Anesthesia-Guided Palliative Care in the Perioperative Surgical Home Model
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E THE OPEN MIND Anesthesia-Guided Palliative Care in the Perioperative Surgical Home Model Julien Cobert, MD, Jennifer Hauck, MD, Ellen Flanagan, MD, Nancy Knudsen, MD, and Anthony Galanos, MD * * * * he emerging concept of† the perioperative surgical used to control disease to those used to relieve suffering. home (PSH) represents a patient-centered model for Simply, it represents a holistic emphasis on alleviating pain Thealth care delivery with an emphasis on shared deci- and managing physical, psychological, social, and spiritual sion making, decreased resource utilization, and improved distress. According to the American Academy for Hospice patient-centered and value-based outcomes, such as length and Palliative Medicine (AAHPM), the field “focuses on of stay, health care utilization and costs, patient satisfaction, improving a patient’s quality of life by managing pain and morbidity and mortality.1 In the current PSH model, an and other distressing symptoms of serious illness.” While episode of care begins at the time of discussion of a surgi- these concepts have existed for millennia,2 it was only in cal solution for a particular problem through 30–90 days the 1970s when the first hospice in the United States was postoperatively. The PSH is often led by anesthesiologists established and in 1983 when hospice was made a benefit and incorporates improved risk assessment, mitigation, and of the Medicare program. In 2006, the American Board of intervention (prehabilitation and optimization) in an effort Medical Specialties and the Accreditation Council for to improve surgical outcomes. However, if anesthesiolo- Graduate Medical Education recognized hospice and pallia- gists hope to redefine their role as perioperative physicians tive medicine (HPM) as an official subspecialty. At present, spanning from preoperative assessment through subacute anesthesiology-trained physicians certified by the American to chronic follow-up postoperatively, then they must take Board of Anesthesiology (ABA) can participate in 12-month responsibility in guiding discussion and care of the frail, the Accreditation Council for Graduate Medical Education chronically ill, and even the palliative and/or dying patient (ACGME)-accredited HPM fellowships and subsequently in the perioperative setting. The role of the anesthesiologist be eligible to take the HPM examination administered by beyond preoperative risk assessment and medical optimi- the American Board of Internal Medicine. Before 2012, some zation of these challenging patient populations remains physicians were eligible to take the HPM examination with- poorly defined and represents an opportunity to consolidate out an ACGME-accredited fellowship if, along with other and coordinate, particularly in the era of enhanced recovery provisions, they demonstrated 800 hours of clinical involve- programs and PSH models. In this article, we describe the ment in subspecialty-level practice of hospice and palliative history of palliative care with an emphasis in the surgical care medicine over the previous 5 years. population and potential opportunities for anesthesiolo- Despite the increase of palliative care medicine special- gists to improve care among these patients in the periopera- ists over the past decades, the demand for palliative care tive and nonsurgical settings based on their unique clinical has outstripped the supply of providers.3 While the reasons skill sets. We argue that, within the PSH model, anesthesi- for the increased demand remain unclear, possible explana- ologists must broaden their role in perioperative palliative tions may be the growing population of elderly (and thus care and even have an opportunity to lead this field. comorbid) patients,4 improved costs and possibly mortal- Palliative care represents a relatively new concept of ity within a certain subset of patients receiving palliative specialized team-based medical care for patients of any care,5 and/or changing reimbursement structures for hos- age and at any disease stage who are suffering from seri- pice.6 The development of an integrated, multidisciplinary, ous illness. The philosophy of palliative care shifted the and team-based approach to palliative care has been pro- delivery of care from providing medical interventions posed as a potential solution for the undersupply problem.7 There has also been an expansion of providers eligible to train in HPM, as evidenced by the growing number of joint From the Department of Anesthesiology, and Division of Palliative Care, Department of Medicine, Duke University Medical Center, Durham, North ventures between various specialties (anesthesiology, gen- Carolina. * † eral surgery, and internal