Top Ten Tips Palliative Care Clinicians Should Know Before Their Patient Undergoes Surgery

Abstract

Many seriously ill patients undergo surgical interventions. Palliative care clinicians may not be familiar with the nuances involved in perioperative care, however they can play a valuable role in enabling the delivery of patient-centered and goal-concordant perioperative care. The interval of time surrounding a surgical intervention is fraught with medical, psychosocial, and relational risks, many of which palliative care clinicians may be well-positioned to navigate. A perioperative palliative care consult may involve exploring gaps between clinician and patient expectations, facilitating continuity of symptom management or helping patients to designate a surrogate decision-maker before undergoing anesthesia. Palliative care clinicians may also be called upon to direct discussions around perioperative management of modified code status orders and to engage around the goal-concordance of proposed interventions. This article, written by a team of surgeons and anesthesiologists, many with subspecialty training in palliative medicine and/or ethics, offers ten tips to support palliative care clinicians and facilitate comprehensive discussion as they engage with patients and clinicians considering surgical interventions.

Introduction

Many seriously ill patients undergo surgery and many disease processes requiring surgery are life-limiting. Nearly one-third of Medicare patients over the age of 65 undergo a surgical intervention in the past year of life.¹ Surgery places frail patients at risk not only of intraoperative morbidity and mortality but also accelerated cognitive and functional decline, deteriorating quality of life, prolonged hospitalization and/or recovery, and increased caregiver burden.^2–8 Despite the high prevalence of surgical need in the seriously ill patients, multiple studies show that conversations around advance care planning, treatment goals, and overall health priorities are infrequently part of routine preoperative counseling.^9–11

Given the frequency of surgery in this population, palliative care clinicians can play key consultative and collaborative roles in perioperative medicine, defined as “the practice of patient-centered, interdisciplinary, and integrated medical care of patients from the moment of contemplation of surgery until full recovery.”¹² Although perioperative medicine is inherently interdisciplinary and ideally integrates the expertise of clinicians from the preoperative clinic, operating room, postanesthesia care unit (PACU), intensive care unit (ICU), and beyond, perioperative care is often siloed from nonsurgical care. These gaps in communication and continuity create a natural and necessary opportunity for palliative care collaboration.

Although the number of anesthesiologists and surgeons seeking formal palliative care training has increased in recent years,¹³ many perioperative clinicians may still feel ill-equipped to support the seriously ill perioperative patient. The expertise of the palliative care clinician can be particularly helpful for surgeons and anesthesiologists who may struggle to align a surgical intervention with patients’ long-term goals.¹³ Anesthesiologists may wrestle with how to discuss treatment limitations in the absence of a longitudinal relationship with their patients,^14,15 and surgeons may grapple with how to commit patients to a potentially challenging postoperative course while also honoring overall goals of care.^16,17 Furthermore, these perioperative clinicians may harbor misconceptions about surgery for the seriously ill patients. For example, research shows that some perioperative clinicians believe that do-not-resuscitate (DNR) orders should be automatically suspended for surgery despite statements from the American Society of Anesthesiologists (ASA) and American College of Surgeons (ACS) to the contrary.^18–20

Palliative care clinicians have much to offer surgical patients, not only in assisting patients in the decision to pursue surgery but also in preoperative preparation and postoperative recovery. Yet the perioperative period is a highly specialized form of health care, with unique considerations for advance care planning, symptom management, and goal-concordant decision-making. These domains, while well-within the scope of palliative care clinicians, may prove challenging for them to navigate without surgical or anesthesia training.

In this article, we incorporate the perspectives of clinicians with a wide range of backgrounds—surgery, anesthesia, palliative care, and pain management—to compile ten key tips about perioperative care for the seriously ill patients (Table 1). We hope to provide a working familiarity with the unique needs of this surgical population, allowing palliative care clinicians to provide invaluable support during what may be a patient’s most vulnerable period.

Table 1.

Summary of Tips

Tip 1: Surgeons view surgery as “a package deal,” and typically expect that surgical consent includes consent for interventions related to perioperative and postoperative care, including intensive care unit stays and management of complications.

