Palliative surgery: state of the science and future directions.

Palliative surgical procedures are operations that aim to alleviate symptoms in a patient with serious, life-limiting illness. They are common, particularly within the field of surgical oncology. However, few high-quality studies have attempted to measure the durability of improvements in symptoms and quality of life after palliative surgery. Furthermore, many of the studies that do exist are outdated and employ highly inconsistent definitions of palliative surgery. Consequently, the paucity of robust and reliable evidence on the benefits, risks, and trade-offs of palliative surgery hampers clinical decision-making for patients and their surgeons. The evidence for palliative surgery suggests that, with effective communication about goals of care and careful patient selection, palliative surgery can provide symptomatic relief and reduce healthcare burdens for certain seriously ill patients.

High symptom burden in patients undergoing gastrectomy for cancer.

BACKGROUND: There is little data describing symptom burden before or after gastrectomy for patients with cancer. We aimed to examine the perioperative patterns of symptom severity in patients undergoing gastrectomy. METHODS: In this single-institution prospective cohort study, patients scheduled to undergo gastrectomy for cancer completed serial symptom measurement questionnaires preoperatively, at postoperative day (POD) 1-3, and POD 4-7. The percent of patients with moderate to severe scores was calculated at each time point. RESULTS: Thirty-nine patients completed 94 surveys. Preoperatively, 46% reported at least one moderate/severe symptom. This increased to 88% during POD 1-3 and 79% during POD 4-7. During the preoperative period, 25% of patients reported moderate to severe interference in at least one aspect of daily life. This increased to 73% of patients at both POD 1-3 and POD 4-7. CONCLUSIONS: Patients undergoing gastrectomy for cancer frequently experience symptoms that interfere with daily life. A better understanding of these symptoms may improve patients' experiences with, and recovery from, gastrectomy.

A Practical Guide to Inflow Control, Retraction, and Exposure for Robotic Hepatectomy.

Establishment of inflow control and gentle effective retraction of the liver for optimal exposure are critical to safe hepatectomy. Multiple methods have been previously reported for inflow control in minimally invasive (MIS) hepatectomy including Huang's Loop.1-3 We describe here the assembly and use of our modified version of Huang's loop that permits adjustable, atraumatic, and totally intracorporeal inflow control. We use a soft 16-French urinary catheter with a single premade opening near the blunt tip, across which a small slit is created. A beveled cut is made to the catheter 12-15 cm from the blunt tip and a suture sewn there that can be grasped to pull this beveled tail through the slit and window around the porta hepatis; this loop can be tightened or loosened with ease. For liver retraction, current techniques can be traumatic, especially when instruments apply traction directly onto the liver.4 Our preferred approach utilizes a liver sling made from a soft, rolled surgical sponge with 15-cm silk ties secured at each end; the length of the sling can be adjusted on the basis of thickness of the liver. The sling applies gentle, atraumatic "pulling" traction and is especially useful for exposure of the right posterior sector. We also use external band retraction to align the transection plane with the camera.5 Both also provide countertraction when advancing instruments into a firm or fibrotic liver. These techniques are commonly used in our MIS practice, and we have found them to be cost-efficient, easily reproducible, and effective.

Communication Frameworks for Palliative Surgical Consultations: A Randomized Study of Advanced Cancer Patients.