medicine included) in offering Accepted for publication November 20, 2017. Certificates of Added Qualifications in HPM. These joint Funding: None. programs suggest that palliative care has become a broad The authors declare no conflicts of interest. and multidisciplinary field requiring unique perspectives Reprints will not be available from the authors. from multiple specialties. This multidisciplinary approach Address correspondence to Julien Cobert, MD, Department of Anesthesiol- has also extended into the surgical specialties as evidenced ogy, Duke University Hospital, 2301 Erwin Rd, DUMC 3094, Durham, NC 27705. Address e-mail to [email protected]. by enhanced surgical guidance from the American College Copyright © 2018 International Anesthesia Research Society of Surgeons, which created the Surgical Palliative Care Task DOI: 10.1213/ANE.0000000000002775 Force in 1998 to aid in surgical palliation decision making.8 XXX 2018 • Volume XXX • Number XXX www.anesthesia-analgesia.org 1 Copyright © 2018 International Anesthesia Research Society. Unauthorized reproduction of this article is prohibited. E THE OPEN MIND Specialty societies and medical education programs have In the context of the PSH, a more concrete blueprint for adopted primary palliative care milestones when assessing the role of the anesthesiologist in the care for the palliative resident professional development. Interestingly, in a recent patient becomes apparent. In the preoperative setting, risk study analyzing primary palliative care–relevant milestones assessment, through any of several risk calculators such as within ACGME-accredited medical and surgical specialties, ACS-NSQIP, Revised Cardiac Risk Index (RCRI), American anesthesiology had the most direct and indirect salient pal- Geriatrics Society (AGS) frailty index, or postoperative liative care skill training and milestones.9 Not surprisingly, respiratory distress calculator, may provide essential infor- many of these milestones involved chronic and acute pain mation to the patient, family, and certainly the oncologist and complex symptom management that represent impor- and surgeon that may inform the decision-making process, tant aspects within anesthesiology training. in particular, when life time may be limited. Triggers to ini- While the past few decades have demonstrated an tiate use of such risk calculators, such as high probability of increasing recognition and appreciation of the role for pal- postoperative complications or mortality, increased length liative care in the surgical patient, there remains a dearth of stay, or high likelihood of discharge to a skilled nursing of data on the subject, as evidenced by a recent meta-anal- facility, may help initiate the discussion of whether the sur- ysis.10 Furthermore, barriers remain in the adoption of pal- gical procedure and likely outcomes are consistent with the liative care and hospice among surgical patients. While the patient’s end-of-life and treatment goals. In addition to risk overall adoption of palliative care (ie, consultations, hos- stratification, the preoperative assessment in the PSH is a pice referrals, inpatient hospice) in the surgical patient has unique time to assess whether patients are medically and been slow, the use of palliative surgery has been common, symptomatically optimized before surgery. For instance, estimated to occur in 12.5%–21% of all surgical procedures review of analgesic regimens may demonstrate suboptimal in cancer patients.11 This may be due to the increasingly pain control, prompting patient referral to pain manage- described notion of “patient buy-in”12 whereby there may be ment services. This may then permit migration of medica- an implicit acceptance or buy-in of aggressive life-support- tion management from the oncologist or primary provider ing interventions after large and/or complex operations. to a more specialized pain service. At our own institu- Such patient buy-in may limit the utilization of palliative tion, our version of PSH, the Perioperative Enhancement care and particularly hospice referral, especially if these Team, routinely applies ACS-NSQIP risk calculations on all services recommend less aggressive and life-sustaining patients in addition to identification of comorbidities ame- interventions. Nonetheless, some recent studies raise ques- nable to medical optimization (eg, anemia, malnutrition, tions on the utility and benefit of certain palliative surger- diabetes mellitus, laboratory abnormalities). The anesthesia ies on selected patients. One retrospective study using the team reviews these potential areas of optimization with the American College of Surgeons National Surgical Quality patient and family members present as well as the surgeon, Improvement Program (ACS-NSQIP) database showed that primary care providers, and/or