Transitions of Care—Disposition Planning

Care transitions are a hot topic in healthcare delivery, research, and policy today because national patient quality and safety data have identified transition of care as a critical time during a patient’s care continuum when both quality and safety are potentially compromised. Poorly executed transitions of care are associated with preventable adverse events and hospital readmissions that are burdensome to patients and their caregivers, correlating to suboptimal outcomes and exorbitant costs. Therefore, reducing both adverse events during a care transition and hospital readmission rates is a matter of clinical and policy priority. High-risk surgical patients are particularly vulnerable to preventable adverse events and readmissions during care transitions because of the complexity of their care needs. To address this problem, governmental and other healthcare organizations are allocating resources and investing in research initiatives to improve, refine, and standardize the transition-of-care process in order to optimize quality of care throughout a patient’s care continuum.

Pharmacopalliation of Pain

Pain is one of the most common symptoms that a surgeon may encounter in their patients with palliative care needs. Pain no longer serves an adaptive, protective mechanism but one that is maladaptive and has no redeeming purpose except to add to the patient’s suffering. Effective management requires the surgeon to consider the bio-psychosocial-spiritual impact of the underlying disease when assessing the patient’s self-report of pain. This chapter is a primer and provides an overview of the most common factors that a surgeon may want to consider in providing primary pharmacopalliation of pain, including analgesic selection and adverse effect management.

The Family Conference

The family conference chapter explores, in detail, one of the primary interventions performed by palliative care providers. A successful meeting can actually be viewed as time saving as it offers an opportunity for many issues to be reviewed and for multiple important decisions to be made in a relatively short period of time. By describing the conference in terms of a surgical procedure, during which we prepare, do, and close, this chapter offers specific guidance in a way most likely to resonate with a surgeon. It reviews the steps necessary to prepare for a family conference and describes how such steps may aid the family and the treatment team in managing uncertainty. It introduces the ask-tell-ask model of communication and discusses how this model can help to facilitate shared decision-making.

Palliative Gastrointestinal Surgery

Palliative surgical consultation is a critical component of multidisciplinary gastrointestinal cancer care. For many types of gastrointestinal malignancies, the majority of patients are not able to achieve cure and develop symptoms attributable to their advanced or incurable malignancy. The most common diagnosis is bowel obstruction, but diagnoses such as bowel perforation, hemorrhage, neutropenia and abdominal pain, and anorectal infections are also included. Safe utilization of surgical intervention can be difficult due to the increased risks of surgery, limited therapeutic options for these complex palliative care situations, and the progressive nature of incurable gastrointestinal cancer. In selected patients, surgical palliation can improve symptoms and quality of life with acceptable reported rates of morbidity and mortality. Even in situations where surgery is not offered, an understanding of the disease processes and outcomes can inform patients and other providers in the optimal management strategy.

Principles, Assessment, and Evaluation for Palliative Surgery

Palliative surgery requires the highest level of surgical decision-making. The surgeon must evaluate the severity of the patient’s symptoms, the patient’s priorities, the available options for treatment, and the morbidity the patient can incur by undergoing an operation. Indications for palliative surgery are influenced by symptom severity and are disease and patient specific. It is a necessity that patients are managed by a multidisciplinary team, which can include surgeons, palliative specialists, endoscopists, interventional radiologists, medical teams, case managers, social workers, nurses, and chaplains. Communication is the cornerstone of successful palliation and can be facilitated by utilizing the palliative triangle. Patient selection requires a deliberate and thoughtful assessment of the specific circumstances and needs of each individual patient. In evaluating outcomes, emphasis should be placed on symptom and quality-of-life improvement, which is subsequently weighed against the morbidity of the operation in the context of anticipated recovery and survival time.

Palliative Care in Transplantation

Organ transplantation is a field where patients often have significant palliative care needs but frequently lack access to palliative care due to a variety of barriers, including some commonly encountered as well as others specific to this patient population. Organ system failure is necessary to qualify for transplantation. Morbidity and mortality of the particular organ failure syndrome have a profound impact on quality of life. Also, the donor process adds another patient group that may benefit from palliative care. For solid-organ transplant candidates, long waiting times on organ transplant lists and limited organ availability shape the patient experience. Death while waiting for transplant for some conditions is not unusual. Furthermore, there is variability in the ability to replace organ function and how these modalities impact quality of life and end-of-life care. An integrated approach introducing end-of-life planning and palliative care early in the course for patients with organ failure awaiting transplant would improve patient knowledge and possibly symptom management and empower patient decision-making at the end of life.

Spirituality and Surgery

Increasing evidence has demonstrated the importance of spirituality and spiritual care for patients with life-threatening illnesses. With the growth of scientific medicine from the nineteenth century, a medical dualism has developed with an intense focus on identifying and treating disease almost to the exclusion of caring for the suffering of the person with the disease. This chapter provides surgeons with an understanding of human suffering and its close connection to spirituality, reviews studies highlighting the importance of spirituality and spiritual care to critically ill patients, and outlines some basic skills surgeons can develop to address the spiritual needs of their patients.

Surgical Palliative Care

Attention to suffering through the comfort and nonabandonment of the sick and injured is an instinctive human response that provides the framework of current palliative care practice. This component of our socialization is so profound it probably pre-dates our Homo sapiens identity. Trauma to humans was a likely stimulus for the development and refinement of this empathic capacity, raising the possibility that someone using rudimentary surgical skills introduced palliative care to civilization long before a surgeon coined the term palliative care in the twentieth century. Many palliative interventions ultimately became cures. The history of surgery repetitively shows that when the first priority for surgical intervention is the response to suffering, the cures will follow, but the reverse is not necessarily true.

Nonpain Symptom Management

Along with pain, surgical palliative care patients often suffer from both physical and psychosocial symptoms in the weeks to months before death. They can have a variety of nonpain symptoms due to their serious illness. Literature suggests these symptoms can be more debilitating than pain, but patients are less likely to self-report. Surgical palliative care providers have an important opportunity to manage these nonpain symptoms to improve a patient’s quality of life. This chapter briefly reviews the principles of nonpain symptom management and focuses on the management of six common nonpain symptoms experienced by surgical palliative care patients: dyspnea, delirium, nausea, constipation, anorexia, and anxiety.

Invasive Pain Management

The use of invasive techniques for palliative pain management is growing, especially when conventional treatments fail. Often pain is improperly managed, even at end of life. Unfortunately, inadequate pain management can often prevent patients from receiving additional palliative therapies. This chapter discusses invasive approaches to pain management according to the mechanism of pain (somatic, visceral, and sympathetic), including the use of intrathecal drug delivery systems, kyphoplasty and vertebroplasty; sympathetic blocks including celiac plexus block and ganglion impar; and spinal cord ablative techniques including cordotomy, myelotomy, and dorsal root entry zone lesioning (DREZotomy). Future directions include less invasive techniques for modulating pain pathways without destroying neural tissue, namely by intradural or epidural spinal cord stimulation.