Palliative Care and Characterization of Symptoms in Patients Undergoing Cytoreductive Surgery/Hyperthermic Intraperitoneal Chemotherapy.

INTRODUCTION: Palliative care for advanced cancer patients has been associated with improvements in symptom management and quality of life (QoL). Patients with peritoneal metastases undergoing cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) often report symptoms adversely affecting QoL. We characterized and compared symptoms elucidated by palliative care versus surgical providers in this setting. METHODS: CRS/HIPEC patients who saw both surgical oncology and palliative care providers from 2016 to 2020 at a tertiary care center were identified from a retrospective database. Documentation of QoL-associated symptoms in surgical oncology and palliative care visits was recorded and analyzed. RESULTS: A total of 118 patients were included in this study. The most common primary histologies were appendiceal (36.4%) and colorectal (28.8%). Symptoms most frequently reported by palliative care were pain (60.2%) and fatigue (54.2%). The median number of symptoms documented was three (2, 5) in palliative care notes and two (0, 3) in surgical oncology notes (P < 0.001). Palliative care providers documented most symptoms statistically more frequently than surgical oncology providers. CONCLUSIONS: Patients who underwent CRS/HIPEC experienced various QoL-associated symptoms. Palliative care providers elicited more symptoms than surgical oncology providers. Additional studies are needed to explore the impact on outcomes of perioperative palliative care in this challenging patient population.

Examining a Novel Legacy Activity for Elders: Oral Histories as Produced Stories.

Background: Many African American elders who participated in The Great Migration are in the latter years of their lives. One way to maintain their memories and those of elders at large is through legacy activities, projects that initiate a life review process resulting in a product surviving after an individual's death. However, literature on culturally attuned legacy activities as well as measurement of impact are limited. Objectives: This project sought to introduce a novel legacy activity for elders-the oral history as produced aural self-story-detailing its creation and examining its therapeutic efficacy. Design Setting and Subjects: Nine African American elders who experienced The Great Migration receiving care from an urban, geriatric clinic were recruited. Oral histories were conducted, produced into aural self-stories, and examined with follow-up interviews and a project evaluation survey. Qualitative analysis of the follow-up interview and a project evaluation survey were used to ascertain therapeutic outcomes. Results: : All participants recommended the project and found self-story listening meaningful or beneficial. Qualitative interviews produced 13 codes; the five most frequent were reflection/contemplation (n = 18), sentimentality/positive affect and affirmation/enlightenment (n = 10), as well as empathy/gratitude and curiosity/intrigue/peculiarity (n = 7). Conclusion: : Our project suggests that aural self-stories produced from oral histories enhance the current elder legacy activity landscape by facilitating meaning and existential affirmation, additionally leaving a product for subsequent generations. Future studies include comparison to existing legacy interventions and project examination in additional elder populations.

Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy postoperative symptomatology: palliative care impact.

OBJECTIVES: Palliative care (PC) for patients with advanced cancer has been associated with improved symptom burden and quality of life (QoL). This study aimed to characterise postoperative symptoms of cytoreductive surgery (CRS)/hyperthermic intraperitoneal chemotherapy (HIPEC) patients and to assess PC impact by analysing symptom burden before and after PC interventions. METHODS: CRS/HIPEC patients with two PC visits within 5 months postoperatively (2016-2021) at a tertiary care centre were identified from a retrospective database. For each patient, documentation of QoL-associated symptoms at the initial PC visit and changes in symptomatology at the second PC visit were recorded. Descriptive statistics were performed. RESULTS: 46 patients were included in this study. Median age was 62.2 (range 31.9-84.6) years. Median peritoneal cancer index was 23.5 (range 0-39). The most common histologies were colorectal (32.6%) and appendiceal (30.4%). Symptoms most frequently reported were pain (84.8%), fatigue (54.3%) and appetite loss/change (52.2%). Following PC interventions, most symptoms were stable or improved. The mean number of symptoms per patient was 3.7, with an average of 3.5 improved/stable and 0.5 worse/new onset at follow-up (p<0.001). CONCLUSION: CRS/HIPEC patients experienced a high QoL-associated symptom burden. Following postoperative PC interventions, significantly more symptoms were reported as improved/stable, compared with worse/new onset.

Early Integrated Palliative Care Within a Surgical Oncology Clinic.

Importance: Advance directive (AD) designation is an important component of advance care planning (ACP) that helps align care with patient goals. However, it is underutilized in high-risk surgical patients with cancer, and multiple barriers contribute to the low AD designation rates in this population. Objective: To assess the association of early palliative care integration with changes in AD designation among patients with cancer who underwent surgery. Design, Setting, and Participants: This cohort study was a retrospective analysis of a prospectively maintained registry of adult patients who underwent elective surgery for advanced abdominal and soft tissue malignant tumors at a surgical oncology clinic in a comprehensive cancer center with expertise in regional therapeutics between June 2016 and May 2022, with a median (IQR) postoperative follow-up duration of 27 (15-43) months. Data analysis was conducted from December 2022 to April 2023. Exposure: Integration of ACP recommendations and early palliative care consultations into the surgical workflow in 2020 using electronic health records (EHR), preoperative checklists, and resident education. Main Outcomes and Measures: The primary outcomes were AD designation and documentation. Multivariable logistic regression was performed to assess factors associated with AD designation and documentation. Results: Among the 326 patients (median [IQR] age 59 [51-67] years; 189 female patients [58.0%]; 243 non-Hispanic White patients [77.9%]) who underwent surgery, 254 patients (77.9%) designated ADs. The designation rate increased from 72.0% (131 of 182 patients) before workflow integration to 85.4% (123 of 144 patients) after workflow integration in 2020 (P = .004). The AD documentation rate did not increase significantly after workflow integration in 2020 (48.9% [89 of 182] ADs documented vs 56.3% [81 of 144] ADs documented; P = .19). AD designation was associated with palliative care consultation (odds ratio [OR], 41.48; 95% CI, 9.59-179.43; P < .001), palliative-intent treatment (OR, 5.12; 95% CI, 1.32-19.89; P = .02), highest age quartile (OR, 3.79; 95% CI, 1.32-10.89; P = .01), and workflow integration (OR, 2.05; 95% CI, 1.01-4.18; P = .048). Patients who self-identified as a race or ethnicity other than non-Hispanic White were less likely to have designated ADs (OR, 0.36; 95% CI, 0.17-0.76; P = .008). AD documentation was associated with palliative care consulation (OR, 4.17; 95% CI, 2.57- 6.77; P < .001) and the highest age quartile (OR, 2.41; 95% CI, 1.21-4.79; P = .01). Conclusions and Relevance: An integrated ACP initiative was associated with increased AD designation rates among patients with advanced cancer who underwent surgery. These findings demonstrate the feasibility and importance of modifying clinical pathways, integrating EHR-based interventions, and cohabiting palliative care physicians in the surgical workflow for patients with advanced care.

Advantages and Challenges of an Interdisciplinary Palliative Care Team Approach to Surgical Care.

Palliative care is an interdisciplinary field that focuses on optimizing quality of life for patients with serious, life-limiting illnesses and includes aggressive management of pain and symptoms; psychological, social, and spiritual support; and discussions of advance care planning, including treatment decision making and complex care coordination. Early palliative care is associated with increased quality of life, decreased symptom burden, decreased health care expenditures, and improved caregiver outcomes. This article discusses integrating interdisciplinary palliative care into surgical practice, and some current models of using and expanding palliative care skill sets in surgery, including training initiatives for both physicians and nurses.