OBJECTIVE: To evaluate whether patients with advanced cancer prefer surgeons to use the best case/worst case (BC/WC) communication framework over the traditional risk/benefit (R/B) framework in the context of palliative surgical scenarios. BACKGROUND: Identifying the patient's preferred communication frameworks may improve satisfaction and outcome measures during difficult clinical decision-making. METHODS: In a video-vignette-based randomized, double-blinded study from November 2020 to May 2021, patients with advanced cancer viewed 2 videos depicting a physician-patient encounter in a palliative surgical scenario, in which the surgeon uses either the BC/WC or the R/B framework to discuss treatment options. The primary outcome was the patients' preferred video surgeon. RESULTS: One hundred fifty-five patients were approached to participate; 66 were randomized and 58 completed the study (mean age 55.8 ± 13.8 years, 60.3% males). 22 patients (37.9%, 95% CI: 25.4%-50.4%) preferred the surgeon using the BC/WC framework, 21 (36.2%, 95% CI: 23.8%-48.6%) preferred the surgeon using the R/B framework, and 15 (25.9%, 95% CI: 14.6%-37.2%) indicated no preference. High trust in the medical profession was inversely associated with a preference for the surgeon using BC/WC framework (odds ratio: 0.83, 95% CI: 0.70-0.98, P = 0.03). The BC/WC framework rated higher for perceived surgeon's listening (4.6 ± 0.7 vs 4.3±0.9, P = 0.03) and confidence in the surgeon's trustworthiness (4.3 ± 0.8 vs 4.0 ± 0.9, P = 0.04). CONCLUSIONS: Surgeon use of the BC/WC communication framework was not universally preferred but was as acceptable to patients as the traditional R/B framework and rated higher in certain aspects of communication. A preference for a surgeon using BC/WC was associated with lower trust in the medical profession. Surgeons should consider the BC/WC framework to individualize their approach to challenging clinical discussions.

What Are the Priorities in Surgical Palliative Care Research?

In the 20 years since the American College of Surgeons outlined the first research agenda for surgical palliative care, there has been immense growth in the evidence. In this article, we briefly review the state of the science and priority research areas in surgical palliative care.

Navigating Difficult Conversations: Breaking Bad News and Exploring Goals of Care in Surgical Patients.

Surgeons who provide care for patients with cancer are sometimes tasked with challenging conversations. Approaching difficult communications using a structured approach for delivering difficult news and exploring goals of care can help surgeons provide support to patients and their families.

Variation in Serious Illness Communication among Surgical Patients Receiving Palliative Care.

Background: Natural language processing (NLP), a form of computer-assisted data abstraction, rapidly identifies serious illness communication domains such as code-status confirmation and goals of care (GOC) discussions within free-text notes, using a codebook of phrases. Differences in the phrases associated with palliative care for patients with different types of illness are unknown. Objective: To compare communication of code-status clarification and GOC discussions between patients with advanced pancreatic cancer undergoing palliative procedures and patients admitted with life-threatening trauma. Design: Retrospective cohort study. Setting/Subjects: Patients with in-hospital admissions within two academic medical centers. Measurements: Sensitivity and specificity of NLP-identified communication domains compared with manual review. Results: Among patients with advanced pancreatic cancer (n = 523), NLP identified code-status clarification in 54% of admissions and GOC discussions in 49% of admissions. The sensitivity and specificity for code-status clarification were 94% and 99% respectively, while the sensitivity and specificity for a GOC discussion were 93% and 100%, respectively. Using the same codebook in patients with life-threatening trauma (n = 2093), NLP identified code-status clarification in 25.9% of admissions and GOC discussions in 6.3% of admissions. While NLP identification had 100% specificity, the sensitivity for code-status clarification and GOC discussion was reduced to 86% and 50%, respectively. Adding dynamic phrases such as "ongoing discussions" and phrases related to "family meetings" increased the sensitivity of the NLP codebook for code status to 98% and for GOC discussions to 100%. Conclusions: Communication of code status and GOC differ between patients with advanced cancer and those with life-threatening trauma. Recognition of these differences can aid in identification in patterns of palliative care delivery.

Mixed-Methods Evaluation of Real-Time Safety Reporting by Hospitalized Patients and Their Care Partners: The MySafeCare Application.

