Palliative Care Interventions for Surgical Patients: A Systematic Review.

Clinical Review & Education

Review

Palliative Care Interventions for Surgical Patients A Systematic Review Elizabeth J. Lilley, MD, MPH; Kashif T. Khan, MD; Fabian M. Johnston, MD, MHS; Ana Berlin, MD, MPH; Angela M. Bader, MD, MPH; Anne C. Mosenthal, MD; Zara Cooper, MD, MSc

IMPORTANCE Inpatient palliative care improves symptom management and patient

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satisfaction with care and reduces hospital costs in seriously ill patients. However, the role of palliative care in the treatment of patients undergoing surgery (surgical patients) remains poorly defined. OBJECTIVE To characterize the content, design, and results of interventions to improve access to palliative care or the quality of palliative care for surgical patients. EVIDENCE REVIEW This systematic review was conducted according to PRIMSA guidelines. Articles were identified through searches of PubMed, PsycINFO, EMBASE, and CINAHL as well as manual review of references. Eligible articles included experimental, quasi-experimental, and observational studies published in English from January 1, 1994, through October 31, 2014, in which patient outcomes of palliative care interventions for adult surgical patients were reported. Data on the study setting, design, intervention, participants, and results were extracted from the final study set and analyzed from December 22, 2014, to February 7, 2015. FINDINGS A total of 3838 abstracts were identified and screened by 2 reviewers, 77 articles were reviewed in full text, and 25 articles (22 unique interventions involving 8575 unique patients) met the study criteria. Interrater agreement was good (κ = 0.78). Nine single-institution retrospective cohort studies, 7 single-institution prospective cohort studies, 7 single-institution randomized clinical studies, and 2 multicenter randomized clinical studies were included. Nineteen of the 23 single-site studies were performed at academic hospitals. Given the heterogeneity of study methods and measures, meta-analysis was not possible. Preoperative decision-making interventions were associated with decreased mortality in 4 studies. Three studies reported improved quality of communication; 4, improved symptom management; and 7, decreased use of health care resources and decreased cost. However, many studies were small, performed in academic settings, and methodologically flawed and did not measure clinically meaningful outcomes. CONCLUSIONS AND RELEVANCE The sparse evidence regarding interventions to introduce or improve palliative care for surgical patients is further limited by methodologic flaws. Rigorous evaluations of standardized palliative care interventions measuring meaningful patient outcomes are needed.

Author Affiliations: Author affiliations are listed at the end of this article.

JAMA Surg. doi:10.1001/jamasurg.2015.3625 Published online November 25, 2015.

Corresponding Author: Zara Cooper, MD, MSc, Center for Surgery and Public Health, Brigham and Women’s Hospital, 75 Francis St, Boston, MA 02115 ([email protected]).

(Reprinted) E1

Copyright 2015 American Medical Association. All rights reserved.

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Clinical Review & Education Review

Palliative Care Interventions for Surgical Patients

M

ultiple studies have documented the benefits of palliative care, including improved pain and symptom management, 1-7 better-quality communication, 2-8 higher satisfaction with care, 1-7,9,10 increased quality of life (QOL),1,7,11,12 and reduced health care costs, for patients with cancer or chronic medical conditions.6,10,13,14 The Institute of Medicine report, Dying in America,15 recommended that all seriously ill patients should have access to high-quality palliative care. However, patients undergoing surgery (surgical patients) are less likely than those undergoing medical interventions to receive palliative care or hospice care in the last year of life.16 The role of palliative care in surgery is understudied and poorly defined. In 2003, recognizing the dearth of data, the American College of Surgeons Palliative Care Workgroup17 identified the following 7 domains as potential research targets for studying the applications of palliative care in surgical settings: (1) surgical decision making, (2) patient decision making, (3) end-of-life (EOL) decision making, (4) symptom management, (5) communication, (6) processes of care, and (7) surgical education about palliative care (Box). More than 1 decade later, research on palliative care in the surgical literature remains sparse. To our knowledge, no existing reviews have described studies addressing these domains in surgery. Therefore, we performed a systematic review of the literature to identify, describe, and assess the effectiveness of interventions. We herein characterize the content and design of palliative interventions for adult surgical patients and describe the results of these studies. Results of this review may have particular value for surgeons and health services researchers by providing an overview of studied interventions and identifying gaps in existing knowledge.

Box. Domains Targeted in Surgical Research in Palliative Carea Surgical Decision Making

Prognostication and natural history of disease Selection of ideal treatment modality Validated outcome measures for surgical care Assessment of new procedures Patient Decision Making

Understanding patient preference Decision aids Informed consent Family and surrogate decision making End-of-Life Decision Making

Advance directives Withdrawal of support Symptom Management

Pain Nonpain symptoms Communication

Breaking bad news Cross-cultural issues Communication with family and caregivers Interdisciplinary and intradisciplinary team communication Processes of Care

Cost-effectiveness Psychosocial effect on health care professionals Surgical Education About Palliative Care

Medical students, residents, and practicing health care professionals

Methods

Comparison of educational modalities

Review Design

a

The protocol for this systematic review was designed in accordance with PRISMA guidelines18,19 and registered with the PROSPERO database.20 We engaged a research librarian to assist in developing the search strategy.

The domains are based on recommendations from the American College of Surgeons Palliative Care Workgroup.17

Inclusion and Exclusion Criteria Data Sources and Search Strategy We performed a literature search of the PubMed, EMBASE, PsycINFO, and CINAHL databases in October 2014 for studies published from January 1, 1994, through October 31, 2014. We used database-specific combinations of the following index terms and text words: advance care planning, advance directive, end-of-life, health care proxy, hospice care, living will, palliative care, power of attorney, religious beliefs, spirituality, surrogate decision maker, or terminal care and surgeon, surgical, or surgery. Terms were combined with filters for adult patients and English-language publication. We also applied filters for study type, omitting articles classified as case reports, clinical conferences, comments, editorials, letters, lectures, meta-analyses, or reviews. The searches were run a second time before we retrieved the final conglomerate of articles, and we included any additional studies that were identified. Details of the database-specific search strategies are available in eTable 1 in the Supplement. These searches were supplemented with a manual review of references from included articles, review articles, and the researchers’ personal archives. E2