Tip 2: Collaborative development and communication of a comprehensive symptom management plan that incorporates existing symptom management needs is key. Palliative care clinicians should engage with anesthesiologists and surgeons around appropriate symptom management and set expectations for postprocedural changes in symptomatology.

Tip 3: Patients should be encouraged to identify and document a designated decision-maker who is familiar with their preferences preoperatively in anticipation of the period of medical incapacity during sedation.

Tip 4: “Do-not-resuscitate” orders do not need to be automatically suspended before surgery; however, plans involving perioperative reversal of a “do-not-resuscitate” order should come with a timeline for reinstatement.

Tip 5: Routine elements of anesthetic care, such as endotracheal intubation and the use of vasopressor agents, may be at odds with a patient’s wishes regarding their code status—further discussion may be warranted to determine whether an intervention can safely proceed.

Tip 6: Surgeons and anesthesiologists may not be able to provide a realistic projection of how a given surgical intervention will impact quality of life; palliative care clinicians can collaborate to ensure that surgical interventions are aligned with a patient’s goals.

Tip 7: The goals of any surgical procedure can be categorized in one of four ways: to improve survival, improve function, maintain function, or make a diagnosis.

Tip 8: There is no such thing as a “low-risk operation,” particularly for frail patients and those near end of life—be prepared to discuss adverse outcomes and complications, including their probability and acceptability to patients and their caregivers.

Tip 9: Most perioperative clinicians have received minimal training in communication skills and may require palliative specialist support in having person-centered conversations about setting expectations and discussing adverse events and undesired surgical outcomes.

Tip 10: Patients enrolled in home hospice may still be candidates for in-hospital palliative procedures, such as pleural drainage catheter placement or venting gastrostomy tube placement.

Tip 1. Surgeons View Surgery as “a Package Deal,” and Typically Expect That Surgical Consent Includes Consent for Interventions Related to Perioperative and Postoperative Care, Including ICU Stays and Management of Complications

There is a consensus among intensivists and nonsurgical providers that surgeons hesitate to withdraw life-sustaining therapy on their operative patients despite a patients or surrogate’s request to do so.²¹ This concept is described as “surgical buy-in”: the contractual relationship between surgeons and patients that influences decisions regarding life-supporting therapy. With surgical buy-in, there is an expectation that by consenting to surgery, patients and their families are signing up for the necessary therapies and interventions required to address any and all complications that may occur in the postoperative setting.²² For many generations, buy-in was implied at the time of surgical consent. Even with the promulgation of informed consent, a tension still exists at the intersection of patients, caregivers, surgeons, and other clinicians if a scenario presents itself where a surgeon may need to assent to withdrawal of life sustaining therapies.

Although surgeons often do not explicitly discuss patient preferences, there is an assumption of tacit understanding that patients believe surgeons share similar values and that decisions about treatment should be determined by the surgeon’s expertise.²³ This attitude can create conflict around goals of care when buy-in is assumed but not discussed: patients may have a preference for a wide range of treatment limitations they had not discussed with their surgeon. Palliative care clinicians can facilitate preoperative conversations with patient and their caregivers that address patients’ preferences for care, inform them on possible outcomes especially in the setting of complex surgery, in addition to ascertaining the presence of advance directive and whether patients have had conversations with their families and/or proxies/surrogates regarding the content.

Tip 2. Collaborative Development and Communication of a Comprehensive Symptom Management Plan That Incorporates Existing Symptom Management Needs Is Key. Palliative Care Clinicians Should Engage With Anesthesiologists and Surgeons Around Appropriate Symptom Management and Set Expectations for Postprocedural Changes in Symptomatology

An interdisciplinary approach is crucial for effective symptom management in seriously ill patients undergoing surgery, blending the complementary expertise of palliative care and perioperative teams. Although palliative care clinicians are skilled in symptom management, they might lack familiarity with perioperative care specifics or the variability and unique significance of surgical patients’ symptoms, for example, indications and contraindications for specific types of regional anesthetics or the implications of specific symptom changes in the immediate postoperative period. This requires a nuanced approach to safe and effective symptom management.²⁴ Such a plan typically involves active engagement between palliative care clinicians and anesthesiologists and may involve reassessment and/or dose adjustment of long- or short-acting opioids and/or discussion of an intraoperative nerve or neuraxial block to facilitate management of acute periprocedural pain (Table 2).

