation for categorical general surgery PGY-1 residents, as well as a Mastering Tough Conversations course over several months at the end of the first year. Surgical Critical Care rotations, Intensive Care Unit debriefs after major complications, deaths, and other high-stress events are described, as is the CME domain, which includes routine Department of Surgery Death Rounds and a focus on palliative care concepts in Departmental Morbidity and Mortality conference. The Peer Support program and Surgical Palliative Care Journal Club round out our current educational endeavor. We describe our plans to create a full spectrum surgical palliative care curriculum that is fully integrated with the 5 clinical years of surgical residency, and include our proposed educational goals and year-specific objectives. The development of a Surgical Palliative Care Service is also described.

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.

Critical decisions in the trauma intensive care unit: Are we practicing primary palliative care?

BACKGROUND: Devastating injuries require both urgent assessment by a trauma service and early attention to patients' goals of care (GOC). American College of Surgeons Trauma Quality Improvement Program (TQIP) guidelines recommend an initial palliative assessment within 24 hours of admission and family meeting, if needed, within 72 hours. We hypothesize that a primary palliative care-based practice improves adherence to TQIP guidelines in trauma patients. METHODS: All adult trauma patients who died while inpatient from January 2014 to December 2018 were reviewed. Timing of GOC discussions, transition to comfort measures only (CMO), and the utilization of specialty palliative services were analyzed with univariate analysis. RESULTS: During the study period, 415 inpatients died. Median Injury Severity Score was 26 (interquartile range [IQR], 17-34), median age was 67 years (IQR, 51-81 years), and 72% (n = 299) transitioned to CMO before death. Documented GOC discussions increased from 77% of patients in 2014 to 95% of patients in 2018 (p < 0.001), and in 2018, the median time to the first GOC discussion was 15 hours (IQR, 7- 24 hours). Specialty palliative care was consulted in 7% of all patients. Of patients who had at least one GOC discussion, 98% were led by the trauma intensive care unit (TICU) team. Median time from admission to first GOC discussion was 27 hours (IQR, 6-91 hours). Median number of GOC discussions was 1 (IQR, 1-2). Median time to CMO after the final GOC discussion was 0 hours (IQR, 0-3). Median time to death after transition to CMO was 4 hours (IQR, 1-18 hours). CONCLUSION: Of those who died during index admission, we demonstrated significant improvement in adherence to American College of Surgeons TQIP palliative guidelines across the 5-year study period, with the TICU team guiding the majority of GOC discussions. Our TICU team has developed an effective primary palliative care approach, selectively consulting specialty palliative care only when needed. LEVEL OF EVIDENCE: Therapeutic/care management, level III.

How I Do It a Surgical Palliative Care Rotation for Residents.

To address the need for increased exposure to the essential components of Palliative Care in our residency, we created a 4 week rotation in Surgical Palliative Care for all of our categorical interns. The rotation includes time on an interdisciplinary inpatient consultative palliative care service as well as time in the outpatient clinic and in the operating room with the Surgical Palliative Care attending. Most patients who are seen and evaluated have surgical issues, allowing exposure to the fundamental aspects of palliative care as they pertain to surgical practice across the continuum of healthcare settings. Communication around serious illness, complicated decision making, complex pain and symptom management, withdrawal of life-sustaining treatment, and end-of-life care are all integral parts of the rotation. The rotation has been very favorably received by the residents, and the impact on the culture of the department has been tremendous as well. The structured approach provided, including goals and objectives and the weekly schedule, make this rotation easily replicable in other residency programs.

Mitigating Burnout.

Burnout is characterized by emotional exhaustion, depersonalization, and a reduced sense of personal accomplishment. All physicians, and especially surgeons, are at risk for developing burnout. The best strategies for mitigating burnout mimic a modern approach to medicine: the development of preventive practices to protect, promote, and maintain health and well-being. Job satisfaction, job engagement, and compassion satisfaction help protect from burnout. Individual commitment to self-care in conjunction with support from within health care organizations create the optimal framework in which burnout can be mitigated.

Surgical palliative care training in general surgery residency: An educational needs assessment.

INTRODUCTION: There is increasing recognition that Surgical Palliative Care is an essential component of the holistic care of surgical patients and involves more than end-of-life care in the intensive care unit. General surgery residents are clinically exposed to patients with palliative care needs during each year of training, but few have a dedicated surgical palliative care curriculum. We undertook this educational needs assessment as the first step towards a longitudinal curriculum. METHODS: We conducted an anonymous survey of 94 general surgery residents and 115 faculty at community and university hospitals to assess their experience and comfort with surgical palliative care delivery. Residents and faculty were asked multiple choice and open-ended questions. RESULTS: There was a 55% response rate from residents and 33% response rate from faculty. The majority (77%) of respondents were junior residents (PGY1-3) and university-based faculty (66%). Approximately half of residents felt comfortable leading conversations in goals of care (58%), comfort-focused care (52%) and delivering bad news (57%), while greater than 90% of faculty agreed that chief residents needed additional training. All residents agreed they needed additional training and 85% wanted a formal curriculum. Analysis of open-ended questions suggests a deficiency in the pre-operative setting as no residents had participated in these conversations in an outpatient setting. CONCLUSION: Residents and faculty believe trainees would benefit from further education in surgical palliative care with a dedicated curriculum. The outpatient, pre-operative counseling of patients was identified as a key learning need. These data support our ongoing work to develop a surgically pertinent palliative care curriculum.