Inclusion and exclusion criteria are summarized in the Figure legend. We included studies of palliative care interventions for surgical decision making, symptom management, screening for palliative care consultation, advance care planning (ACP), EOL decision making, communication, and educational interventions for health care professionals. Included studies were peer reviewed, measured 1 or more patient-oriented outcome, included adult patients, had at least 20% surgical patients (defined as patients under the care of a surgeon at the time of the intervention), and used an experimental, quasi-experimental, or observational design. We excluded studies describing a single palliative surgical procedure (procedures to alleviate symptoms or improve QOL with minimal anticipated effect on overall patient survival21), interventions for acute postsurgical pain symptoms, and complementary and alternative medicine interventions because we believed each of these areas was broad enough to warrant its own review. In addition, we excluded studies of educational interventions for health care professionals that did not measure patient outcomes, studies without

JAMA Surgery Published online November 25, 2015 (Reprinted)



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Review Clinical Review & Education

Figure. Flowchart of Literature Search Strategy 4726 Records identified through database searcha

19 Additional records identified through other sources

dicated by a third reviewer (Z.C.). Data were extracted from the final set of included studies for the following 6 variables: (1) country of origin, (2) setting, (3) design, (4) details of the intervention, (5) study participants, and (6) results.

Data Analysis 3838 Records after 907 duplicates removed

3838 Records screened 3761 Records excluded 77 Full-text articles assessed for eligibility

25 Studies included in qualitative synthesis (22 unique interventions involving 8575 unique patients)

52 Full-text articles excludedb 15 No intervention 9 Does not specify No. of surgical patients 7 No control or comparison group 6 18 years); more than 20% surgical patients; peer review; and measurement of more than 1 patient-oriented outcome. Exclusion criteria consisted of single palliative surgical procedure; acute postoperative pain intervention; complementary and alternative medicine; full text not available in English; no control or comparison group; and review, editorial, abstract, or conference proceedings. a

Articles were identified from PubMed (n = 1963), EMBASE (n = 1283), CINAHL (n = 1051), and PsycINFO (n = 429).

b

Total does not equal 52 because all reasons for exclusion were given, and some articles had more than one.

the full text available in English, studies without a control or comparison group (a past or concurrent group receiving usual care, as defined by the intervention), and reviews, editorials, abstracts, or conference proceedings. Patient-oriented outcomes of interest included palliative care consultation, ACP discussions, symptom burden, QOL, patient and caregiver satisfaction, hospice referral, quality communication, use and cost of health care services, and mortality. The authors were contacted whenever possible to obtain missing information.

Study Selection and Data Extraction Article selection proceeded in 2 phases. In phase 1, two of us (E.J.L. and K.T.K.) independently screened titles and abstracts of search results using the inclusion and exclusion criteria. Full-text articles were obtained for abstracts identified by one or both reviewers as potentially relevant. In phase 2, the same two of us independently reviewed full-text articles for eligibility. Any discrepancies were adjujamasurgery.com

Data were analyzed from December 22, 2014, to February 7, 2015. Given the heterogeneity of the study methods and measures, data pooling for meta-analysis was not possible. We therefore performed a qualitative synthesis to categorize study interventions by the primary and secondary research domains addressed. These were determined and assigned by consensus among the 3 reviewers (E.J.L., K.T.K., and Z.C.).

Quality Assessment In characterizing research on palliative care interventions for surgical patients, we sought to assess the quality of included studies. Two reviewers (E.J.L. and K.T.K.) independently assessed risk for bias using the Cochrane Handbook for Systematic Reviews of Interventions22 for randomized clinical trials and the NewcastleOttawa Scale23 for nonrandomized studies.24 Studies received an overall quality rating of high, moderate, low, or very low based on the study design and risk for bias. A detailed explanation of quality assessment is available in eTable 2 in the Supplement. The overarching goal of this review was to report all studies regarding palliative care interventions in surgical patients. As such, no studies were excluded on the basis of quality.

Results Search Outcome The initial database searches identified 4726 articles, and the manual search yielded an additional 19 titles (Figure). Of these, 907 articles were duplicates. Titles and abstracts were screened for the remaining 3838 articles, and we excluded 3761 articles that did not meet inclusion criteria. Full-text articles were reviewed for the 77 studies identified by one or both screeners as potentially eligible. Twenty-five articles were selected for inclusion. Interrater agreement was good (κ = 0.78). Three interventions were examined in 2 separate studies. Results from a single study were reported in 2 articles, so we extracted data from both articles as a single study.25,26 One study used previously reported results for comparison, so we extracted data from both articles as a single study.27,28 Therefore, our final analysis of 27 articles included 25 studies of 22 unique interventions.

Study and Patient Characteristics Table 1 and Table 2 summarize the 25 studies that met eligibility criteria. The included studies represented 9 countries, with 15 studies performed in the United States. Nine single-institution retrospective cohort studies,* 7 single-institution prospective cohort studies,38-40,44,45,48,49 7 single-institution randomized clinical studies,31,32,35,41,42,47,50 and 2 multicenter randomized clinical studies25,26,51 were included. Nineteen of the 23 single-site studies were performed at academic hospitals. *References 27, 29, 30, 33, 34, 36, 37, 43, 46 (Reprinted) JAMA Surgery Published online November 25, 2015



E3

E4

Randomized, controlled study Outpatient clinics at a single academic medical center

Randomized, controlled study Outpatient preoperative testing center at a single academic medical center

Retrospective, preintervention/ postintervention cohort study Outpatient clinic at a single Veterans Affairs hospital

Retrospective, preintervention/ postintervention cohort study Inpatient surgical wards at a single district general hospital

Randomized, controlled study Outpatient preoperative clinic at a single academic medical center

Briggs et al,31 2004 (United States)

Cooper et al,32 2014 (United States)

Ernst et al,33 2014 (United States)

Fisher and Parker,34 1999 (United Kingdom)

Grimaldo et al,35 2001 (United States)



Downloaded From: http://archsurg.jamanetwork.com/ by a Tufts Univ. Hirsh Health Sciences Library User on 11/25/2015 Preoperative anesthesiologist-led information session during outpatient preoperative testing focusing on importance of communicating with surrogate and providing examples of LST

