Abstract
Dear Editor:
In a recent article in the Journal of Palliative Medicine, Doherty et al. 1 report on a patient who underwent significantly high-risk surgery after a preoperative palliative care (PC) team intervention to explore his goals and values and discuss his wishes regarding life-sustaining therapies (LSTs) in the event of postoperative complications. We agree that a preoperative PC intervention can support patients, families, and health care providers in shared decision making and informed consent conversations, which should include discussion of limitations and preferences regarding LST as a standard of care before high-risk surgery.
We have had significant experience with preoperative goals of care conversations in surgical patients. In 2014, our PC service implemented a mandatory PC intervention before all left ventricular assist device (LVAD) operations. 2 Having seen nearly 300 patients as part of this program, which was well received by the LVAD surgical team, we found an increase in PC consultations at the end of life and a decrease in hospital resource utilization for deceased patients who underwent LVAD implantation. 3 One of us (A.B.) has participated in a “surgeon–surgeon consultative model,” which utilizes the support of a surgical colleague with PC skills in high-risk cases preoperatively. 4
Although promising, there are challenges to implementing such interventions. The first is the potential reluctance by surgeons to having PC specialists or teams see their patients preoperatively. In much of surgical culture, PC is stigmatized, viewed as incompatible with disease-modifying surgical treatment, and conflated with end-of-life care. 5 In our institution, we have found that this can be surmounted by demonstrating that our service can improve patient and family outcomes broadly, and that benefits are not restricted merely to helping transition patients who are nearing the end of life. Preliminary and unpublished analyses of our pilot data suggest that patients seen by PC experience longer days alive outside the hospital, less costs associated with care, and report less pain compared with LVAD patients who had not seen by PC.
The knowledge and skill gap for providing PC services is another challenge. Many surgeons lack basic primary-level PC skills required to fully explore goals of care and conduct shared decision making preoperatively. Yet, due to the PC workforce shortage, it would not be practical for PC specialists to facilitate preoperative conversations for all high-risk surgery patients. We propose a communication training and “mentoring model” to build capacity for surgeons (or others) to conduct these preoperative conversations. In 2017, we started a mandatory communication skills practice training for general surgical residents derived from VitalTalk, conducting seven 2-hour sessions to train 31 residents. Given the positive feedback from learners, this has been formally added to the residency curriculum at our institution.
A “blended” PC educational intervention with ongoing mentoring of surgeons, coupled with specialist-level PC involvement for more complex cases, may be a viable and effective model to ensure that patients facing high-risk surgery or considering long-term device therapy have opportunities to express their deepest values and priorities, and enhance goal-concordant care at the end of life. Further research is warranted to evaluate the feasibility and impact on patient-centered outcomes of such interventions.