Tuesday, February 10, 2015

Timing is everything



by: Jason Johanning, vascular surgeon, University of Nebraska

We as surgeons know that the timing of an intervention is an incredibly important decision. Intervene too early and you expose the patient to potential unneeded risk. Intervene too late and the disease process has already taken its toll.

From a surgical perspective, palliative care consultation on the surgical patient can be looked at in a very similar perspective. Not all patients need a palliative care consult prior to surgery. But for a select few, the consultation provides many salient and real benefits. And this I believe can be a good thing for all parties involved.

Contrast this thought with the postoperative palliative care consult process. In my travels I have heard stories of nurses ordering palliative care consultations without surgeon knowledge or consent. I have heard of patients being taken off ventilators on postoperative day 2 without surgeon knowledge by palliative care and ICU teams. To say that postoperative care in the best of circumstances is challenging for the frail patient in the ICU is correct. But throw into the mix multiple provider and nursing factions not on the same page; and now bring in Palliative care to “sort things out”, and you get the picture of why surgeons may have issue with postoperative palliative care consultations. Especially when the patient is having complications that we knew were going to occur and we discussed with the patient and family (or at least we thought we talked about it and we thought the patient heard us).

But the real benefit of preoperative consultation for the surgeon and the palliative care team are the bonds built prior to an operation and the resulting concepts that are addressed. These concepts are often espoused in the literature but are elusive in addressing in the real world. With a preoperative palliative care consultation on the frail elderly patient, the team (surgeon, palliative care team, anesthesia, ICU) goes into the procedure with eyes wide open, ready to address the expected course of operative and postoperative care with recognition of markedly elevated perioperative risk. Prior to the operation, we have addressed shared decision making with the patient and family as we notify them of their individualized increased risk and realistic benefits. With palliative care consultation preoperatively, we now have surgical buy in as a total team agreeing to push through major but survivable complications (pneumonia, myocardial infarction, pulmonary embolism). We have also primed the anesthesia and ICU services to rescue the patient in these high risk circumstances. Just as important, in the setting of these complex decisions, the ability of the palliative care service to clarify goals of care, power of attorney, DNR/DNI status, and be on the same page as the surgical team throughout the operative process can result in a significant reduction of emotional angst for all parties involved postoperatively.

At the end of the day, we will still need palliative care consultations both pre- and postoperatively on our surgical patients. Be we all need to be aware, timing is everything.

2 comments:

Gloria Lewis said...

Very thought-provoking comment. I think you demonstrate the need for a palliative care consult before surgery. Unfortunately, so many patients and families too often just nod their heads that they understand the surgical risks. In my experience as a palliative care nurse, difficult conversations about end-of-life issues are too often discussed when a patient is having a medical crisis. Patients and their families often feel everything must be done when, in fact,many times it is only futile care. In the United States,there is a culture of a false belief that death is yet another disease to be cured. A palliative care consultation completed outside of the hospital setting in a clinic , home care, or SNF facilitates early assessment and an honest and caring intervention. Discussing life-limiting diseases earlier rather than later offers patients and their families an opportunity to hear about the realities of a disease, treatment options, and to complete advance care planning. Too often, a palliative care consult is requested when a patient is in a crisis situation in a hospital, and the focus is on aggressive treatment that does not offer significant benefit and may actually shorten a patient's life. However, every patient is unique and treatment options depend on where a patient is at on a life-limiting disease trajectory. When I worked as a palliative care nurse at a Kaiser hospital in California, the best palliative care consults were those that includes an interdisciplinary approach and I often did consults with surgeons. Gloria Lewis, EdD, MSN,MHA, RN, CCM

Jerry said...

Excellent points, and encouraging to consider pre-op consults. Talking beats not talking, and talking while there's some elbow room beats trying to talk in the middle of a crisis.