Palliative care physician and a general surgeon with special interest in oncology performed joint ward rounds 1 d/wk

Preoperative frailty screening to identify patients who may benefit from palliative care consultation. Frail patients were encouraged to undergo preoperative palliative care consultation, which included ACP and GOC discussion and EOL planning

Preoperative ACP discussion with the patient and surrogate to elicit the patient’s goals for surgery and values for perioperative treatment

Facilitated patient-centered ACP interview to explore disease understanding and treatment preferences with patient and surrogate

Primary: EOL decision making Secondary: patient decision making

Primary: processes of care Secondary: communication

Primary: processes of care Secondary: surgical decision making, patient decision making

Primary: EOL decision making Secondary: communication, patient decision making

Primary: EOL decision making Secondary: patient decision making, communication

Adult patients, 65 y and older, scheduled for surgery (mean age, 72.8 y) (185 [48.1])

Adult surgical inpatients referred for inpatient palliative care consultation (ages not reported) (37 [70.3])

Adult patients scheduled for a surgical procedure (mean age, 69.8 y) (310 [51.6])

Adult high-risk surgical patients with planned postoperative SICU stay (mean age, 61.1 y) (13 [61.5])

Adult patients with congestive heart failure, end-stage renal disease, or planned open heart surgery and their surrogates (mean age, 68.7 y) (27 [48.1])

Adult patients admitted to the SICU (mean age, 53.5 y) (644 [53.4])

Retrospective, preintervention/ postintervention cohort study Inpatients admitted to the SICU at a single academic medical center

Bradley et al,30 2010 (United States) Primary: processes of care Secondary: communication

Adult postoperative patients with symptomatic, incurable cancer (aged 49-88 y) (97 [42.3])

Primary: symptom management Secondary: communication, processes of care

A referral-based PSS with outpatient and home visits from trained nurses focusing on symptom control, home care needs, and care coordination

Retrospective, preintervention/ postintervention cohort study Outpatient and home visit program for patients treated at a single county hospital

Axelsson and Christensen,29 1998 (Sweden)

Triggers to identify patients with poor prognosis or family conflict who would benefit from palliative care consultation

Participants (No. [%] in Intervention)

Research Domains

Intervention

Design and Setting

Source (Country of Origin)

Table 1. Summary of Articles Included in Review

Intervention group had 170% higher rate of documentation of durable power of attorney

140% Increase in palliative care referral rate during intervention period, with earlier referrals and increase in referrals for symptom control or placement advice Increased involvement of palliative care in patients who died in hospital or were discharged to hospice

180-d Mortality rate decreased from 70.6% before implementation to 44.0% during the intervention period Annual palliative care consultation rate increased by 75% during intervention period During intervention period, higher proportion of consultations ordered by surgeons (56.7% vs 24.4%) and more preoperative consultations (52.0% vs 26.3%)

50% of Patients and 63% of surrogates found conversation very helpful Intervention improved concordance for treatment preferences between patient and surrogate 75% of Patients preferred to have conversation before preoperative visit

Intervention improved concordance for treatment preferences between patient and surrogate Patients in intervention group had lower decisional conflict Intervention group had higher perceived quality of communication

No difference in rate of palliative care consultations or in-hospital mortality

Study group had 70% reduction in median duration of terminal hospitalization, 48% increase in ratio of days home to inclusion days, and 14% more days at home in last 2 mo of life PSS generated a potential net savings of approximately $2400 per patient

Results

(continued)

Moderate

Very low

Moderate

Low

Low

Moderate

Low

Study Qualitya

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Retrospective, preintervention/ postintervention cohort study Inpatients admitted to MICU and SICU at a single academic medical center

Retrospective, preintervention/ postintervention cohort study Inpatients admitted to the SICU at a single academic medical center

Prospective, preintervention/ postintervention cohort study Inpatients admitted to the SICU at a single academic medical center

Prospective, nonrandomized controlled study Outpatient and telephone contact intervention at a single academic medical center

Prospective, nonrandomized controlled study Outpatient and telephone contact intervention at a single academic medical center

Randomized controlled study Outpatient home visits and telephone contacts for patients at a single academic medical center

Randomized controlled study Outpatient home visits and telephone contacts for patients at a single academic medical center

Holloran et al,37 1995 (United States)

Lamba et al,38 2012 (United States)

Liao et al,39 2009 (Taiwan)

Liao et al,40 2014 (Taiwan)

McCorkle et al,41 2009 (United States)

McCorkle et al,42 2000 (United States)

Design and Setting

Hall et al,36 2004 (Canada)


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Downloaded From: http://archsurg.jamanetwork.com/ by a Tufts Univ. Hirsh Health Sciences Library User on 11/25/2015 Home nursing intervention with 8 scheduled contacts for a 30-d period, with an oncology APN focusing on symptom management, functional ability, mental health, caregiver’s strengths, and care coordination

Home nursing intervention with 18 scheduled contacts in 6 mo with an oncology APN designed to provide individualized assistance developing and maintaining self-management skills and to facilitate active participation in subsequent care decisions Patients with high distress received PCLN evaluation

Trained nurse performed evaluation of individual needs and provided health education pamphlets, face-to-face meetings, and telephone calls to provide informational and emotional support

Trained nurse performed evaluation of individual needs and provided health education pamphlets, face-to-face meetings, and telephone calls to provide informational and emotional support

2-Part multifaceted palliative care intervention involving early comprehensive assessment of palliative needs, social support, and GOC discussions; involvement of palliative care in daily rounds; and integration of palliative care into professional peer review

Case-based education program for surgical residents in SICU on EOL communications and common ethics situations in the SICU; facilitated by SICU attending and nursing director

EOL care initiative program: Physician education about early GOC discussions, nursing education, hospital policy changes regarding comfort medication prescribing practices, and toolkits to standardize WLST and DNR orders

Intervention

Table 1. Summary of Articles Included in Review (continued)

Primary: symptom management Secondary: patient decision making, communication

Primary: symptom management Secondary: patient decision making, communication

Primary: communication Secondary: symptom management


Primary: communication Secondary: patient decision making, EOL decision making, surgical education about palliative care

