Palliative care—a specialty approach that provides services to aid in the quality of life for patients with serious or painful illnesses, such as cancer or organ failure—has been underused in surgical care, despite having support from leading organizations such as the American College of Surgeons (ACS).
In fact, the ACS Task Force on Surgical Palliative Care and the Committee on Ethics in 2005 released a Statement of Principles of Palliative Care, which stated1:
Palliative care aims to relieve physical pain and psychological, social, and spiritual suffering while supporting the patient’s treatment goals and respecting the patient’s racial, ethnic, religious, and cultural values. Like all good patient care, palliative care is based on the fundamental ethical principles of autonomy, beneficence, nonmaleficence, justice, and duty.
Although palliative care includes hospice care and care near the time of death, it also embraces the management of pain and suffering in medical and surgical conditions throughout life. If palliation is taken to apply solely to care near the time of death, or “comfort measures only,” it fails to include the life-affirming quality of active, symptomatic efforts to relieve the pain and suffering of individuals with chronic illness and injury. In this respect, palliative care is required in the management of a broad range of surgical patients and is not restricted to those at the end of life.
The tradition and heritage of surgery emphasize that the control of suffering is of equal importance to the cure of disease.
Palliative care infrequently is considered for or applied to all the patients who require it. It is increasingly important to understand the relevance and importance of addressing palliative care concepts with patients and their families. Palliative care is becoming critically important for those patients who languish in intensive care units and on medical and surgical floors where the caregiver, the patient, and the family struggle to arrive at a management solution that is in their best interests.
Study Encourages Further Use of Palliative Care
To further understand this issue, a group led by John S. House, a fourth-year medical student at the University of Arkansas for Medical Sciences, conducted a study looking into the barriers to integrating palliative care into surgical care, as well as learning what quality improvements might be gained by incorporating those services for surgical patients. The study, “The Impact of Palliative Medicine Consultation on Readmission Rates and Hospital Costs in Surgical Patients Requiring Prolonged Mechanical Ventilation,” was published in the May 2022 issue of The Joint Commission Journal on Quality and Patient Safety.†
“Postsurgical patients requiring prolonged mechanical ventilation have increased mortality and costs of care; outcomes from adding palliative care services to this population have been poorly investigated,” the authors wrote. “The objective of this study was to determine the impact of palliative medicine consultation on readmission rates and hospitalization costs in postsurgical patients requiring prolonged mechanical ventilation.”
The authors used the Nationwide Readmissions Database (NRD) to research cases involving adults ages 18 and older from 2010 to 2014 who underwent a major operation that required mechanical ventilation for more than 96 consecutive hours and survived until discharge. They also identified patients among those records who received a palliative medicine consultation during hospitalization.
The study found:
- Of 53,450 patients, 3.4% received a palliative care consultation
- Patients who received a consultation had a lower readmission rate (14.8% versus 24.8%, p < 0.001) and lower average cost of hospitalization during the initial admission ($109,007 versus $124,218, p < 0.001)
- Ultimately, the authors concluded that despite low use of palliative care in surgical patients, “palliative care consultation in postsurgical patients requiring prolonged mechanical ventilation was associated with lower cost and rate of readmission.” They noted, however, that more research was needed to determine how to integrate palliative care services into surgical care.
The study authors wrote in a subsequent Improvement Insights blog post published by The Joint Commission‡:
“Our study was only possible with the NRD. The NRD is compiled from the Healthcare Cost and Utilization Project State Inpatient Databases which are fairly unique federal-state-industry partnerships and have a vast amount of data related to US hospital admissions. The National Inpatient Sample has been extensively used in surgical research, but few publications use the NRD, which allows for tracking of hospital admissions and re-admissions across a calendar year.
We were curious to see how helpful the NRD would be in addressing a clinically relevant question. We were delighted to see that it could be used in a meaningful fashion to extract and interpret nationwide clinical data. While it has its pitfalls, as discussed at length in the limitations section of our paper, we hope this study inspires other researchers to use it.
We look forward to tracking the application of palliative care across nationwide cohorts as more and more recent data becomes available. We believe future research that identifies which specific surgical populations could benefit most from the involvement of palliative care could be valuable as criteria to effectively identify these patients are currently lacking. Additionally, we hope that palliative care is integrated into daily practices in the surgical ICU—involving bedside surgical teams and palliative care teams, as well as additional resources and training for these teams.
The full study is available here.
Disclaimer
The thoughts and opinions expressed in this column are solely those of Dr. Jacobs and do not necessarily reflect those of The Joint Commission or the American College of Surgeons.
*Task Force on Surgical Palliative Care and the Committee on Ethics. Statement of Principles of Palliative Care. American College of Surgeons. Available at https://www.facs.org/about-acs/statements/50-palliative-care. Accessed May 26, 2022.
†House JS, Hyde CR, Corwin HL, et al. The Impact of Palliative Medicine Consultation on Readmission Rates and Hospital Costs in Surgical Patients Requiring Prolonged Mechanical Ventilation. Jt Comm J Qual Patient Saf. 2022 May;48(5):280-286.
