Commentary

Palliative care ‘in my hands’


 

A randomized controlled multicenter study published by Carson et al. in JAMA concluded that, for patients with “chronic critical illness” (defined as requiring 7 days of mechanical ventilation), palliative care team-led informational and emotional support meetings did not reduce anxiety or depression for families and may have increased posttraumatic stress disorder symptoms (2016:316[1]:51-62. doi: 10.1001/jama.2016.8474).

This report may surprise surgeons, as well as practitioners in other specialties, as the disconnect between palliative care and critical care services has been previously perceived as an education and access issue, not an outcome problem.

Dr. Emily Rivet

Dr. Emily Rivet

Where can we look in the fields of surgery and palliative care to explain and improve these outcomes? We could start with our openness to cross-pollination of these fields. Just as the field of surgery is evolving through the assimilation of palliative care principles, the field of palliative care may also evolve through the perspectives of surgery, including the uniqueness of the surgeon. When describing techniques and outcomes, surgeons often employ the phrase, “in my hands,” to rationalize variable outcomes stemming from subtle differences in surgical technique, population, relationships, institutional culture, and processes which defy easy quantification. Although the field of surgery is shifting from a cult of personality to protocol-based approaches in its undertakings, there is still a place for “surgeon preference” for equipment and other elements of surgical care. Palliative care is comparably dependent on individual approaches, relationships, and culture.

Carson and colleagues point out that fidelity to some components of the meeting “templates” was low, suggesting that there was some flexibility baked into the study design. However, as Russ and Kaufman aptly described, patients and families vary greatly in their appetite for explicit information about prognosis (Cult Med Psychiatry 2005;29[1]:103-23). Conversely, the hypothesis that direct communication about prognosis will be welcomed by families is a core element of the Carson study. The manuscript supplement reports that discussion of the patient’s condition and prognosis took place in 100% of initial meetings. If the same variability in family receptiveness to this information exists in this population as was described by Russ and Kaufman, it is not hard to see why some families experienced negative consequences because of these discussions.

Furthermore, the authors of the Carson study point out that it was not intended to replicate the components of specialist palliative care (JAMA. 2016;316[15]:1598-9).

Essential elements of specialist palliative care include symptom management, a multidisciplinary approach, and fairly close contact in the acute care setting. These features were lacking in the study protocol. Experienced providers of palliative care will often use symptom assessment and symptom management optimization as a conduit for building rapport and to avoid focusing on prognosis until trust has been established. A period of delay before broaching challenging subjects also allows the palliative care team to develop an understanding of the patient’s or surrogates’ preferences regarding the amount and type of information communicated. Palliative care providers benefit from the deepening of relationships with patients and families over time, as much as or possibly more so than providers of other specialties.

The necessity of the multidisciplinary approach to successful palliative care outcomes cannot be overstated. In many programs, patients seen for specialist palliative care consultation are seen by a physician or advanced practitioner, a chaplain, and a social worker within 24-48 hours of initial referral, and these providers have key roles in addressing the sequelae of anxiety, depression, and stress that were the key outcomes in the JAMA study. In the study, the “support and information team” included a palliative care physician and an advanced practice nurse but not a chaplain or social worker, despite the significance of existential/spiritual and social consequences of ventilator withdrawal or progression to tracheostomy for long-term vent support.

Palliative care providers consider the family meeting to be the “procedure” of their field, a belief that may seem incongruous with a surgical understanding of the nature of procedures but is informative as a framework for understanding the results of the Carson study. Just as surgical procedures carry risk of complications or adverse outcomes, family meetings have risk for worsening instead of improving the coping of families and surrogates. And, as surgical technique can be connected to complications, the family meeting technique applied by Carson et al. may be related to its results. Although there was formalized communication between the ICU team and the palliative care team regarding the patient’s condition, prognosis, and treatment plan, there was not a representative from the critical care team present during the majority of the support and information team led family meetings. This represents a marked deviation from common practice at our institution and many others. Our usual practice is to have a member of the ICU team present for discussions focused on patient prognosis, in order to make sure that there is alignment between the messages of the ICU and palliative care teams and also to prevent the crippling of palliative support that occurs when it becomes the sole repository of unwelcome news.

Because the relief of suffering is a core value of surgery and palliative care, there are countless ways these disciplines can inform one another. The outcome of the Carson study is a cautionary tale about the fallibility of the integration of surgical and palliative care teams, both of which would acknowledge the importance of the multidisciplinary approach, relationships developed over time, and symptom management. As surgeons intuitively understand from their operative experience, the “procedure” (the family meeting) has the potential for both risk and benefit, the outcome of which may be determined “in my hands.”

Dr. Rivet is a colon and rectal surgeon with training and board certification in hospice and palliative medicine. She is an assistant professor, departments of surgery and internal medicine, Virginia Commonwealth University, Richmond. She has no disclosures.

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