Primary: surgical education about palliative care Secondary: communication, EOL decision making

Primary: EOL decision making Secondary: communication, processes of care

Research Domains

Postsurgical cancer patients, 60 y or older, with prognosis of >6 mo survival (129 aged 60-64 y; 246 aged ≥65 y) (375 [59.7])

Postsurgical adult female patients with suspected diagnosis of ovarian cancer (mean age, 60.3 y) (123 [51.2])

Postsurgical adult female patients with breast cancer (mean age, 50.7 y) (80 [50])

Adult female patients awaiting biopsy for suspected breast cancer (mean age, 49.3 y) (122 [50.8])

Adult patients on the liver transplant service admitted to the SICU (mean age, 51 y) (183 [56.8])

Adult patients who died in the SICU after >30-d ICU stay (ages not reported) (288)

Adult patients who died in the MICU or SICU after WLST (mean age, 62.3 y) (306 [54.9])


Low

Low

Study Qualitya

Low

Low

Intervention group had longer survival (mean, 7 mo) than controls No difference in HRQOL scores despite higher proportion of patients with late-stage disease in the intervention group

(continued)

Low

Low Intervention group had less feelings of uncertainty about health at 6 mo Patients who had intervention and received PCLN consult had less uncertainty, less symptom distress, and higher HRQOL scores than controls

Intervention group had less symptom distress and fewer unmet health care and support needs

Intervention group had fewer unmet health care and support needs

Low Increased and earlier institution of DNR status (81% vs 52%), increase in proportion of deaths preceded by WLST (68% vs 35%), and decreased mean LOS among decedents and survivors during intervention period Increase in GOC discussion on rounds during intervention period (38% vs 2%) No difference in mortality rate

Earlier and increased documented discussions with patients and families regarding goals of care, statements of patients’ preferences for care, clinical course, ACP, use of time-limited trials, code status, or limiting aggressive care Decrease in mean (SD) SICU LOS from 27.8 (3.7) d in the first year to 15.7 (2.4) d in the fourth year Decrease in SICU days from 2028 to 1003 d No change in overall mortality

Mean time from ICU admission to WLST was shorter during intervention period (191 vs 205 h) Reduction in total use of comfort medications per patient Increase in pastoral care involvement at EOL

Results

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E5

E6

Retrospective, preintervention/ postintervention cohort study Inpatient medical and surgical patients at a single, non-academic, tertiary referral hospital

Retrospective, preintervention/ postintervention cohort study Outpatients seen at a single academic medical center

Prospective, preintervention/ postintervention, within-subjects cohort study Outpatient clinics at a single academic medical center

Prospective, preintervention/ postintervention cohort study Inpatients admitted to the SICU at a single academic medical center

Randomized controlled study Outpatient home-visit, multisite intervention including 8 hospitals

Retrospective, preintervention/ postintervention cohort study Inpatients admitted to MICU or SICU at a single academic medical center

Miner et al,27 2011; Miner et al,28 2004 (United States)

Moorhouse and Mallery,44 2012 (Canada)

Mosenthal et al,45 2008 (United States)

Ross et al,25 2009; Ross et al,26 2005 (Denmark)

Sihra et al,46 2011 (United States)

Design and Setting

Meilink et al,43 2006 (the Netherlands)

Source (Country of Origin) Results



Downloaded From: http://archsurg.jamanetwork.com/ by a Tufts Univ. Hirsh Health Sciences Library User on 11/25/2015 Screening program in MICU and SICU to identify patients with baseline serious illness or acute critical illness who could potentially benefit from palliative care

Home-based psychosocial intervention with 10 home visits in a 2-y period focused on providing emotional support and information

Primary: processes of care Secondary: communication

Primary: communication Secondary: none

Primary: communication Secondary: patient decision making, EOL decision making, surgical education about palliative care

Adult patients admitted to the MICU or SICU (ages not reported) (5611 [47.9])

Postsurgical patients, 18 y and older, who underwent abdominal surgery for colorectal cancer (intervention group median age, 68.8 y; control group median age, 68.1 y) (249 [50.2])

Adult trauma patients admitted to the SICU (mean age, 40.4 y) (721 [57.3])

Palliative care consultations in SICU patients increased by 51% during intervention period

No differences in survival or well-being

Decreased mean time admission to DNR (7 vs 20 d) Decreased mean time from admission to WLST (7 vs 11 d) Decreased median ICU LOS (1 vs 3 d) Increased discussion of symptom management and GOC during rounds (36% vs 4%) No difference in overall rate of DNR, WLST, or mortality

(continued)

Low

Low

Low

Very low After intervention, 77% of patients scheduled for cardiac surgery and 100% of patients scheduled for noncardiac surgery declined to continue with procedure

Frail adult patients and surrogates referred for assistance with decision making; subanalysis of patients scheduled for ≥1 procedure at time of assessment (mean age, 81 y) (71 [100])

Primary: patient decision making Secondary: surgical decision making, communication

Palliative and Therapeutic Harmonization model for decision making in frail older adults divides decision making into 3 clinical encounters in which a physician or NP met with the patient and caregiver Model aims to understand the patient’s health status, provide health and prognosis information, and improve ability to make decisions in the context of frailty 2-Part multifaceted palliative care intervention involving early comprehensive assessment of palliative needs, social support, and GOC discussions; involvement of palliative care in daily rounds; and integration of palliative care into professional peer review

Low

Intervention period surgical patients had higher rates of postsurgical symptom resolution (90.7% vs 80%), longer survival (528 d vs 194 d), and lower 30-d morbidity (20.1% vs 40.0%) and mortality (3.9% vs 11.0%)

Low

Study Qualitya

Adult patients with symptomatic, advanced locoregional cancer, referred to surgery for consideration of a palliative procedure, and comparison group of historical controls from previously published data28 (age range, 24-97 y) (1150 [19.7])

No difference in rate of completion for DNR All medical and surgical inpatient admissions (mean age, documentation 48.5 y for intervention group; not reported for preintervention group) (2517 [50.9])


Primary: surgical decision making Secondary: patient decision making, symptom management, communication