Table 2.

Types of Anesthesia, Contexts for Use, and implications²⁵

Anesthetic type	Definition	Example	Relevant implications for palliative care clinicians
Local anesthesia (LA)	“Numbs up” or blocks sensation in a specific area of the body by blocking nerve impulses.	Local infiltration of the skin with lidocaine for minor dermatological procedures such as removal of superficial skin lesion.	LA can be administered alone or with sedation such as moderate sedation or monitored anesthesia care.
Moderate Sedation/Analgesia (“Conscious sedation”) (MS)	MS results in a drug-induced depression of consciousness during which patients respond purposefully to verbal commands that may be accompanied by light tactile stimulation.	A procedure room nurse administering boluses of fentanyl and/or midazolam for patient comfort during a cardiac catheterization procedure.	MS typically involves short-acting opioids and/or benzodiazepines, which is administered by a trained nurse, and does not necessitate a trained anesthesia provider. No interventions are required to maintain a patent airway and spontaneous ventilation is adequate.
Deep Sedation/Analgesia (DS)	DS results in a drug-induced depression of consciousness during which patients cannot be easily aroused but respond purposefully following repeated or painful stimulation.	An anesthesiologist provides deep sedation for endoscopic retrograde cholangiopancreatography. Mediations such as propofol, ketamine, and dexmedetomidine may be used. Deep sedation is required to ensure patient comfort and stillness. Airway support may be required.	Involves clinicians trained in DS (anesthesia clinicians, emergency medicine, critical care, etc.) During DS the ability to maintain ventilatory function may be impaired. Patients may require assistance and clinical intervention to maintain a patent airway and spontaneous ventilation.
Monitored anesthesia care (MAC)	An anesthesia service that provides a continuum of depth of sedation including awake, moderate sedation, and deep sedation. There is an expectation that the patient may require more intense anesthesia care at any time including general anesthesia.	A patient with end-stage renal disease is brought to the operating room for the creation of an arteriovenous fistula. Initially during the procedure sedation and analgesia are provided with boluses of midazolam and fentanyl. As the case progresses and becomes more painful, deep sedation is required and the anesthesiologist administers propofol. Initially the patient tolerated the propofol but eventually requires frequent airway interventions such as oral airway and jaw thrust. Therefore, the anesthesia providers consider conversion to general anesthesia.	Requires a trained anesthesia clinician. Typically, does not involve invasive airway support, though conversion to general anesthesia is always a possibility.
General anesthesia (GA)	GA results in a drug-induced loss of consciousness during which patients are not arousable, even by painful stimulation. The loss of consciousness is achieved by systemic administration of anesthetics, analgesics, and sometimes sedatives during a procedure.	Used for most major surgical procedures including intracranial, intrathoracic, and intraabdominal procedures.	GA requires a trained anesthesia clinician. Independent ventilatory function is often impaired and requires advanced airway management such as endotracheal tube or laryngeal mask airway. Cardiovascular function also requires vigilant monitoring and may become depressed requiring vasopressor support.
Regional anesthesia (RA)	A targeted anesthesia technique that blocks pain in a specific area of the body by interrupting nerve signals. This method can be administered through injections near nerves (peripheral nerve blocks) or around the spinal cord (neuraxial blocks), effectively numbing the region of interest without affecting consciousness. Suitable for procedures or pain management where localized control is preferred, minimizing systemic effects and enhancing recovery.	RA can be employed alone but is more typically combined with MAC or GA in the perioperative or periprocedural setting.
Neuraxial anesthesia (NA)	Regional anesthetic technique involving administration of local anesthetics and/or opioids into the epidural or intrathecal space. NA results in pain signals being blocked across multiple dermatomes that cover an entire region or segment of the body.	NA can be associated with hypotension requiring initiation of pressors. NA can also result in postdural puncture headache. NA is rarely used without MAC during surgical procedures.	Epidural for peri/postprocedural pain control after major abdominal surgery. Spinal anesthetic (intrathecal) for lower extremity orthopedic surgery.
Peripheral nerve block (PNB)	Regional anesthetic technique involving infiltration of local anesthetics near peripheral nerve structures. This results in pain signals being blocked in the particular area of the body that is innervated by the targeted peripheral nerves.	PNBs decrease systemic medication use, speed up recovery, and are versatile for postoperative pain. Techniques range from single injections to continuous infusions. PNBs are typically performed with ultrasound guidance.	Ultrasound-guided infraclavicular brachial plexus block for anesthesia in wrist or hand surgery. Transversus abdominis plane (TAP) block for postoperative pain relief following abdominal surgery.

