Palliative Care Consult Tied to Better End-of-Life Care, QoL After High-Risk Surgery

By Marilynn Larkin

January 08, 2020

NEW YORK (Reuters Health) - A palliative care consultation was associated with better end-of-life care and experiences for families of patients who died after high-risk surgery, a retrospective analysis suggests. However, such a consult is not widely implemented.

"Our paper reflects a growing body of research and experience that shows the value and use of palliative care around the time of surgery," Dr. Karl Lorenz Section Chief, VA Palo Alto - Stanford Palliative Care Programs in California, told Reuters Health by email. "It's time to start applying this knowledge."

"On the one hand, the 'right patients get the right care,' as better communication about risks and personal values helps target surgery," he noted. "However, it might also be true that 'knowing risks helps teams proceed carefully,' in that a team of individuals aware of risks can better monitor for adverse events and prepare to proactively address them."

The secondary analysis of data from the Veterans Affairs Healthcare System included patients who underwent any of 227 high-risk operations between 2012 - 2015. Outcomes were family-reported ratings of overall care, communication, and support in the patient's last month of life, as assessed by the VA's Bereaved Family Survey.

As reported in JAMA Surgery, 95,204 patients underwent high-risk operations in 129 inpatient VA medical centers. Most (72.8%) were 65 years or older, and the most common procedures were cardiothoracic (32.7%) or vascular (24.7%).

The 90-day mortality rate was 6%, varying by subspecialty from 3.8% in urologic surgery to 14.1% in neurosurgery.

After adjustment for patient characteristics, surgical subspecialty of the high-risk operation, and survey nonresponse, families of decedents who received a palliative-care consultation within 30 days before or 90 days after surgery were 47% more likely to rate overall care in the last month of life as excellent (odds ratio, 1.47).

Similarly, families of decedents who received palliative care were more likely to rate as excellent both the end-of-life communication (OR, 1.43) and support (OR, 1.31) components of medical care.

However, of the entire cohort, only 3,374 patients (3.5%) had a palliative care consultation within the perioperative window, and only 0.8% received it preoperatively. The median time to consultation was 12 days postoperatively.

Exposure to palliative care was higher among decedents who died within 90 days (29.9%); however, few had it before surgery (5.6%).

Coauthor Dr. Jason M. Johanning of Nebraska-Western Iowa VA Medical Center, Omaha, said two main obstacles stand in the way of widespread use of palliative care in surgical patients: "The first is the ability to recognize those most likely to benefit from palliative care. Secondly, the field of palliative care is challenged by a limited number of providers to physically see and attend to this growing population as we experience the silver tsunami - i.e., palliative care workforce issues."

Dr. Daniel Hall of the University of Pittsburgh and Veterans Affairs Pittsburgh Healthcare System, author of a related editorial, commented by email, "As important as it is to minimize all-cause mortality, the ultimate success of surgery depends on how well it fosters a sense of flourishing in the aspects of life, other than mere health, that make life worth living."

"I see logistical, technical and moral barriers," he told Reuters Health. "Logistically, there are not enough palliative care providers to meet the needs of the silver tsunami of aging baby boomers. This leads to the technical problem that most physicians lack training in the discrete communication skills necessary for this work, and the entrance requirements for medical training do not emphasize these skills."

"All of this stems from the moral failure that as a culture, both within medicine and in the wider public, we have lost the will to acknowledge and discuss the inevitability of death," he said. "Death is difficult and scary, and without robust cultural supports, we typically adopt the posture of the ostrich with our heads firmly buried in the sand."

The study authors as well as Dr. Hall urge widespread adoption of the VA's Bereaved Family Survey (http://bit.ly/36ykKWI).

SOURCE: http://bit.ly/2ZVNeaf and http://bit.ly/301E2kP JAMA Surgery, online January 2, 2020.

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