Primary: EOL decision making Secondary: surgical education about palliative care, processes of care

Research Domains

The palliative triangle technique, a model for shared decision making and improved patient selection for palliative operations, was used to explore patient’s complaints, values, and emotional support and evaluate for palliative surgical procedures

Systemwide initiative to improve DNR documentation by providing patients with informational sheets and personally encouraging physicians to complete documentation

Intervention


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Randomized controlled study Outpatient clinics at a single academic medical center

Prospective nonrandomized cohort study Inpatients at a single academic medical center

Prospective, nonrandomized controlled study Care provided across outpatient and inpatient settings at a single nonacademic medical center

Randomized controlled study Inpatients at a single academic medical center

Randomized, controlled study Outpatient, telephone contact, multisite intervention including 23 hospitals

Song et al,47 2005 (United States)

Swetz et al,48 2011 (United States)

Tan et al,49 2011 (Singapore)

Wallen et al,50 2012 (United States)

Young et al,51 2013 (Australia) 5 Telephone calls by a trained nurse using standardized clinical protocols to screen for physical, psychosocial, informational, supportive, and rehabilitation/follow-up needs after discharge from surgical visit

Early postoperative pain and palliative care consultation for comprehensive assessment of physical, psychological, emotional, and spiritual needs

Transdisciplinary GSS that tailors perioperative care to elderly patients with emphasis on prehabilitaiton, psychosocial needs, and functional recovery Team-based approach to surgical decision making and patient management

Proactive palliative medicine consultation offered to patients consented for LVAD as DT before implantation or shortly after Consultation aimed to delineate GOC and assist family with LVAD-specific ACP

Facilitated patient-centered ACP interview to explore disease understanding and treatment preferences with patient and surrogate

Intervention

a

Postsurgical adult patients after treatment of primary colorectal cancer (mean age, 67.8 y) (756 [51.2])

Adult patients with advanced malignant disease who were enrolled in NCI Surgery Branch clinical trials (mean age, 52.4 y) (152 [50])

Adult patients, ≥65 y who underwent major colorectal resection (mean age, 81.4 y) (61 [47.5])

Adult patients with end-stage heart disease consented for LVAD as DT (age range, 55-77 y) (19 [68.4])

Adult patients 50 y and older scheduled for semielective cardiac surgery and their surrogates (mean age, 68.9 y) (32 [50])


No difference in unmet supportive care needs, distress or HRQOL score, or unplanned readmissions or ED visits

No differences in pain intensity or symptom burden during 1-y follow-up Intervention group cited consistent communication, emotional support, and pain and symptom management as beneficial aspects

Intervention patients had trend toward sequential improvement in successful outcomes (mortality, prolonged hospital stay, or functional status below baseline at 6 wk were considered failures) Median LOS was 2.5 d shorter in intervention group Intervention group had high rate of functional recovery within 6 wk (not measured for controls)

Nonsignificant trend toward increased documentation of advance directives among patients who received the intervention compared with those who did not

Intervention group patients had less decisional conflict (Δ = -0.77) and higher patient and surrogate concordance on treatment preferences (Δ = 1.27) No differences in anxiety

Results

Moderate

Low

Low

Very low

Low

Study Qualitya

Based on study design and risk of bias. Detailed definitions for each of the quality ratings (high, moderate, low, and very low) are given in eTable 3 in the Supplement.


Primary: symptom management Secondary: communication

Primary: surgical decision making Secondary: patient decision making, communication, processes of care



Research Domains

Abbreviations: ACP, advance care planning; APN, advanced practice nurse; DNR, do not resuscitate; DT, destination therapy; EOL, end of life; ED, emergency department; GOC, goals of care; GSS, geriatric surgical service; HRQOL, health-related quality of life; ICU, intensive care unit; LOS, length of stay; LST, life-sustaining treatments; LVAD, left ventricular assist device; MICU, medical ICU; NCI, National Cancer Institute; NP, nurse practitioner; PCLN, psychiatric consultation-liason nurse; PSS, palliative support service; SICU, surgical ICU; WLST, withdrawal of LST.

Design and Setting



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Table 2. Outcome Measures of Studies Meeting Inclusion Criteria

Mortality

Health Care Utilization

Health Care Cost

−

X

−

−

−

−

X

X

−

−

−

−

−

X

−

−

Palliative Care Consultation

ACP Discussions

Symptom Burden

Quality of Life

Patient or Caregiver Satisfaction

Hospice Referral

Quality Communication

Miner et al,27 2011; Miner et al,28 2004

−

−

X

X

−

−

Tan et al,49 2011

−

−

−

−

−

−

−

−

−

Source Surgical decision making

Patient decision making Moorhouse and Mallery,44 2012 EOL decision making

−

Briggs et al,31 2004

−

Xa

−

−

X

−

Xa

−

−

Cooper et al,32 2014

−

X

−

−

X

−

X

−

−

−

Grimaldo et al,35 2001

−

Xa

−

−

X

−

X

X

−

− −

Hall et al,36 2004

−

X

−

−

−

−

−

X

Xa

Meilink et al,43 2006

−

X

−

−

−

−

−

X

−

−

Song et al,47 2005

−

Xa

−

−

−

−

−

−

−

−

Swetz et al,48 2011

−

X

−

−

X

−

X

−

−

−

Axelsson and Christensen,29 1998

−

−

−

−

−

−

−

X

Xa

X

McCorkle et al,41 2009

−

−

Xa

Xa

−

−

−

−

−

−

−

−

X

−

−

−

Xa

−

−

−

−

X

−

−

−

−

−

−

−

Xa

−

Symptom management

42

McCorkle et al,

2000

Wallen et al,50 2012 Communication Lamba et al,38 2012 39

Liao et al,

−

−

X

X

Xa

−

a

−

−

2009

−

−

−

−

X

−

−

−

−

Liao et al,40 2014

−

−

−

−

Xa

−

−

−

−

−

Mosenthal et al,45 2008

−

Xa

−

−

−

−

X

X

Xa

−

Ross et al,25 2009; Ross et al,26 2005

−

−

−

X

−

−

−

X

−

−

Young et al,51 2013

−

−

−

X

X

−

−

X

X

−

Processes of care Bradley et al,30 2010

X

−

−

−

−

−

−

X

X

−

Ernst et al,33 2014

Xa

−

−

−

−

−

−

Xa

Xa

−

Fisher and Parker,34 1999

X

−

−

−

−

−

−

−

−

−

Sihra et al,46 2011

Xa

−

−

−

−

−

−

−

−

−

−

−

−

−

−

−

Xa

−

Xa

−

Surgical education about palliative care Holloran et al,37 1995

Abbreviations: ACP, advance care planning; EOL, end-of-life; minus sign, not measured; X, measured by the study. a

Outcome was statistically significant.

