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J Pain Symptom Manage. 2019 Jun;57(6):1080-1088.e1. doi: 10.1016/j.jpainsymman.2019.01.018. Epub 2019 Feb 10.

Delays in Palliative Care Referral Among Surgical Patients: Perspectives of Surgical Residents Across the State of Michigan.

Author information

1
Department of Surgery, University of Wisconsin, Madison, Wisconsin, USA.
2
Center for Healthcare Outcomes and Policy, Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan, USA.
3
Division of Geriatric and Palliative Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA; Geriatric Research, Education and Clinical Center (GRECC), Veterans Affairs Health Affairs, VA Ann Arbor Health Care System, Ann Arbor, Michigan, USA.
4
Center for Clinical Management Research, Veterans Affairs Health Services Research & Development, VA Ann Arbor Health Care System, Ann Arbor, Michigan, USA.
5
Center for Healthcare Outcomes and Policy, Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan, USA; Department of Surgery, University of Michigan, Ann Arbor, Michigan, USA.
6
Center for Healthcare Outcomes and Policy, Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan, USA; Department of Surgery, University of Michigan, Ann Arbor, Michigan, USA. Electronic address: pasuwan@med.umich.edu.

Abstract

CONTEXT:

Palliative care services (PCS) are underutilized and frequently delayed among surgical patients. Surgical residents often serve at the forefront for patient issues, including conducting conversations regarding prognosis and goals of care.

OBJECTIVES:

This qualitative study identifies critical barriers to palliative care referral among seriously ill surgical patients from the perspective of surgical residents.

METHODS:

We conducted semistructured interviews with surgical residents (n = 18) across the state of Michigan, which focused on experiences with seriously ill surgical patients and PCS. Inductive thematic analysis was used to establish themes based on the research objectives and data collected.

RESULTS:

Four dominant themes of resident-perceived barriers to palliative care referral were identified: 1) challenges with prognostication, 2) communication barriers, 3) respect for the surgical hierarchy, and 4) surgeon mentality. Residents consistently expressed challenges in predicting patient outcomes, and verbalizing this to both attendings and families augmented this uncertainty in seeking PCS. Communicative challenges included managing discordant provider opinions and the stigma associated with PCS. Finally, residents perceived that an attending surgeon's decisive authority and mentality negatively influenced the delivery of PCS.

CONCLUSIONS:

Among resident trainees, unpredictable patient outcomes led to uncertainty in the timing and appropriateness of palliative care referral and further complicated communicating plans of care. Residents perceived and relied on the attending surgeon as the ultimate decision maker, wherein the surgeon's sense of responsibility to the patient was identified as a significant barrier to PCS referral. Further studies are needed to test surgeon-specific interventions to improve access to and delivery of PCS.

KEYWORDS:

Palliative care; palliative surgery; surgical patients

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