The palliative path: Talking with elderly patients facing emergency surgery

An expert panel has developed a communication framework to improve treatment of older, seriously ill patients who have surgical emergencies, which has been published online in Annals of Surgery.

A substantial portion of older patients who undergo emergency surgeries already have serious life-limiting illnesses such as cardiopulmonary disease, renal failure, liver failure, dementia, severe neurological impairment, or malignancy. The advisory panel based its work on the premise that surgery in these circumstances can lead to significant further morbidity, health care utilization, functional decline, prolonged hospital stay or institutionalization, and death, with attendant physical discomfort and psychological distress at the end of these patients’ lives.

Surgeons consulted in the emergency setting for these patients are hampered by patients unable to communicate well because they are in extremis, by surrogates who are unprepared for their role, and by time constraints, lack of familiarity with the patient, poor understanding of the illness by patients and families, prognostic uncertainty, and inadequate advance care planning. In addition, “many surgeons lack skills to engage in conversations about end-of-life care, or are too unfamiliar with palliative options to discuss them well,” or feel obligated to maintain postoperative life support despite the patient’s wishes, said Dr. Zara Cooper, of Ariadne Labs and the Center for Surgery and Public Health at Brigham and Women’s Hospital, both in Boston, and her associates.

To address these issues and assist surgeons in caring for such patients, an expert panel of 23 national leaders in acute care surgery, general surgery, surgical oncology, palliative medicine, critical care, emergency medicine, anesthesia, and health care innovation was convened at Harvard Medical School, Boston.

The focus of the panel’s recommendations was a structured communications framework prototype to facilitate shared decision-making in these difficult circumstances.

Among the panel’s recommendations for surgeons were the following priorities:

• Review the medical record and consult the treatment team to fully understand the patient’s current condition, comorbidities, expected illness trajectory, and preferences for end-of-life care.

• Assess functional performance as part of the routine history and physical to fully understand the patient’s fitness for surgery.

• Formulate a prognosis regarding the patient’s overall health both with and without surgery.

The panel offered a set of principles and specific elements for the meeting with the patient and family:

• The surgeon should begin by introducing himself or herself; according to reports in the literature, physicians fail to do this approximately half of the time.

• Pay attention to nonverbal communication, such as eye contact and physical contact, as this is critical to building rapport. Immediately address pain, anxiety, and other indicators of distress, to maximize the patients’ and the families’ engagement in subsequent medical discussions. “Although adequate analgesia may render a patient unable to make their own decisions, surrogates are more likely to make appropriate decisions when they feel their loved one is comfortable,” the panel noted.

• Allow pauses and silences to occur. Let the patient and the family process information and their own emotions.

• Elicit the patients’ or the surrogates’ understanding of the illness and their views of the patients’ likely trajectory, correcting any inaccuracies. This substantially influences their decisions regarding the aggressiveness of subsequent treatments.

• Inform the patient and family of the life-threatening nature of the patient’s acute condition and its potential impact on the rest of his or her life, including the possibility of prolonged life support, ICU stay, burdensome treatment, and loss of independence. Use accepted techniques for breaking bad news, and check to be sure the patient understands what was conveyed.

• At this point, the surgeon should synthesize and summarize the information from the patient, the family, and the medical record, then pause to give them time to process the information and to assess their emotional state. It is helpful to label and respond to the patient’s emotions at this juncture, and to build empathy with statements such as “I know this is difficult news, and I wish it were different.”

• Describe the benefits, burdens, and range of likely outcomes if surgery is undertaken and if it is not. The surgeon should use nonmedical language to describe symptoms, and should convey his or her expectations regarding length of hospitalization, need for and duration of life support, burdensome symptoms, discharge to an institution, and functional recovery.

• Surgeons should be able to communicate palliative options possible either in combination with surgery or instead of surgery. Palliative care can aid in managing advanced symptoms, providing psychosocial support for patients and caregivers, facilitating interdisciplinary communication, and facilitating medical decisions and care transitions.

• Avoid describing surgical procedures as “doing everything” and palliative care as “doing nothing.” This can make patients and families “feel abandoned, fearful, isolated, and angry, and fails to encompass palliative care’s practices of proactive communication, aggressive symptom management, and timely emotional support to alleviate suffering and affirm quality of life,” the panel said.