Collectively, the 25 studies included 8575 unique patients with mean reported ages of 40.1 to 81.4 years. In studies reporting sex, 1950 of 3960 patients (49.2%) were female. Many studies focused solely on patients with cancer25-29,39-42,50,51; among the 6 studies reporting race,31,32,35,41,42,47 the patients were predominantly white (640 of 740 [86.5%]). Palliative care interventions for surgical patients were related to communication and decision making in addition to symptom management and were implemented during the prehospital,27,31-33,35,44,47,49 perioperative,†andpostdischarge25,26,29,39-42,51 phasesofsurgicalcare. Outcome measures and study findings were heterogeneous (Table 2). Mortality was the most frequently measured outcome in 13 of 24 †References 30, 34, 36-38, 43, 45, 46, 48, 50 E8

studies,‡with2reportingstatisticallysignificantincreasesinsurvival33,42 andnonereportingincreasedmortality.Threeof4studies33,34,46 found thatinterventionsincreasedtherateofpalliativecareconsultation.Discussions of ACP and the use of health care resources were each measured by 9 studies§ and 10 studies, { respectively, of which more than half reported statistically significant improvements. Symptom burden,27,41,50 QOL,26,27,41,42,51 satisfaction,31,32,35,39,40,48,51 and communicationquality31,32,35,37,38,45,48 weremeasuredlessfrequently,with fewstudies31,39-41 reportingstatisticallysignificantevidence.Onestudy29 measured health care costs and reported decreased spending but did ‡References 25, 27, 29, 30, 33, 36-38, 42, 43, 45, 49, 51 §References 31, 32, 35, 36, 38, 43, 45, 47, 48 {References 30, 33, 36-38, 40, 44, 45, 49, 51




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not perform statistical analysis. None of the studies examined hospice enrollment, an accepted quality marker for EOL care.52-54

Quality of Included Studies and Risk for Bias The methodologic quality of included randomized clinical studies and cohort studies is available in eTables 3 and 4, respectively, in the Supplement. Randomized clinical studies had a high risk for performance and selection bias. Cohort studies ranged from 2 to 6 stars on the Newcastle-Ottawa scale (range, 0-9; a lower score indicates methodologic weakness), and selection and performance bias were common. In addition, studies were limited by small sample sizes, difficult recruitment, high rates of attrition, and nonequivalent comparison groups.

Summary of Evidence by Research Domain Surgical Decision Making

Only 2 interventions27,49 focused primarily on surgical decision making. Miner et al27 used a communication technique, the palliative triangle, to guide decisions about palliative surgery for patients with advanced cancer. This model incorporates patients’ symptoms, values, and treatment goals to create a context for decisions about surgery or medical treatments. Compared with the cohort of patients who underwent palliative procedures performed before this intervention,28 patients selected for palliative operations using the palliative triangle approach had higher rates of symptom resolution (90.7% vs 80.0%), longer overall survival (median, 528 vs 194 days), and lower associated 30-day morbidity (20.1% vs 40%) and mortality (3.9% vs 11.0%). A study by Tan et al49 tailored perioperative care to older patients undergoing colorectal surgery with emphasis on preoperative evaluation, prehabilitation, psychosocial needs, and functional recovery. Surgical decision making was informed by the broad input from a transdisciplinary team. Compared with patients receiving usual care, patients whose treatment was managed by this team demonstrated lower rates of 30-day mortality (6.9% vs 9.6%) and major complications (17.2% vs 30.8%).49


study’s small sample size was inadequately powered to detect statistically significant differences. Conversely, Grimaldo et al35 found that a brief, anesthesiologist-led information session was associated with a 32% increase in preoperative EOL conversations between patients and their proxies and with a 170% increase in documentation of durable power of attorney compared with the control group. Three studies31,32,47 examined ACP discussions with patients and surrogates. Briggs et al31 and Song et al47 found that ACP interviews before cardiac surgery improved concordance between patients and surrogates regarding postoperative use of lifesustaining treatment (LST) decisions, led to greater satisfaction with decision making,31 and reduced patients’ decisional conflict.47 Similarly, a study by Cooper et al32 used a structured preoperative conversation with high-risk surgical patients and their surrogates that explored the patient’s goals and values for treatment, clarified the surrogate role, and encouraged further discussion between the patient or surrogate and the surgeon about treatment preferences. They also found that dyads who received the intervention demonstrated higher concordance between patients and surrogates regarding LST preferences, and, overall, patients and surrogates were satisfied with the conversation.32 However, that study was limited by a small sample size and low recruitment, which may have introduced selection bias. Among studies exploring patients’ preferences for treatments and EOL care, we found inadequate follow-up to conclude how these interventions translated to practice. Previous research shows advance directives are sometimes ignored 55,56 or rejected by surgeons.57-61 Therefore, the effect of these interventions on clinically meaningful outcomes is undetermined. Hall and colleagues36 implemented a systemwide initiative in 2 medical-surgical intensive care units (ICUs) of a single tertiary care medical center to clarify donot-resuscitate orders, standardize processes for withdrawal of LST, and change policies regarding analgesia and sedation in EOL care. This intervention was associated with earlier withdrawal of LST and decreased use of health care resources in the hours preceding death. Symptom Management

Patient Decision Making

Patient decision making was poorly represented in the literature. Only 1 study described an intervention focused primarily on exploring patients’ goals and preferences for surgical procedures. Moorhouse and Mallery44 described a decision-making intervention for frail older adults, which used 3 clinical encounters with a physician or a nurse practitioner to understand the patients’ health status, communicate information about prognosis, and place medical decision making in the context of frailty. The investigators reported a 75% reduction in the demand for offered procedures.44 However, the referral-based nature of the program may overestimate its effect on a broader patient population, and no concurrent control group received usual care. EOL Decision Making

