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

Top Ten Tips Palliative Care Clinicians Should Know Before Their Patient Undergoes Surgery

Many seriously ill patients undergo surgical interventions. Palliative care clinicians may not be familiar with the nuances involved in perioperative care, however they can play a valuable role in enabling the delivery of patient-centered and goal-concordant perioperative care. The interval of time surrounding a surgical intervention is fraught with medical, psychosocial, and relational risks, many of which palliative care clinicians may be well-positioned to navigate. A perioperative palliative care consult may involve exploring gaps between clinician and patient expectations, facilitating continuity of symptom management or helping patients to designate a surrogate decision-maker before undergoing anesthesia. Palliative care clinicians may also be called upon to direct discussions around perioperative management of modified code status orders and to engage around the goal-concordance of proposed interventions. This article, written by a team of surgeons and anesthesiologists, many with subspecialty training in palliative medicine and/or ethics, offers ten tips to support palliative care clinicians and facilitate comprehensive discussion as they engage with patients and clinicians considering surgical interventions.

Opportunities for Incorporation of Primary Palliative Care in Acute Care Surgery: A Narrative Review

BACKGROUND

Palliative care is highly relevant to acute care surgery due to the patient populations and severity of illness. Efforts to routinely incorporate palliative care principles in the practice of acute care surgery by the primary surgical team may benefit patients and their families.

METHODS

We present a narrative review of the literature examining the current state of incorporation of primary palliative care in acute care surgery, including basic principles and strategies, evolving approaches, limitations, and opportunities for growth.

RESULTS

Implementation begins with early identification of patients who may benefit from primary palliative care. Primary palliative interventions may include medical symptom management, patient and caregiver support, and use of frameworks for communication in the setting of severe illness. Significant barriers to primary palliative care practice exist, including institutional differences in approaches to primary palliative care, socioeconomic and cultural factors, and varying patient and clinician perspectives about the role of primary palliative care. Over the last few decades, there has been increased awareness of a role for primary palliative care in acute care surgery, leading to recent advances in quality, education, and advocacy.

CONCLUSIONS

Despite the known benefits of primary palliative care, it is still underutilized in acute care surgical patients. Shifting attitudes toward primary palliative care are helping to increase its use in surgical settings as well as promote education for surgical trainees. However, it is important to recognize the many opportunities for improvement of primary palliative care incorporation in acute care surgery.

Teaching Residents Patient-Centered Communication: A Call for Standardized Programming

OBJECTIVE

Surgical residency Program Directors (PDs) use the Accreditation Council for Graduate Medical Education (ACGME) milestones to measure general surgery competencies including interpersonal communication skills and professionalism. These programs face myriad barriers implementing communication training, including competing educational priorities and insufficient local expertise. The goal of this work is to generate hypotheses regarding barriers and facilitators to successful communication, leadership, and professionalism training (CLPT) in surgical residency programs.

DESIGN AND SETTING

We implemented a qualitative study using semi structured 30-minute interviews; grounded theory guided our systematic data collection, coding, and analysis to enable us to identify patterns and relationships within the available dataset.

PARTICIPANTS

Eligible participants were surgical educators known to provide or interested in providing communication training or were surgical trainees focused on education and/or CLPT. Surgeon participants (N=18) included 4 communication researcher/content experts, 9 Program Director (PD) or former PD faculty, 4 Associate PDs, 1 fellow, and 2 residents.

RESULTS

Themes abstracted from interview data include 1) the importance of providing formal CLPT, 2) readiness of residency programs to include CLPT, 3) challenges and barriers to implementing CLPT, and 4) recommendations for implementation. Barriers included the "crowded educational schedule," lack of local expertise, absence of programmatic guidance nationally, and paucity of standardized materials. Facilitators to implementation included the nature of CLPT curricula such as content, approach, and ease of implementation, and suggestions to achieve learner and leadership support. The availability of expert guidance and standardized materials would ease the incorporation of sustainable CLPT into a residency program that could become increasingly engaged and skilled in communication.

CONCLUSIONS

This research serves as a call for direction from ACGME regarding CLPT educational priorities and urges surgical educators to continue to test and develop CLPT content and assessment materials for wide distribution along with providing guidance on implementation.

Decision-Making in Surgery

Surgeons face unique challenges in perioperative decision-making and communication with patients and families. In cardiothoracic surgery, the stakes are high, life and death decisions must be made quickly, and surgeons often lack a longstanding relationship with patients and families prior to intervention. This review considers specific challenges in the preoperative period followed by those faced postoperatively. While preoperative deliberation and informed consent focus on reaching a decision between 2 or more alternative approaches, the most vexing postoperative decisions often involve the patient's discontent with the best-case outcome or how to ensure goal-concordant care when complications arise. This review explores the preoperative ethical and legal requirement for informed consent by describing the contemporary preferred method, shared decision-making. We also present a framework to optimize surgeon communication and promote patient and family engagement in the setting of high-risk surgery for older patients with serious illness. In the postoperative period the family is often tasked with deciding what to do about major complications when the patient has lost decision-making capacity. We discuss several examples and offer strategies for surgeons to navigate these challenging situations. We also explore the concepts of clinical heroism and futility in relation to communicating with patients and families about the outcomes of surgery. Persistent ethical challenges in decision-making suggest that surgeons should improve their skills in communicating with patients to better engage with them, both before and after surgery.