The significance of this integrated care model is underscored by the association between preoperative symptoms—such as pain, social functioning, anxiety, and activity level—and postoperative outcomes, including morbidity, mortality, care satisfaction, and quality of life.²⁶ Patients undergoing major oncologic surgery often present with a wide range of preoperative symptoms, including fatigue, reflux abdominal pain, neuropathy, dyspnea, anxiety, nausea, and constipation. A significant percentage of patients exhibit two or more symptoms with 35% reporting 10 symptoms or more.²⁴ Such diversity and prevalence of symptoms even before surgery emphasize the critical need for comprehensive preoperative symptom assessment and management, reinforcing the value of an interdisciplinary approach with palliative care involvement for optimal patient care.

Tip 3. Patients Should Be Encouraged to Identify and Document a Designated Decision-Maker Who Is Familiar with Their Preferences Pre-Operatively, in Anticipation of the Period of Medical Incapacity During Sedation

Medical decision-making capacity, that is, an individual’s ability to make medical decisions,²⁷ is essential for a patient to be able to sign legal medical documents, such as consents and/or advance directives, and to be legally able to make medical decisions for themselves. Patients are assumed to have decision-making capacity unless proven otherwise, but clinicians regularly fail to recognize incapacity. One past study suggested that 2.8% of healthy older adults and 26% of hospitalized older adults lack decision-making capacity, yet that deficit was only identified in 42% of cases.

During the perioperative or periprocedural period, even when the primary anesthetic may be a regional anesthetic, “monitored anesthesia care, or “conscious sedation”, a patient typically receives medications, such as benzodiazepines, narcotics, and/or anesthetics, that render them incapable of making decisions for some period²⁸ (Table 2). Thus, before a surgery, procedure, and/or anesthetic, patients should expect and plan for a period—hopefully brief—of lacking medical decision-making capacity. Preparation for this time should include: (1) naming a surrogate decision-maker and, if possible, (2) having an advance care planning conversation with that surrogate decision-maker about preferences, goals, and activities and capabilities that constitute a meaningful quality of life to the patient.^29,30 Palliative care clinicians should be aware of these preoperative needs and be prepared to facilitate identification and documentation of designated health agents.

Tip 4. “Do-Not-Resuscitate” Orders Do Not Need to Be Automatically Suspended Before Surgery; However, Plans Involving Perioperative Reversal of a DNR Order Should Come with a Timeline for Reinstatement

Although once commonplace, policies automatically suspending a patient’s DNR order in the perioperative period are now recognized as problematic owing to infringement on patient autonomy and self-determination. The ASA and the ACS both recommend discussing risks, benefits, and alternatives of resuscitation in the perioperative period with patients and/or their surrogate decision-makers.^31,32 Palliative care clinicians may be asked to engage in/facilitate conversations about management of DNR orders during the perioperative period and must be aware of the practice guidelines and logistical considerations which impact decision-making during this period.

These discussions should highlight the unique components of the intraoperative and postoperative setting that may influence resuscitation preferences. Many necessary practices that are commonplace in perioperative care could be classified as “resuscitation” in other contexts, such as placement of an endotracheal tube or administration of vasoactive medications. By the discussion’s conclusion, patients should understand whether and which life-sustaining procedures may be essential for their specific surgical procedure.^29,33

If a patient consents to perioperative resuscitation, they must also know when their preexisting DNR order resumes its effect. Hospitals and surgery centers may have specific policies regarding this timing, which may extend beyond the operating room to include PACU and/or ICU admission. This timing must be clearly communicated to the patient and their care teams (see example case with roles for palliative care clinicians in Table 3).