Three studies examined interventions to improve documentation of EOL preferences.35,43,48 A study by Meilink and colleagues43 using a patient information packet about code status failed to improve code status documentation. Similarly, a study by Swetz and colleagues48 found that palliative care consultation for preparedness planning did not increase documentation of advance directives. However, that jamasurgery.com

Four studies29,41,42,50 examined the role of palliative care in providing symptom management for patients after surgery. Axelsson and Christensen29 studied a home-based palliative support service for postoperative care of patients with symptomatic incurable cancer. Compared with controls, patients receiving the intervention had a shorter median duration of terminal hospitalization (3 vs 10 days), more days at home in the last 2 months of life (44 vs 38.5 days), and a mean cost savings of $2500 per patient. Studies by McCorkle and colleagues41,42 used home nursing care for postoperative treatment of patients with cancer that involved tailored, specialized care by an advanced practice nurse specializing in oncology, including symptom management, emotional support, and care coordination. They found increased survival,42 less uncertainty,41 and less symptom distress.41 One study41 found improved QOL outcomes, defined as depressive symptoms, symptom distress, uncertainty, and overall QOL, whereas the other study42 reported comparable QOL outcomes, defined as depressive symptoms, symptom distress, and enforced social dependency, despite a larger burden of late-stage disease in the intervention group. In contrast, Wallen et al50 found no benefit for pain and symptom distress after early postoperative consultation with a hospital-based pain and palliative care service (Reprinted) JAMA Surgery Published online November 25, 2015



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for patients with advanced-stage cancers. However, qualitative interviews with those receiving palliative care showed that patients valued the communication, emotional support, and symptom management that they received.50

found preoperative screening and palliative care consultation were associated with an increased rate of cancellations (19.3% vs 5.6%; P < .05) and decreased mortality among frail older patients at 30, 180, and 360 days.

Communication

Surgical Education About Palliative Care

Several studies25,26,38-40,45,51 examined communication interventions for surgical patients in different phases of care. Studies by Liao et al39,40 found that a supportive care intervention incorporating informational support, emotional support, and continuous follow-up led to fewer unmet health care and support needs compared with controls. Studies by Lamba et al38 and Mosenthal et al45 examined a structured communication intervention in patients undergoing liver transplant and treatment for trauma, respectively. Both studies used 2-part interventions designed to improve assessment of palliative needs in the surgical ICU by means of an early comprehensive assessment of palliative care needs and integration of palliative care into daily rounds, family meetings, and professional peer review.21 They found increases in goals of care discussions during physician rounds and earlier institution of do-not-resuscitate orders and withdrawal of LST orders without changes in mortality rates.38,45 In contrast, a home-care psychosocial communication intervention for patients with colorectal cancer undergoing postoperative care25,26 found no benefit compared with usual care for anxiety, depression, or QOL. Similarly, a nurse-led intervention that used telephone-based communication and care coordination for patients with colorectal cancer undergoing postoperative care51 found nO improvement in distress or QOL compared with controls. However, in semistructured interviews with 29 patients, the investigators found that a subset of patients with active postoperative issues or limited access to health care professionals considered the intervention important to their recovery.51

Although our search revealed several studies of educational interventions for health care professionals, only one measured patientoriented outcomes and was eligible for inclusion. Holloran and colleagues37 found that a case-based educational intervention for surgical residents improved communication and reduced the surgical ICU length of stay without increasing mortality.

Processes of Care

Identifying surgical patients who could benefit from palliative care consultation is critical to improving access to these services. A study by Fisher and Parker34 instituted weekly joint palliative care and surgical ward rounds with a hospital palliative care physician and a general surgeon who specialized in oncologic surgery. They found a 140% increase in palliative care team referrals after initiation of joint ward rounds and an increase in consultations for symptom management.34 A study by Bradley and colleagues30 used triggers for palliative care consultation in the surgical ICU and found no difference in the rate of palliative care consultation as a result of implementation. Less than 30% of patients who met at least 1 trigger criterion were referred for palliative care consultation, indicating a lack of investment among treating surgeons and intensivists and among patients and their families about the benefits of palliative care in this setting. The triggers, including futility considered or declared by the medical team, death expected during the same surgical ICU stay, and multiple-organ system failure involving more than 3 systems, identified patients with acute critical illness who were not expected to survive, and only approximately 6% of patients met a single trigger.30 In contrast, studies by Sihra et al46 and Ernst et al33 found an increased rate of palliative care consultation with the use of screening criteria that also identified patients with serious chronic illness who may benefit from palliative care. Furthermore, Ernst et al33 E10

Discussion This systematic review outlines the current landscape of palliative care research in surgery and reveals critical gaps in knowledge that require further investigation. Each research domain recommended by the American College of Surgeons Palliative Care Workgroup17 was addressed, but we found a paucity of studies, most of which were conducted at academic centers and carried a potentially high risk for bias. Overall, the existing literature provides evidence that palliative care interventions for surgical patients reduce the use of health care resources and improve discussions about ACP without increasing mortality. The generally poor study quality echoes findings from previous systematic reviews5,62 and bibliometric analysis63 of palliative care research in patients undergoing medical interventions and treatment of cancer. Despite a nearly 10-fold increase in federal funding from 1997 to 2010, palliative and EOL care research continues to represent a small fraction of the annual investment in biomedical sciences research.64 A crucial first step will be updating the research agenda to direct future research on palliative care specifically for surgical patients. In addition to the 7 domains proposed in 2003,17 an updated agenda should call for more studies in the following areas: (1) validation of measures commonly used in palliative care research (ie, function, symptom burden, QOL, and EOL outcomes) in surgical patients; (2) the association between perioperative palliative care and postoperative use of health care resources and costs; (3) the effect of perioperative palliative care on mortality and the patient experience, including communication with health care professionals, transitions of care, QOL, symptom burden, and EOL outcomes; and (4) how palliative care education for surgeons translates into changes in surgical practice. The success of this research agenda will require surgeon engagement and will hinge on recognition of palliative care research as a funding priority and sustained support from the National Institutes of Health, National Palliative Care Research Center, surgical societies, and partners in the private sector. This review should be considered in the context of some limitations. Variation in literature indexing led to difficulty identifying appropriate search terms and may have limited the comprehensiveness of our database search. This limitation has been reported by previous systematic reviews of palliative care in different patient populations. For example, in a systematic review assessing interventions to improve palliative and EOL care in patients with cancer, chronic heart failure, and dementia,17,65 the authors commented on the lack of common keywords and indexing terms for literature on




