Journal of the American Medical Association outlines the importance of advance directives and palliative care for high-risk patients.

November 28, 2023

Read full article here.

Delivering care in alignment with patient goals is a critical aspect of serious illness care. Eliciting and documenting high-risk patients’ goals, particularly in advance of a surgical procedure, is central to advanced care planning and definitionally good quality care. Achieving documentation of goals that truly reflect patient wishes as they face dynamically changing circumstances of treatment, improvement, and decline is challenging to operationalize. Advanced directive (AD) designation of a health care power of attorney and/or a living will represents a discrete and measurable outcome of good care communication.

Bansal et al1 make a novel contribution by demonstrating that palliative and surgical workflow integration are associated with increased AD designation for patients facing surgery. Specifically, in a surgical oncology clinic at a comprehensive cancer center, the authors1 evaluated the integration of early palliative care consultations into the surgical workflow. Their study1 demonstrates that with a process change facilitated by a shared electronic health record, preoperative checklists, and physician training, improving perioperative goals of care documentation is possible. These findings are notable because although the study1 consisted of a small sample in a single cohort, it diverged from other contemporary studies2 that have failed to demonstrate a clear benefit of perioperative palliative care integration.

The fact that a change in workflow integration was associated with a measurable outcome of increased AD designation opens up a whole new line of questions. Was it having a shared system of accountability across disciplines in the electronic health record that was the mechanism behind the association? Perhaps there was a key champion or type of leadership support that was invisible in the intervention description that contributed to the success at the site. Maybe it was the interdisciplinary colocation aspect of the intervention that was most important? Further, is colocation itself enough for success or was it through colocation that the surgical and palliative care clinicians were able to build relationships?

Recent work by Sasnal et al1 explored interdisciplinary clinician perspectives on building cross-disciplinary relationships between palliative care clinicians and surgeons. Interdisciplinary interviews revealed that successful collaborative relationships between palliative care and surgeons had 6 central features including mutual trust, mutual respect, perceived usefulness, shared clinical objectives, effective communication, and organizational enablers.3 Did the surgeons and palliative care clinicians from Bansal et al1 perceive themselves to be a team? Teams can be conceptualized as a group of individuals who identify as working together toward a common shared goal.4 Is improving care quality (specifically preoperative goals of care communication) a compelling enough shared goal to motivate clinicians to take on additional roles and interdisciplinary work?

Outside of serious illness communication and advanced care planning, good quality surgical care is inherently interdisciplinary. The American College of Surgeons and the American Society of Anesthesiologists issued a 2016 joint statement5 acknowledging the importance of coordinated interdisciplinary team-based care in improving patient experience and outcomes in the perioperative period. Goals of care communication may be outside the comfort zone of many in the surgical practice community; however, this skill sits squarely in the wheelhouse of palliative care disciplinary expertise. To achieve better communication-related outcomes, teaming across disciplines and incorporating palliative care early must be strategic. … (read more)

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