Table 3.

Example Case with Roles for Palliative Care Team Members

Case

Roles for palliative care team: -Engage with the perioperative team around peri- and postoperative symptom management to ensure acceptable symptom control -Provide spiritual and psychosocial support in the context of an acute change in health status -Elicit patient goals and priorities and help the surgical team contextualize them within the potential outcomes of the offered intervention -Facilitate transparent discussion with the patient and his family caregivers about his care needs during the surgical and postoperative period and their alignment with preexisting goals of care -Ensure that the patient has designated a surrogate decision-maker who understands the patient’s wishes and priorities for the perioperative period -Engage surgical and anesthetic teams around options for safe perioperative care (e.g., offering regional anesthesia with sedation and endotracheal intubation as “emergency backup” vs. potential need for neuromuscular blockade to facilitate surgical exposure, which would de facto require intubation) -If the decision is made to proceed with surgery and with a temporary change in code status, determine and document a time course for reverting to full code status

An 84-year-old male with a history of hypertension, hyperlipidemia, and prostate cancer with bony metastasis presents with a pathological hip fracture. He is offered surgical intervention, with the understanding that it will provide symptom relief and improve functionality. At home, he takes extended release and immediate control morphine for management of pain associated with metastases; however, he reports that his home regimen is not adequately treating his acute, fracture-associated pain. The patient has a code status of DNR/DNI. He is currently receiving palliative immunotherapy and hopes to return to his baseline functional status. Palliative care is consulted to facilitate discussion of perioperative goals of care.

Tip 5. Routine Elements of Anesthetic Care, Such as Endotracheal Intubation and the Use of Vasopressor Agents, May Be at Odds with a Patient’s Wishes Regarding Their Code Status—Further Discussion May Be Warranted to Determine Whether an Intervention Can Safely Proceed

The strategy of “required reconsideration” endorsed by the ACS and ASA advocates for development of a goal directed, individualized plan for perioperative resuscitative needs.³⁰ Although educational videos exist that can assist anesthesiologists in having these discussions,³⁴ these training tools provide limited guidance on managing situations where patient wishes are incompatible with the care needed to proceed with surgery. For example, an agreement not to perform electrical shocks or chest compressions may be more easily supported than a request for limited airway support in the operating room.

Patients may have unrealistic expectations regarding the type of anesthesia the procedure requires. Planning for goal-concordant perioperative care requires careful assessment of these preferences within the context of necessary procedural care, particularly with regard to intraoperative airway support. In cases that cannot be performed without intubation, a discussion with the surgeon may be necessary to determine whether to proceed with surgery if the patient continues to decline intubation. Even when a different type of anesthesia is planned, the ability to support the patient’s airway without intubation is never guaranteed. As such, the implications of specific requests during the operating room period need to be carefully assessed within the context of the procedure and anesthetic plan (Table 2). When asked to participate in conversations about goal-concordant perioperative care, palliative care clinicians should engage with the perioperative team to determine what sort of interventions may be required for a given case to facilitate clear discussion of realistic care options with the patient and their loved ones.

Tip 6. Surgeons and Anesthesiologists May Not Be Able to Provide a Realistic Projection of How a Given Surgical Intervention Will Impact Quality of Life; Palliative Care Clinicians Can Collaborate to Ensure That Surgical Interventions Are Aligned with a Patient’s Goals

Several factors influence surgeons and anesthesiologists’ abilities to counsel patients on realistic quality-of-life outcomes following surgery. First, there is limited data on quality-of-life outcomes for patients in the perioperative period. Although evidence supports the quality-of-life benefits of palliative care in oncology and other fields, its impact in the perioperative setting remains inconclusive.³⁵ Second, although a recent surge in interest in integrating palliative care principles into surgical care in the United States³⁶ may directly impact current trainees, many practicing surgeons and anesthesiologists completed residency with minimal formal education on palliative care or communication in the serious illness context. This combination of sparse outcomes data and limited training poses challenges for surgeons and anesthesiologists in accurately counseling patients on the long-term quality-of-life effects of surgery.