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the care of patients with advanced illness as a barrier to identifying relevant studies. To overcome limitations imposed by variation in indexing, we enlisted the help of a research librarian, performed reference and hand searches, and used multiple national and international databases. To build on the evidence for palliative care in surgery, consistency in indexing is an imperative undertaking for authors and journals. We recommend the keywords palliative care and surgical patients as identifiers for relevant studies and assigning palliative surgery as a distinct moniker specifically for surgical interventions that are undertaken with the explicit intent of relieving symptoms rather than curing a disease or condition. A second limitation was that heterogeneity among studies with respect to their approaches to palliative care, types of interventions, and measurement of outcomes made performance of a meta-analysis impossible. Thus, findings are difficult to compare across studies. Finally, unpublished studies and reports were excluded, which may have omitted data from studies with negative findings or those reporting adverse outcomes. However, unpublished studies are gener-

ally of lower methodologic quality, and so the findings may have not been as robust as the studies included herein.66

Conclusions This study is, to our knowledge, the first systematic review to characterize the content, design, and results of interventions to improve access to or quality of palliative care for surgical patients. Despite the growth in attention to palliative care, evidence substantiating its usefulness in surgery is sparse. Although most studies reported positive findings, the evidence was inconsistent, and many studies were small and did not measure the outcomes they intended to achieve, such as goal-concordant care. In the absence of data from high-quality research, the role of palliative care in improving surgical practice remains poorly defined. More work is needed to demonstrate which surgical patients most benefit from palliative care and how palliative care should be delivered.

Accepted for Publication: August 23, 2015.

management of patients with lung cancer: randomised trial. BMJ. 2002;325(7373):1145.

Published Online: November 25, 2015. doi:10.1001/jamasurg.2015.3625.

2. Morrison RS, Meier DE. Clinical practice: palliative care. N Engl J Med. 2004;350(25):2582-2590.

Author Affiliations: Center for Surgery and Public Health, Brigham and Women’s Hospital, Boston, Massachusetts (Lilley, Bader, Cooper); Department of Surgery, Rutgers–Robert Wood Johnson Medical School, New Brunswick, New Jersey (Lilley); Department of Surgery, Brigham and Women’s Hospital, Boston, Massachusetts (Khan, Cooper); Harvard School of Public Health, Boston, Massachusetts (Khan, Bader); Department of Surgery, Medical College of Wisconsin, Milwaukee (Johnston); Department of Surgery, Rutgers–New Jersey Medical School, Newark (Berlin, Mosenthal); Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital, Boston, Massachusetts (Bader); Department of Surgery, Harvard Medical School, Boston, Massachusetts (Bader, Cooper).

3. Morrison RS, Penrod JD, Cassel JB, et al; Palliative Care Leadership Centers’ Outcomes Group. Cost savings associated with US hospital palliative care consultation programs. Arch Intern Med. 2008;168(16):1783-1790.

ARTICLE INFORMATION

Author Contributions: Drs Lilley and Cooper had full access to the data presented in this study and take responsibility for the integrity of the data and accuracy of the data analysis. Study concept and design: Lilley, Berlin, Bader, Mosenthal, Cooper. Acquisition, analysis, or interpretation of data: Lilley, Khan, Johnston, Berlin, Mosenthal, Cooper. Drafting of the manuscript: Lilley, Cooper. Critical revision of the manuscript for important intellectual content: All authors. Administrative, technical, or material support: Lilley, Khan, Cooper. Study supervision: Lilley, Johnston, Bader, Cooper. Conflict of Interest Disclosures: None reported. Additional Contributions: Julia S. Whelan, MS, reference and education librarian at the Countway Library of Medicine at Harvard Medical School, assisted with development and execution of the database search strategy. She was not compensated for this contribution.

4. Nelson JE, Curtis JR, Mulkerin C, et al; Improving Palliative Care in the ICU (IPAL-ICU) Project Advisory Board. Choosing and using screening criteria for palliative care consultation in the ICU: a report from the Improving Palliative Care in the ICU (IPAL-ICU) Advisory Board. Crit Care Med. 2013; 41(10):2318-2327. 5. Zimmermann C, Riechelmann R, Krzyzanowska M, Rodin G, Tannock I. Effectiveness of specialized palliative care: a systematic review. JAMA. 2008; 299(14):1698-1709. 6. Gade G, Venohr I, Conner D, et al. Impact of an inpatient palliative care team: a randomized control trial. J Palliat Med. 2008;11(2):180-190. 7. Temel JS, Greer JA, Muzikansky A, et al. Early palliative care for patients with metastatic non–small-cell lung cancer. N Engl J Med. 2010;363 (8):733-742. 8. Casarett D, Pickard A, Bailey FA, et al. Do palliative consultations improve patient outcomes? J Am Geriatr Soc. 2008;56(4):593-599. 9. Bookbinder M, Coyle N, Kiss M, et al. Implementing national standards for cancer pain management: program model and evaluation. J Pain Symptom Manage. 1996;12(6):334-347. 10. O’Mahony S, Blank AE, Zallman L, Selwyn PA. The benefits of a hospital-based inpatient palliative care consultation service: preliminary outcome data. J Palliat Med. 2005;8(5):1033-1039.

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Pharmacological treatments for fatigue associated with palliative care: executive summary of a Cochrane Collaboration systematic review.

Transition to adult services for children and young people with palliative care needs: a systematic review.

Surgical interventions for anterior shoulder instability in rugby players: A systematic review.

A comprehensive review of palliative care in patients with cancer.

The clinical efficacy of surgical interventions for empty nose syndrome: A systematic review.