While colorectal surgeons value palliative and end-of-life care, they perceive multiple barriers to its optimal implementation at the patient, family, and clinician level, results of a recent survey suggest.

“We found that surgeons reported the most important barriers to be their own,” said Pasithorn A. Suwanabol, MD, division of colorectal surgery, University of Michigan, Ann Arbor, and coauthors of a report on the survey.

More than three-quarters of surgeons said they had no formal education in palliative care, and a substantial number specifically noted inadequate training in both communication and techniques to forgo life-sustaining measures, according to the report, published in the Journal of Palliative Medicine.

Dr. Suwanabol and her colleagues sought surgeon perspectives on palliative care for stage IV colorectal cancer in part because palliative care is often not integrated with cancer treatment in these potentially incurable patients.

“Compared with patients treated by primary providers, surgical patients with terminal diseases are significantly less likely to receive palliative or end-of-life care,” they said in the report.

They conducted a mixed methods study including members of a surgical society (American Society of Colon and Rectal Surgeons) who were asked to submit Internet responses to a validated survey. This mixed methods study is believed to be the first to characterize surgeons’ perceived barriers to optimal palliative and end-of life care for patients with advanced colorectal cancer, Dr. Suwanabol and her colleagues noted.

A total of 131 surgeons responded to the survey, for a response rate of 16.5%. The majority of surgeons responding (76.1%) said they did not have any formal palliative care training, while 42.7% said they lacked specific education in communication and 37.9% lacked training in techniques to forgo life-sustaining measures.

Many patients with stage IV colorectal cancer are candidates for palliative care. “Specialty palliative care should be offered to patients who have more complex issues such as refractory pain, depression and anxiety, and existential distress. In addition, specialty palliative care may be helpful in those with challenging family dynamics and/or conflict between family members and/or members of the care team. Patients with stage IV colon cancer may not be candidates for curative therapies and a palliative approach allows the surgeon and patient to carefully weigh the risk and benefits of each therapy in the context of the overall goals of the patient,” Dr. Suwanabol said in an interview.

Among the survey responders, 61.8% said discussion of palliation was limited because of patients and families who had unrealistic expectations and demanded aggressive interventions.

One such recollection in the report reads as follows: ‘‘Patient with poorly responding stage IV colon cancer in multisystem organ failure getting same chemo that already failed ... family wanted everything done…’’

The report includes a number of other reflections from surgeons that suggest a level of anxiety, frustration, disappointment, or uncertainty regarding palliative care.

“I once operated on a young man with carcinomatosis, implants everywhere in the abdominal cavity,” one surgeon said in his survey response. “(He) went to another major center where they reoperated … I still have doubts about whether or not (a) I didn’t do enough for the patient or (b) the other center did too much.’’

Another surgeon reflected on the uncertainty of prognostication in some cases of advanced colon cancer. “I had a patient in the ICU with florid sepsis and multisystem organ failure. The entire care team began to wonder how long we should continue to press on with a patient who clearly could not survive. Days later he is awake and alert, off pressors, on trach collar, and fully communicative. Sometimes even experienced clinicians cannot predict when a patient will die or recover.”

Communication barriers remain. “A number of surgeons reported not knowing how to discuss this with families knowing that there is a stigma associated with palliative care – how to convey that they may pursue continued treatment in conjunction with palliative care,” said Dr. Suwanabol.

Surgeons adept at incorporating palliative care into their treatment plans continue to see the patients. “Even if a patient is not pursuing curative treatment, we do not want the patient to lose hope or feel abandoned by us, and I continue seeing my patients in follow-up until they feel overburdened by their clinic visits and choose not to come,” said Dr. Suwanabol.

In the absence of required palliative care training in medical schools or residencies, alternative approaches to achieving competency could include the American College of Surgeons Palliative Surgical Care Course, mentorships or collaborations with local palliative care specialists, or structured curricula implemented by experienced faculty, they added.

Dr. Suwanabol and her coauthors reported that they had no competing financial interests related to their study.

SOURCE: Suwanabol PA, et al. J Palliat Med. 2018 Mar 13. doi: 10.1089/jpm.2017.0470.

Colorectal surgeons see barriers to optimal palliative care