Additional factors that may contribute to this challenge include the medical complexity and medical acuity of patients with life-limiting illness, where accurate assessment of quality-of-life outcomes involves determining how the surgical procedure interacts with an individual’s health status, functional status, and comorbidities. Time limitations may also hinder in-depth discussions on quality-of-life outcomes and palliative care options. Lastly, surgeons and anesthesiologists may feel ill-equipped to manage the complex emotions expressed by patients when discussing quality of life.

Palliative care clinicians’ expertise in counseling patients on quality-of-life issues makes them valuable partners in this clinical setting, particularly with the growing interest in integration of palliative care principles and subspecialist consultation in the perioperative period.³⁷ Their ability to delineate patient preferences amid multiple comorbidities and high illness severity positions them as excellent collaborators with surgeons and anesthesiologists to ensure the surgical procedure aligns with the patient’s goal.

Tip 7. The Goals of Any Surgical Procedure Can Be Categorized in One of Four Ways: To Improve Survival, Improve Function, Maintain Function, or Make a Diagnosis

A now-classical animated video parody “Orthopedics versus Anesthesia”³⁸ depicts an exchange between an anesthesiologist and an orthopedic surgeon requesting to schedule an operation for a patient with a broken femur. The surgeon, intractably focused on the fracture, repeats “I need to fix it,” even as the patient is revealed to be an elderly woman in cardiac arrest for whom resuscitative attempts have failed. This sardonic commentary reflects the pervasive perception in medical settings that the reason to do surgery is to fix a problem. Yet the “fix-it” model does nothing to help patients understand whether surgery will improve their lives.³⁹ There are four possible goals of surgery: improving survival, feeling better (improving function), preventing a disability (maintaining function), or making a diagnosis, yet surgeons identify one of these goals in less than 25% of preoperative consultations.⁴⁰

When patients with poor functional status present for major surgery, perioperative clinicians worry that the surgical team’s focus on fixing the problem has led to a treatment plan that will not make them better off. Precision about the goal of surgery can help navigate these concerns: for a very ill, frail patient, surgery may reduce pain even when life prolongation is unlikely. Palliative care clinicians can advocate for the identification of one of these goals and discuss its plausibility with the team given what they know about the patient’s overall health to keep everyone on the same page about how surgery can lead to outcomes that matter to patients.

Tip 8. There Is No Such Thing as a “Low-Risk Operation,” Particularly for Frail Patients and Those Near End of Life—Be Prepared to Discuss Adverse Outcomes and Complications, Including Their Probability and Acceptability to Patients and Their Caregivers

Different surgical procedures are associated with varying levels of risk. In some cases, the risk can be quite concrete and tangible (e.g., the risk of a particular type of complication, the risk of death soon after a procedure, etc.). However, there are also cases where the type of risk may not be as readily apparent. For example, a patient with incurable cancer who is functionally independent with a good quality of life may have the option of undergoing a procedure associated with uncertain additional quantity of life, but this could come at the expense of a decrement in their quality of life and functional independence.

There is a frequent misperception that the “eyeball test” can identify patients who can safely undergo a lower risk procedure. Unfortunately, clinicians are frequently unable to accurately predict important outcomes for patients with critical illness (such predictions may be even worse for patients who are ambulatory and outpatient).⁴¹ Although we frequently have information about the average level of risk associated with a particular procedure across many patients, we forget that each patient is unique and each clinical context is different. So even if the risk associated with a procedure is low, if a patient experiences an adverse outcome, their realized risk is 100%.

An important adage for surgical and nonsurgical health care providers to share with patients, especially those who may be near or at the end-of-life, who are facing a critical decision about the value of a palliative intervention is the following:

It is very hard for surgery to make “good” “better,” but surgery can very quickly make “good” “worse”.

Palliative care clinicians can help interventionalists frame procedures not only in terms of immediate risk but also in terms of anticipated quality-of-life and ensure that the likely outcomes of an intervention align with patient and family priorities.