OBJECTIVE: The aims of the study were to evaluate the amount and content of data patients and care partners reported using a real-time electronic safety tool compared with other reporting mechanisms and to understand their perspectives on safety concerns and reporting in the hospital. METHODS: This study used mixed methods including 20-month preimplementation and postimplementation trial evaluating MySafeCare, a web-based application, which allows hospitalized patients/care partners to report safety concerns in real time. The study compared MySafeCare submission rates for three hospital units (oncology acute care, vascular intermediate care, medical intensive care) with submissions rates of Patient Family Relations (PFR) Department, a hospital service to address patient/family concerns. The study used triangulation of quantitative data with thematic analysis of safety concern submissions and patient/care partner interviews to understand submission content and perspectives on safety reporting. RESULTS: Thirty-two MySafeCare submissions were received with an average rate of 1.7 submissions per 1000 patient-days and a range of 0.3 to 4.8 submissions per 1000 patient-days across all units, indicating notable variation between units. MySafeCare submission rates were significantly higher than PFR submission rates during the postintervention period on the vascular unit (4.3 [95% confidence interval = 2.8-6.5] versus 1.5 [95% confidence interval = 0.7-3.1], Poisson) (P = 0.01). Overall trends indicated a decrease in PFR submissions after MySafeCare implementation. Triangulated data indicated patients preferred to report anonymously and did not want concerns submitted directly to their care team. CONCLUSIONS: MySafeCare evaluation confirmed the potential value of providing an electronic, anonymous reporting tool in the hospital to capture safety concerns in real time. Such applications should be tested further as part of patient safety programs.

Deficits in the Palliative Care Process Measures in Patients with Advanced Pancreatic Cancer Undergoing Operative and Invasive Nonoperative Palliative Procedures.

BACKGROUND: Given survival measured in months, metrics, such as 30-day mortality, are poorly suited to measure the quality of palliative procedures for patients with advanced cancer. Nationally endorsed process measures associated with high-quality PC include code-status clarification, goals-of-care discussions, palliative-care referral, and hospice assessment. The impact of the performance of these process measures on subsequent healthcare utilization is unknown. METHODS: Administrative data and manual review were used to identify hospital admissions with performance of palliative procedures for advanced pancreatic cancer at two tertiary care hospitals from 2011 to 2016. Natural language processing, a form of computer-assisted abstraction, identified process measures in associated free-text notes. Healthcare utilization was compared using a Cox proportional hazard model. RESULTS: We identified 823 hospital admissions with performance of a palliative procedure. PC process measures were identified in 68% of admissions. Patients with documented process measures were older (66 vs. 63; p = 0.04) and had a longer length of stay (9 vs. 6 days; p < 0.001). In multivariate analysis, patients treated by surgeons were less likely to have PC process measures performed (odds ratio 0.19; 95% confidence interval 0.10-0.37). Performance of PC process measures was associated with decreased healthcare utilization in a Cox proportional hazard model. CONCLUSIONS: PC process measures were not performed in almost one-third of hospital admissions for palliative procedures in patients with advanced pancreatic cancer. Performance of established high-quality process measures for seriously ill patients undergoing palliative procedures may help patients to avoid burdensome, high-intensity care at the end-of-life.

Natural Language Processing to Assess End-of-Life Quality Indicators in Cancer Patients Receiving Palliative Surgery.

BACKGROUND: Palliative surgical procedures are frequently performed to reduce symptoms in patients with advanced cancer, but quality is difficult to measure. OBJECTIVE: To determine whether natural language processing (NLP) of the electronic health record (EHR) can be used to (1) identify a population of cancer patients receiving palliative gastrostomy and (2) assess documentation of end-of-life process measures in the EHR. DESIGN/SETTING: Retrospective cohort study of 302 adult cancer patients who received a gastrostomy tube at a single tertiary medical center. MEASUREMENTS: Sensitivity and specificity of NLP compared to gold standard of manual chart abstraction in identifying a palliative indication for gastrostomy tube placement and documentation of goals of care discussions, code status determination, palliative care referral, and hospice assessment. RESULTS: Among 302 cancer patients who underwent gastrostomy, 68 (22.5%) were classified by NLP as having a palliative indication for the procedure compared to 71 patients (23.5%) classified by human coders. Human chart abstraction took >2600 times longer than NLP (28 hours vs. 38 seconds). NLP identified the correct patients with 95.8% sensitivity and 97.4% specificity. NLP also identified end-of-life process measures with high sensitivity (85.7%-92.9%,) and specificity (96.7%-98.9%). In the two months leading up to palliative gastrostomy placement, 20.5% of patients had goals of care discussions documented. During the index hospitalization, 67.7% had goals of care discussions documented. CONCLUSIONS: NLP offers opportunities to identify patients receiving palliative surgical procedures and can rapidly assess established end-of-life process measures with an accuracy approaching that of human coders.