• Surgeons should explicitly support the patients’ medical decisions, whether or not they choose surgery.

The panel also cited a few factors that would assist surgeons in following these recommendations. First, surgeons must recognize the importance of communicating well with seriously ill older patients and acknowledge that this is a crucial clinical skill for them to cultivate. They must also recognize that palliative care is vital to delivering high-quality surgical care. Surgeons should consider discharging patients to hospice, which can improve pain and symptom management, improve patient and family satisfaction with care, and avoid unwanted hospitalization or cardiopulmonary resuscitation.

“There are a number of major barriers to introducing palliative care in these situations. One is an education problem - the perception on the part of patients and clinicians, and surgeons in particular, that palliative care is only limited to end-of-life care, which it is not. It is a misperception of what palliative care means in this equation - that palliative care and hospice are the same thing, which they absolutely are not,”said Dr. Cooper in an interview.

”The definition of palliative care has evolved over the past decade and the focus of palliative care is on quality of life and alleviating symptoms. End-of-life palliative care is part of that, and as patients get closer to the end of life, symptom management and quality of life become more focal than life-prolonging treatment... But for patients with chronic and serious illness, there has to be a role for palliative care because we know that when patients feel better, they tend to live longer. And when patients feel their emotional concerns and physical needs are being addressed, they tend to do better. Patients families have improved satisfaction when their loved one receives palliative care,” she noted.”

However, the number of palliative providers is completely inadequate to meet the needs of the number of seriously ill patients, she said. And a lot of hospital-based palliative care is by necessity limited to end-of-life care because of a lack of palliative resources.

Dr. Atul Gawande, a coauthor of the panel recommendations, wrote a best-selling book, Being Mortal (New York: Metropolitan Books, 2014) addressing the shortcomings and potential remaking of medical care in the context of age-related frailty, grave illness, and death. Dr. Cooper noted that there is a growing sentiment among the general public that they want to have their quality of life addressed in the type of medical care they receive. She said that Dr. Gawande’s book tapped into the perception of a lack of recognition of personhood of seriously ill patients.

“We often focus on diagnosis and we don’t have the ‘bandwidth’ to focus on the person carrying that diagnosis, and our patients and focus on the person carrying that diagnosis, but our patients and their families are demanding different types of care. So, ultimately, the patients will be the ones to push us to do better for them.”

The next steps to further developing a widely used and validated communication framework would be to create educational opportunities for clinicians to develop clinical skills in communication with seriously ill patients and palliative care, and to study the impact of these initiatives on improving outcomes most relevant to older patient. This work was supported by the Ariadne Labs, a Joint Center for Health System Innovation at Brigham and Women’s Hospital. Dr. Cooper and her associates reported having no relevant financial disclosures.

An expert panel has developed a communication framework to improve treatment of older, seriously ill patients who have surgical emergencies, which has been published online in Annals of Surgery.

A substantial portion of older patients who undergo emergency surgeries already have serious life-limiting illnesses such as cardiopulmonary disease, renal failure, liver failure, dementia, severe neurological impairment, or malignancy. The advisory panel based its work on the premise that surgery in these circumstances can lead to significant further morbidity, health care utilization, functional decline, prolonged hospital stay or institutionalization, and death, with attendant physical discomfort and psychological distress at the end of these patients’ lives.

Surgeons consulted in the emergency setting for these patients are hampered by patients unable to communicate well because they are in extremis, by surrogates who are unprepared for their role, and by time constraints, lack of familiarity with the patient, poor understanding of the illness by patients and families, prognostic uncertainty, and inadequate advance care planning. In addition, “many surgeons lack skills to engage in conversations about end-of-life care, or are too unfamiliar with palliative options to discuss them well,” or feel obligated to maintain postoperative life support despite the patient’s wishes, said Dr. Zara Cooper, of Ariadne Labs and the Center for Surgery and Public Health at Brigham and Women’s Hospital, both in Boston, and her associates.

To address these issues and assist surgeons in caring for such patients, an expert panel of 23 national leaders in acute care surgery, general surgery, surgical oncology, palliative medicine, critical care, emergency medicine, anesthesia, and health care innovation was convened at Harvard Medical School, Boston.