Tip 9. Most Perioperative Clinicians Have Received Minimal Training in Communication Skills and May Require Palliative Specialist Support in Having Person-Centered Conversations About Setting Expectations and Discussing Adverse Events and Undesired Surgical Outcomes

As the ACS issued a statement supporting palliative care delivery to all seriously ill patients undergoing surgery,⁴² surgical training curricula has evolved to emphasize serious illness communication. However, in practice, formal palliative care and communication training in surgery remains limited.⁴³ Similarly, although the American Board of Anesthesiology offers certification in hospice and palliative medicine, only a small number of anesthesiologists pursue subspecialty training.⁴⁴ Although there is increased awareness of the importance of serious illness communication skills in the management of patients undergoing surgery, training in these skills falls short. As such, perioperative clinicians continue to benefit from palliative specialist support in discussing expectations around surgery and potential surgical complications.

Perioperatively, palliative care clinicians can help set grounded expectations, discuss potential complications, and facilitate goal-concordant decision-making regarding treatments and procedures. Especially in the interdisciplinary care of complex patients facing surgery, palliative care specialists can help teams achieve prognostic alignment, developing a unified understanding of a patient’s illness trajectory and streamline communication to patients and their families. Although further research is needed to determine which patients benefit from specialist palliative care in the perioperative period, palliative care clinicians have more extensive training in communication and can facilitate serious illness conversations alongside their perioperative colleagues.

Tip 10. Patients Enrolled in Home Hospice May Still Be Candidates for In-Hospital Palliative Procedures, Such as Pleural Drainage Catheter Placement or Venting Gastrostomy Tube Placement

Although expert palliation of symptoms in hospice may involve helping patients avoid intensive and invasive procedures that do not align with their goals, there are particular instances where certain palliative interventions may be considered.⁴⁵ These procedures are not aimed to cure, but to reduce suffering and improve quality of life for the limited time these individuals have remaining with them. Patients enrolled in hospice care may be candidates for such procedures,³⁷ which can include venting gastrostomy tubes for malignant bowel obstructions⁴⁶ or placement of a catheter to aid in drainage of symptomatic ascites or pleural effusions.

Although not common, physicians may occasionally see patients in a surgical suite who are also enrolled in hospice care. Many, but not all,⁴⁶ will have a DNR order in their medical record. It is critically important to discuss this status with the patient or legal decision-maker and how it applies in the peri-procedural setting. Perioperative clinicians may not be aware of the distinction between palliative care and hospice and may struggle with the logistics of providing safe and appropriate patient-centered care to these patients. Palliative care clinicians may be able to facilitate conversations about surgical risk and code status for these patients. They can also serve as transitional supports and channels of communication between surgical and postacute care teams and hospice teams to ensure optimal symptom management plans and to anticipate caregiver distress during postoperative and home discharge periods.

Conclusion

All palliative care clinicians will care for patients who are contemplating surgery or experiencing its repercussions. Yet palliative care clinicians are not often counted as traditional members of the perioperative team, and perioperative medicine may be challenging to navigate for those without surgical or anesthesia backgrounds.

Nevertheless, palliative care clinicians offer a critical perspective in the perioperative period. They can provide support at every stage, from weighing the risks and benefits of surgery to optimizing postoperative symptom management. Establishing a baseline knowledge of the unique considerations of perioperative care can allow palliative care clinicians to gain the trust of patients, surgeons, and anesthesiologists, and thus become more consistently incorporated into the longitudinal care of surgical patients. We offer these ten tips as a starting point for further discussion across disciplines.

Perioperative care should not exist in a silo. For patients with multiple comorbidities, surgery can be an inflection point in a patient’s overall health trajectory. Despite increasing interest and research in the intersections of palliative care and surgery, gaps still exist in the care we provide this at-risk population. Palliative care clinicians can help close these gaps, ensuring that surgical patients receive person-centered care that aligns with their overall goals.

Author Disclosure Statement

No competing financial interests exist.

Funding Information

R.H. is supported by a Foundation for Anesthesia Education and Research Mentored Training Grant. M.L.F. is supported by the National Cancer Institute of the National Institutes of Health under Award T32CA090217. W.E.R. is partially funded by NCI/NIH P30 CA008748. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH.