Palliative Care Interventions in Periprocedural Care

The specialty of palliative care aims to support patients with serious illness in decision-making and symptom management. Palliative care expertise in these areas has been used to improve care processes in a number of settings, such as outpatient oncology clinics, intensive care units, and emergency rooms. In medical oncology, early palliative care involvement has been shown to improve symptom management and quality of life, reduce costs, and increase goal-concordant care. Palliative care integration into a preexisting care process often takes one of two pathways. In some instances, palliative care specialist clinicians are invited into and embedded within the care process. In other instances, palliative care specialists train clinicians already involved in the care process in the primary skills and knowledge of palliative care.

Compared to medical oncology, palliative care has been slow to be fully embraced and integrated into periprocedural care processes, such as surgical oncology. One possible reason is that the goals of palliative care and the periprocedural period appear to be at odds. The two aims of palliative care – decision-making and symptom management – appear to have already been addressed by the very decision to move forward with the procedure: the decision was made when the procedure was scheduled. The goal of the procedure itself is clear and aimed to alleviate symptoms or possibly to cure. As a result, where is the need for palliative care in periprocedural care processes?

Two recent studies looked at the benefits of palliative care for surgical oncology patients. In 2023, Shinall et al. published the first single-center randomized clinical trial of specialist palliative care intervention in the periprocedural period for patients undergoing surgery for abdominal malignancies with curative intent. The specialist palliative care intervention included preoperative consultation, postoperative inpatient visits, follow-up outpatient palliative care visits, and inpatient palliative care visits during any readmission. The primary outcome was physical and functional quality of life at 90 days. Secondary outcomes included overall quality of life and days alive at 90 days, along with overall survival to one year. The study showed no statistically significant differences between usual care and the specialist palliative care intervention for the primary or secondary outcomes (JAMA Surg 2023;158:747-55).

Aslakson et al., in 2023, published the first multicenter randomized clinical trial of specialist palliative care intervention in the periprocedural period for patients undergoing surgery for upper GI cancer with curative intent. The specialist palliative care intervention included preoperative consultation and postoperative outpatient follow-up visits at one week, one month, two months, and three months after surgery. The primary outcome was health-related quality of life at three months after surgery. The study found no difference in primary outcome between the intervention group and the control group. Of note, the study also found no measurable harm from the palliative care intervention in the control group of patients or in the group of participating surgeons (JAMA Netw Open 2023;6:e2314660).

Palliative care interventions around other interventions aimed at cures – like bone marrow transplant – have been shown to improve patient well-being (Blood 2023;142:913). The randomized controlled trials described above may have applied their palliative care intervention too broadly or too early in the patients’ disease trajectory to show benefit. Still, a key takeaway from these studies is that periprocedural palliative care did not increase distress – in either patients or surgeons. This is an important finding, as clinicians can be reticent to have conversations about prognosis in serious illness (Arch Intern Med 1998;158:2389-95). While a broad periprocedural specialist palliative care intervention may not be effective, we advocate for building up primary palliative care skills among periprocedural clinicians, along with minimizing barriers to specialty palliative care consultation when needed. This would enable timely and effective palliative care to be provided for periprocedural patients who have specific palliative care needs.

One periprocedural need is clear communication and patient-centered decision-making within the periprocedural process. When patients need to have a conversation about prognosis, including what might happen as a result of a procedure, periprocedural clinicians benefit from having palliative care communication skills (or access to palliative care communication experts) to support the difficult work of having these conversations. Within the field of palliative care, talking about prognosis is often compared to performing a procedure, like a central line (JAMA Intern Med 2015;175:1268-9). Both a structured conversation and a line placement have defined steps that only make sense when completed in order. It’s foolish to do the chlorhexidine wash after having inserted the needle. Familiarity with the basic steps of structured communication can support periprocedural clinicians as they guide conversations around prognosis.

Conversations that discuss prognosis and planning can be divided into four key steps (Figure). These steps are elaborated into more detailed structured communications tools used by many providers and institutions across the country such as SPIKES, the Serious Illness Conversation Guide, and REMAP (Reframe, Expect emotion, Map out patient goals, Align with goals, and Propose a plan) (Oncologist 2000;5:302-11; Palliat Med Rep 2020;1:135-42; J Oncol Pract 2017;13:e844-e850). Employing structured communication can support discussions of prognosis whenever risks and benefits need to be considered (or reconsidered) – during an initial consultation with a surgeon, a preoperative assessment/optimization clinic visit with an anesthesiologist or other periprocedural clinician, or even on the day of surgery. Conversations about prognosis often lead to strong emotions. Yet, clinicians can be reassured by remembering that such emotions confirm that the patient or family member is comprehending the news being delivered. Taking a moment to address emotion with empathy can make further cognitive recommendations and planning more effective (JAMA 1997;277:678-82).

For anesthesiologists, or clinicians other than the surgeon/proceduralist, discussing prognoses with patients can feel out of place in the preoperative period. Some might feel this must have already been addressed in the initial surgical consult. There are, however, multiple reasons why periprocedural clinicians should feel empowered to discuss a prognosis with patients and families in a structured way. On one hand, anesthesia itself can create physiologic stressors – such as the risk of postoperative cognitive deficit in patients with early-stage dementia. A periprocedural clinician other than the surgeon may be the best person to assess and convey this prognostic information. On the other hand, the periprocedural process itself may uncover new medical information that might warrant reconsideration of the prognosis. In this second case, structured communication tools can be used in discussions with both the patients and the interdisciplinary clinical team. Wish/worry/wonder is a structure for aligning values (wish), updating the medical context (worry), and making a recommendation (wonder). Wish/worry/wonder statements could be utilized to convey prognostic concern, not just to patients, but to the surgeon themselves:

“I also wish for Ms. Y to have a successful cholecystectomy, while minimizing her risks from anesthesia. Unfortunately, her echo showed worsening pulmonary hypertension. Iworrythat a laparoscopic surgery would be higher risk for her than an open surgery. Iwonderif the procedure could be done open, in order to decrease her OR time and avoid laparoscopic surgery. What do you think?”

The primary tenet of palliative care is patient-focused support through excellence in symptom management and communication. The aim is for medical care to achieve a patient’s goals while preserving what a patient values. For complex medical issues or psychosocial situations, specialty palliative care referral may be the best way to achieve this. For most situations, however, a clinician familiar with these tenets and tools can provide primary palliative care, such as when discussing a “prognosis” with patients, including what might happen as a result of a procedure. While becoming truly proficient in primary palliative care does require knowledge acquisition and skills practice, the work to acquire this proficiency can benefit periprocedural patients, their families, and the clinicians themselves.