The focus of the panel’s recommendations was a structured communications framework prototype to facilitate shared decision-making in these difficult circumstances.

Among the panel’s recommendations for surgeons were the following priorities:

• Review the medical record and consult the treatment team to fully understand the patient’s current condition, comorbidities, expected illness trajectory, and preferences for end-of-life care.

• Assess functional performance as part of the routine history and physical to fully understand the patient’s fitness for surgery.

• Formulate a prognosis regarding the patient’s overall health both with and without surgery.

The panel offered a set of principles and specific elements for the meeting with the patient and family:

• The surgeon should begin by introducing himself or herself; according to reports in the literature, physicians fail to do this approximately half of the time.

• Pay attention to nonverbal communication, such as eye contact and physical contact, as this is critical to building rapport. Immediately address pain, anxiety, and other indicators of distress, to maximize the patients’ and the families’ engagement in subsequent medical discussions. “Although adequate analgesia may render a patient unable to make their own decisions, surrogates are more likely to make appropriate decisions when they feel their loved one is comfortable,” the panel noted.

• Allow pauses and silences to occur. Let the patient and the family process information and their own emotions.

• Elicit the patients’ or the surrogates’ understanding of the illness and their views of the patients’ likely trajectory, correcting any inaccuracies. This substantially influences their decisions regarding the aggressiveness of subsequent treatments.

• Inform the patient and family of the life-threatening nature of the patient’s acute condition and its potential impact on the rest of his or her life, including the possibility of prolonged life support, ICU stay, burdensome treatment, and loss of independence. Use accepted techniques for breaking bad news, and check to be sure the patient understands what was conveyed.

• At this point, the surgeon should synthesize and summarize the information from the patient, the family, and the medical record, then pause to give them time to process the information and to assess their emotional state. It is helpful to label and respond to the patient’s emotions at this juncture, and to build empathy with statements such as “I know this is difficult news, and I wish it were different.”

• Describe the benefits, burdens, and range of likely outcomes if surgery is undertaken and if it is not. The surgeon should use nonmedical language to describe symptoms, and should convey his or her expectations regarding length of hospitalization, need for and duration of life support, burdensome symptoms, discharge to an institution, and functional recovery.

• Surgeons should be able to communicate palliative options possible either in combination with surgery or instead of surgery. Palliative care can aid in managing advanced symptoms, providing psychosocial support for patients and caregivers, facilitating interdisciplinary communication, and facilitating medical decisions and care transitions.

• Avoid describing surgical procedures as “doing everything” and palliative care as “doing nothing.” This can make patients and families “feel abandoned, fearful, isolated, and angry, and fails to encompass palliative care’s practices of proactive communication, aggressive symptom management, and timely emotional support to alleviate suffering and affirm quality of life,” the panel said.

• Surgeons should explicitly support the patients’ medical decisions, whether or not they choose surgery.

The panel also cited a few factors that would assist surgeons in following these recommendations. First, surgeons must recognize the importance of communicating well with seriously ill older patients and acknowledge that this is a crucial clinical skill for them to cultivate. They must also recognize that palliative care is vital to delivering high-quality surgical care. Surgeons should consider discharging patients to hospice, which can improve pain and symptom management, improve patient and family satisfaction with care, and avoid unwanted hospitalization or cardiopulmonary resuscitation.

“There are a number of major barriers to introducing palliative care in these situations. One is an education problem - the perception on the part of patients and clinicians, and surgeons in particular, that palliative care is only limited to end-of-life care, which it is not. It is a misperception of what palliative care means in this equation - that palliative care and hospice are the same thing, which they absolutely are not,”said Dr. Cooper in an interview.

”The definition of palliative care has evolved over the past decade and the focus of palliative care is on quality of life and alleviating symptoms. End-of-life palliative care is part of that, and as patients get closer to the end of life, symptom management and quality of life become more focal than life-prolonging treatment... But for patients with chronic and serious illness, there has to be a role for palliative care because we know that when patients feel better, they tend to live longer. And when patients feel their emotional concerns and physical needs are being addressed, they tend to do better. Patients families have improved satisfaction when their loved one receives palliative care,” she noted.”

However, the number of palliative providers is completely inadequate to meet the needs of the number of seriously ill patients, she said. And a lot of hospital-based palliative care is by necessity limited to end-of-life care because of a lack of palliative resources.

Dr. Atul Gawande, a coauthor of the panel recommendations, wrote a best-selling book, Being Mortal (New York: Metropolitan Books, 2014) addressing the shortcomings and potential remaking of medical care in the context of age-related frailty, grave illness, and death. Dr. Cooper noted that there is a growing sentiment among the general public that they want to have their quality of life addressed in the type of medical care they receive. She said that Dr. Gawande’s book tapped into the perception of a lack of recognition of personhood of seriously ill patients.

“We often focus on diagnosis and we don’t have the ‘bandwidth’ to focus on the person carrying that diagnosis, and our patients and focus on the person carrying that diagnosis, but our patients and their families are demanding different types of care. So, ultimately, the patients will be the ones to push us to do better for them.”

The next steps to further developing a widely used and validated communication framework would be to create educational opportunities for clinicians to develop clinical skills in communication with seriously ill patients and palliative care, and to study the impact of these initiatives on improving outcomes most relevant to older patient. This work was supported by the Ariadne Labs, a Joint Center for Health System Innovation at Brigham and Women’s Hospital. Dr. Cooper and her associates reported having no relevant financial disclosures.

An expert panel has developed a communication framework to improve treatment of older, seriously ill patients who have surgical emergencies, which has been published online in Annals of Surgery.

A substantial portion of older patients who undergo emergency surgeries already have serious life-limiting illnesses such as cardiopulmonary disease, renal failure, liver failure, dementia, severe neurological impairment, or malignancy. The advisory panel based its work on the premise that surgery in these circumstances can lead to significant further morbidity, health care utilization, functional decline, prolonged hospital stay or institutionalization, and death, with attendant physical discomfort and psychological distress at the end of these patients’ lives.

Surgeons consulted in the emergency setting for these patients are hampered by patients unable to communicate well because they are in extremis, by surrogates who are unprepared for their role, and by time constraints, lack of familiarity with the patient, poor understanding of the illness by patients and families, prognostic uncertainty, and inadequate advance care planning. In addition, “many surgeons lack skills to engage in conversations about end-of-life care, or are too unfamiliar with palliative options to discuss them well,” or feel obligated to maintain postoperative life support despite the patient’s wishes, said Dr. Zara Cooper, of Ariadne Labs and the Center for Surgery and Public Health at Brigham and Women’s Hospital, both in Boston, and her associates.

To address these issues and assist surgeons in caring for such patients, an expert panel of 23 national leaders in acute care surgery, general surgery, surgical oncology, palliative medicine, critical care, emergency medicine, anesthesia, and health care innovation was convened at Harvard Medical School, Boston.

The focus of the panel’s recommendations was a structured communications framework prototype to facilitate shared decision-making in these difficult circumstances.

Among the panel’s recommendations for surgeons were the following priorities:

• Review the medical record and consult the treatment team to fully understand the patient’s current condition, comorbidities, expected illness trajectory, and preferences for end-of-life care.

• Assess functional performance as part of the routine history and physical to fully understand the patient’s fitness for surgery.

• Formulate a prognosis regarding the patient’s overall health both with and without surgery.

The panel offered a set of principles and specific elements for the meeting with the patient and family:

• The surgeon should begin by introducing himself or herself; according to reports in the literature, physicians fail to do this approximately half of the time.

• Pay attention to nonverbal communication, such as eye contact and physical contact, as this is critical to building rapport. Immediately address pain, anxiety, and other indicators of distress, to maximize the patients’ and the families’ engagement in subsequent medical discussions. “Although adequate analgesia may render a patient unable to make their own decisions, surrogates are more likely to make appropriate decisions when they feel their loved one is comfortable,” the panel noted.

• Allow pauses and silences to occur. Let the patient and the family process information and their own emotions.

• Elicit the patients’ or the surrogates’ understanding of the illness and their views of the patients’ likely trajectory, correcting any inaccuracies. This substantially influences their decisions regarding the aggressiveness of subsequent treatments.

