by Dr. Jason Johanning MD, MS
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. 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 post-op care in the best of circumstances is challenging for a frail patient in the ICU is correct. But throw into the mix multiple provider and nursing factions not on the same page, now bring in palliative care to “sort things out”, and you get the picture of why surgeons may have issue with post-op palliative care consultations. This is especially true 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 to address 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 a palliative care consultation completed 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 also have 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. Learn more about the role of palliative care in surgery at HM15; Mark Katlic and I will be presenting “Redesigning Surgical Decision Making for High-Risk Patients” on Wednesday, April 1st at 7:40 am.
Jason Johanning, MD, MS has been with the Department of Veterans Affairs since 2001, serving VISN Chief Surgical Consultant since 2014 after being Medical Director of the VISN 23 Surgery/Specialty Care Service Line from 2012-2014. He served as the Chief of Surgery for VA Nebraska/Western Iowa HCS from 2008-2014. Dr. Johanning earned his undergraduate degree in psychology at Northwestern University in Evanston, Illinois, and Doctor of Medicine at the University of Kansas Medical School and Masters at the University Of Nebraska Medical Center. He completed a General Surgery Residency at Saginaw Cooperative Hospitals, and a Vascular Surgery Fellowship at Geisinger Medical Center in Danville, PA. His research and quality interests include peripheral arterial disease, frailty and palliative care, with a current focus of improving the quality of end of life surgical care for patients, families, providers and hospital systems.