High Burden of Palliative Care Needs of Older Adults During Emergency Major Abdominal Surgery.

OBJECTIVES: To quantify preoperative illness burden in older adults undergoing emergency major abdominal surgery (EMAS), to examine the association between illness burden and postoperative outcomes, and to describe end-of-life care in the year after discharge. DESIGN: Retrospective study using data from Health and Retirement Study interviews linked to Medicare claims (2000-2012). SETTING: National population-based dataset. PARTICIPANTS: Medicare beneficiaries who underwent EMAS. MEASUREMENTS: High illness burden, defined as ≥2 of the following vulnerabilities: functional dependence, dementia, use of helpers, multimorbidity, poor prognosis, high healthcare utilization. In-hospital outcomes were complications and mortality. Postdischarge outcomes included emergency department (ED) visits, hospitalization, intensive care unit (ICU) stay, and 365-day mortality. For individuals discharged alive who died within 365 days of surgery, outcomes included hospice use, hospitalization, ICU use, and ED use in the last 30 days of life. Multivariable regression was used to determine the association between illness burden and outcomes. RESULTS: Of 411 participants, 57% had high illness burden. More individuals with high illness burden had complications (45% vs 28% p=0.00) and in-hospital death (20% vs 9%, p=0.00) than those without. After discharge (n=349), individuals with high illness burden experienced more ED visits (57% vs 46%, P=.04) and were more likely to die (35% vs 13%, p=0.00). Of those who died after discharge (n=86), 75% had high illness burden, median survival was 67 days (range 21-141 days), 48% enrolled in hospice, 32% died in the hospital, 23% were in the ICU in the last 30 days of life and 37% had an ED visit in the last 30 days of life. CONCLUSION: Most older adults undergoing EMAS have preexisting high illness burden and experience high mortality and healthcare use in the year after surgery, particularly near the end of life. Concurrent surgical and palliative care may improve quality of life and end-of-life care in these people. J Am Geriatr Soc 66:2072-2078, 2018.

Association of pain after trauma with long-term functional and mental health outcomes.

BACKGROUND: Chronic pain after trauma is associated with serious clinical, social, and economic burden. Due to limitations in trauma registry data and previous studies, the current prevalence of chronic pain after trauma is unknown, and little is known about the association of pain with other long-term outcomes. We sought to describe the long-term burden of self-reported pain after injury and to determine its association with positive screen for posttraumatic stress disorder (PTSD), functional status, and return to work. METHODS: Trauma survivors with moderate or severe injuries and one completed follow-up interview at either 6 months or 12 months after injury were identified from the Functional Outcomes and Recovery after Trauma Emergencies project. Multivariable logistic regression models clustered by facility and adjusting for confounders were used to obtain the odds of positive PTSD screening, not returning to work, and functional limitation at 6 months and 12 months after injury, in trauma patients who reported to have pain on a daily basis compared to those who did not. RESULTS: We completed interviews on 650 patients (43% of eligible patients). Half of patients (50%) reported experiencing pain daily, and 23% reported taking pain medications daily between 6 months and 12 months after injury. Compared to patients without pain, patients with pain were more likely to screen positive for PTSD (odds ratio [OR], 5.12; 95% confidence interval [CI], 2.97-8.85), have functional limitations for at least one daily activity (OR, 2.42; 95% CI, 1.38-4.26]), and not return to work (OR, 1.86; 95% CI, 1.02-3.39). CONCLUSIONS: There is a significant amount of self-reported chronic pain after trauma, which is in turn associated with positive screen for PTSD, functional limitations, and delayed return to work. New metrics for measuring successful care of the trauma patient are needed that span beyond mortality, and it is important we shift our focus beyond the trauma center and toward improving the long-term morbidity of trauma survivors. LEVEL OF EVIDENCE: Therapeutic/Care management, level III.

The impact of inpatient palliative care on end-of-life care among older trauma patients who die after hospital discharge.

BACKGROUND: Palliative care (PC) is associated with lower-intensity treatment and better outcomes at the end of life. Trauma surgeons play a critical role in end-of-life (EOL) care; however, the impact of PC on health care utilization at the end of life has yet to be characterized in older trauma patients. METHODS: This retrospective cohort study using 2006 to 2011 national Medicare claims included trauma patients 65 years or older who died within 180 days after discharge. The exposure of interest was inpatient PC during the trauma admission. A non-PC control group was developed by exact matching for age, comorbidity, admission year, injury severity, length of stay, and post-discharge survival. We used logistic regression to evaluate six EOL care outcomes: discharge to hospice, rehospitalization, skilled nursing facility or long-term acute care hospital admission, death in an institutional setting, and intensive care unit admission or receipt of life-sustaining treatments during a subsequent hospitalization. RESULTS: Of 294,665 patients who died within 180 days after discharge, 2.1% received inpatient PC. Among 5,693 matched pairs, inpatient PC was associated with increased odds of discharge to hospice (odds ratio [OR], 3.80; 95% confidence interval [CI], 3.54-4.09) and reduced odds of rehospitalization (OR, 0.17; 95% CI, 0.15-0.20), skilled nursing facility/long-term acute care hospital admission (OR, 0.43; 95% CI, 0.39-0.47), death in an institutional setting (OR, 0.34; 95% CI, 0.30-0.39), subsequent intensive care unit admission (OR, 0.51; 95% CI, 0.36-0.72), or receiving life-sustaining treatments (OR, 0.56; 95% CI, 0.39-0.80). CONCLUSION: Inpatient PC is associated with lower-intensity and less burdensome EOL care in the geriatric trauma population. Nonetheless, it remains underused among those who die within 6 months after discharge. LEVEL OF EVIDENCE: Therapeutic/Care management, level III.

Applying User-Centered Design Methods to the Development of an mHealth Application for Use in the Hospital Setting by Patients and Care Partners.

INTRODUCTION: Developing an optimized and user-friendly mHealth application for patients and family members in the hospital environment presents unique challenges given the diverse patient population and patients' various states of well-being. OBJECTIVE: This article describes user-centered design methods and results for developing the patient and family facing user interface and functionality of MySafeCare, a safety reporting tool for hospitalized patients and their family members. METHODS: Individual and group usability sessions were conducted with specific testing scenarios for participants to follow to test the usability and functionality of the tool. Participants included patients, family members, and Patient and Family Advisory Council (PFAC) members. Engagement rounds were also conducted on study units and lessons learned provided additional information to the usability work. Usability results were aligned with Nielsen's Usability Heuristics. RESULTS: Eleven patients and family members and 25 PFAC members participated in usability testing and over 250 patients and family members were engaged during research team rounding. Specific themes resulting from the usability testing sessions influenced the changes made to the user interface design, workflow functionality, and terminology. CONCLUSION: User-centered design should focus on workflow functionality, terminology, and user interface issues for mHealth applications. These themes illustrated issues aligned with four of Nielsen's Usability Heuristics: match between system and the real world, consistency and standards, flexibility and efficiency of use, and aesthetic and minimalist design. We identified workflow and terminology issues that may be specific to the use of an mHealth application focused on safety and used by hospitalized patients and their families.

Increased hospice enrollment and decreased neurosurgical interventions without changes in mortality for older Medicare patients with moderate to severe traumatic brain injury.