• Inform the patient and family of the life-threatening nature of the patient’s acute condition and its potential impact on the rest of his or her life, including the possibility of prolonged life support, ICU stay, burdensome treatment, and loss of independence. Use accepted techniques for breaking bad news, and check to be sure the patient understands what was conveyed.

• At this point, the surgeon should synthesize and summarize the information from the patient, the family, and the medical record, then pause to give them time to process the information and to assess their emotional state. It is helpful to label and respond to the patient’s emotions at this juncture, and to build empathy with statements such as “I know this is difficult news, and I wish it were different.”

• Describe the benefits, burdens, and range of likely outcomes if surgery is undertaken and if it is not. The surgeon should use nonmedical language to describe symptoms, and should convey his or her expectations regarding length of hospitalization, need for and duration of life support, burdensome symptoms, discharge to an institution, and functional recovery.

• Surgeons should be able to communicate palliative options possible either in combination with surgery or instead of surgery. Palliative care can aid in managing advanced symptoms, providing psychosocial support for patients and caregivers, facilitating interdisciplinary communication, and facilitating medical decisions and care transitions.

• Avoid describing surgical procedures as “doing everything” and palliative care as “doing nothing.” This can make patients and families “feel abandoned, fearful, isolated, and angry, and fails to encompass palliative care’s practices of proactive communication, aggressive symptom management, and timely emotional support to alleviate suffering and affirm quality of life,” the panel said.

• Surgeons should explicitly support the patients’ medical decisions, whether or not they choose surgery.

The panel also cited a few factors that would assist surgeons in following these recommendations. First, surgeons must recognize the importance of communicating well with seriously ill older patients and acknowledge that this is a crucial clinical skill for them to cultivate. They must also recognize that palliative care is vital to delivering high-quality surgical care. Surgeons should consider discharging patients to hospice, which can improve pain and symptom management, improve patient and family satisfaction with care, and avoid unwanted hospitalization or cardiopulmonary resuscitation.

“There are a number of major barriers to introducing palliative care in these situations. One is an education problem - the perception on the part of patients and clinicians, and surgeons in particular, that palliative care is only limited to end-of-life care, which it is not. It is a misperception of what palliative care means in this equation - that palliative care and hospice are the same thing, which they absolutely are not,”said Dr. Cooper in an interview.

”The definition of palliative care has evolved over the past decade and the focus of palliative care is on quality of life and alleviating symptoms. End-of-life palliative care is part of that, and as patients get closer to the end of life, symptom management and quality of life become more focal than life-prolonging treatment... But for patients with chronic and serious illness, there has to be a role for palliative care because we know that when patients feel better, they tend to live longer. And when patients feel their emotional concerns and physical needs are being addressed, they tend to do better. Patients families have improved satisfaction when their loved one receives palliative care,” she noted.”

However, the number of palliative providers is completely inadequate to meet the needs of the number of seriously ill patients, she said. And a lot of hospital-based palliative care is by necessity limited to end-of-life care because of a lack of palliative resources.

Dr. Atul Gawande, a coauthor of the panel recommendations, wrote a best-selling book, Being Mortal (New York: Metropolitan Books, 2014) addressing the shortcomings and potential remaking of medical care in the context of age-related frailty, grave illness, and death. Dr. Cooper noted that there is a growing sentiment among the general public that they want to have their quality of life addressed in the type of medical care they receive. She said that Dr. Gawande’s book tapped into the perception of a lack of recognition of personhood of seriously ill patients.

“We often focus on diagnosis and we don’t have the ‘bandwidth’ to focus on the person carrying that diagnosis, and our patients and focus on the person carrying that diagnosis, but our patients and their families are demanding different types of care. So, ultimately, the patients will be the ones to push us to do better for them.”

The next steps to further developing a widely used and validated communication framework would be to create educational opportunities for clinicians to develop clinical skills in communication with seriously ill patients and palliative care, and to study the impact of these initiatives on improving outcomes most relevant to older patient. This work was supported by the Ariadne Labs, a Joint Center for Health System Innovation at Brigham and Women’s Hospital. Dr. Cooper and her associates reported having no relevant financial disclosures.