BACKGROUND: Hospice improves quality and value of end of life care (EOLC), and enrollment has increased for older patients dying from chronic medical conditions. It remains unknown if the same is true for older patients who die after moderate to severe traumatic brain injury (msTBI). METHODS: Subjects included Medicare beneficiaries (≥65 years) who were hospitalized for msTBI from 2005 to 2011. Outcomes included intensity and quality of EOLC for decedents within 30 days of admission, and 30-day mortality for the entire cohort. Logistic regression was used to analyze the association between year of admission, mortality, and EOLC. RESULTS: Among 50,342 older adults, 30-day mortality was 61.2%. Mortality was unchanged over the study period (aOR 0.93 [0.87-1.00], p = 0.06). Additionally, 30-day non-survivors had greater odds of hospice enrollment, lower odds of undergoing neurosurgery, but greater odds of gastrostomy. CONCLUSION: Between 2005 and 2011, hospice enrollment increased, but there was no change in 30-day mortality.

A Pilot Study to Evaluate Compliance with Guidelines for Preprocedural Reconsideration of Code Status Limitations.

BACKGROUND: Periprocedural providers are encountering more patients with code status limitations (CSLs) regarding their preferences for resuscitation and life-sustaining treatment who choose to undergo palliative procedures. Surgical and anesthesia guidelines for preprocedural reconsideration of CSLs have been available for several years, but it is not known whether they are being followed in practice. OBJECTIVE: We assessed compliance with existing guidelines for patients undergoing venting gastrostomy tube (VGT) for malignant bowel obstruction (MBO), serving as an example of a palliative procedure received by patients near the end of life. DESIGN: Code status was determined at admission and throughout the hospitalization by chart review. Documentation of code status discussions (CSDs) was identified from provider notes and compared with existing guidelines. SETTING/SUBJECTS: An institutional database retrospectively identified patients who underwent VGT placement for MBO at two academic hospitals (2014-2015). MEASUREMENTS: We identified 53 patients who underwent VGT placement for MBO. Interventional radiologists performed 88% of these procedures. Other periprocedural providers involved in these cases included surgeons, gastroenterologists, anesthesiologists, and sedation nurses. RESULTS: CSLs were documented before the procedure in only 43% of cases, and a documented CSD with a periprocedural provider was identified in only 22% of CSL cases. Of all VGT placements performed in patients with CSLs before the procedure, only 13% were compliant with the guidelines of preprocedural reconsideration of CSLs. CONCLUSIONS: Increased compliance with guidelines published by the American Society of Anesthesiologists, the American College of Surgeons, and the Association of Perioperative Registered Nurses is necessary to ensure goal-concordant care of patients with CSLs who undergo a procedure. Efforts should be made to incorporate these guidelines into the training of all periprocedural providers.

Critical differences between elective and emergency surgery: identifying domains for quality improvement in emergency general surgery.

OBJECTIVE: The objective of our study was to characterize providers' impressions of factors contributing to disproportionate rates of morbidity and mortality in emergency general surgery to identify targets for care quality improvement. BACKGROUND: Emergency general surgery is characterized by a high-cost burden and disproportionate morbidity and mortality. Factors contributing to these observed disparities are not comprehensively understood and targets for quality improvement have not been formally developed. METHODS: Using a grounded theory approach, emergency general surgery providers were recruited through purposive-criterion-based sampling to participate in semi-structured interviews and focus groups. Participants were asked to identify contributors to emergency general surgery outcomes, to define effective care for EGS patients, and to describe operating room team structure. Interviews were performed to thematic saturation. Transcripts were iteratively coded and analyzed within and across cases to identify emergent themes. Member checking was performed to establish credibility of the findings. RESULTS: A total of 40 participants from 5 academic hospitals participated in either individual interviews (n = 25 [9 anesthesia, 12 surgery, 4 nursing]) or focus groups (n = 2 [15 nursing]). Emergency general surgery was characterized by an exceptionally high level of variability, which can be subcategorized as patient-variability (acute physiology and comorbidities) and system-variability (operating room resources and workforce). Multidisciplinary communication is identified as a modifier to variability in emergency general surgery; however, nursing is often left out of early communication exchanges. CONCLUSION: Critical variability in emergency general surgery may impact outcomes. Patient-variability and system-variability, with focus on multidisciplinary communication, represent potential domains for quality improvement in this field.