Palliative Care and End of Life Considerations for the Frail Patient

Abstract

Patients with frailty experience substantial physical and emotional distress related to their condition, and face increased morbidity and mortality compared with their non-frail peers. Palliative care is an interdisciplinary medical specialty focused on improving quality of life for patients with serious illness, including those with frailty, throughout their disease course. Anesthesiology providers will frequently encounter frail patients in the perioperative period and the intensive care unit (ICU) and can contribute to improving quality of life for these patients through the provision of palliative care. We highlight the opportunities to incorporate primary palliative care, including basic symptom management and straightforward goals of care discussions, provided by the primary clinicians; and when necessary, timely consultation by a specialty palliative care team to assist with complex symptom management and goals of care discussions in the face of team and/or family conflict. In this review, we apply the principles of palliative care to patients with frailty and synthesize the evidence regarding methods to integrate palliative care into the perioperative and intensive care unit settings.

Introduction

The concept of frailty captures a loss of physiologic reserve, such that affected patients are vulnerable to medical stressors and are less able to recover from them.¹ Although there is no consensus definition or standardized criteria for frailty, multiple screening tools exist to identify frail patients.² The two most commonly used tools capture this concept in different ways: the frailty index is a ratio derived from the number of deficits present in a given patient to the total number of deficits screened in that patient;³ and the frailty phenotype consists of three or more of the following traits in older adults: unintentional weight loss, fatigue, weakness, slow walking speed, and low physical activity.⁴ The Risk Analysis Index (RAI) tool, a 14-item instrument for measuring frailty in surgical populations,^5–7 may be of particular interest to anesthesiology providers given its use in predicting post-operative complications.^6,8,9 Given the lack of a universal definition, this review will assume that all included studies on frailty are relevant, regardless of the definition and criteria used by the authors.

Frail patients are more likely than their non-frail peers to experience adverse health outcomes, including falls, hospitalizations, and even death.¹⁰ The syndrome is associated with adverse outcomes in common conditions, including increased risk of a major adverse cardiac event in peripheral vascular disease,¹¹ increased incidence and duration of hospitalizations in chronic obstructive pulmonary disease (COPD),¹² and increased hospitalization and mortality in chronic kidney disease.¹³ Furthermore, patients with this syndrome are more likely to suffer from complications such as infection and respiratory failure following procedures ranging from ambulatory to complex operations, putting these patients at increased risk for prolonged hospitalizations and in some cases, mortality.^6,14,15 Although frailty in isolation may not constitute a serious illness, a wide range of diseases and events may become serious for the patient with frailty, making palliative care an important consideration for this population¹⁶.

Palliative care is defined by the Center to Advance Palliative Care (CAPC), as “specialized medical care for people living with serious illnesses, [focused] on providing patients with relief from the symptoms and stress of a serious illness—whatever the diagnosis. The goal is to improve quality of life for both the patient and the family. Palliative care is provided by a team of doctors, nurses, and other specialists who work with a patient’s other doctors to provide an extra layer of support. [It] is appropriate at any age and at any stage in a serious illness, and can be provided together with curative treatment.”¹⁷ Its benefits include improved patient quality of life,¹⁸ increased patient and caregiver satisfaction,¹⁹ and reduced healthcare costs.²⁰ This manuscript will describe the palliative care needs of frail patients, introduce primary and specialty palliative care with special consideration for the role of the anesthesiology provider, and review existing studies of palliative care in the intensive care unit (ICU) and perioperative settings. We will also discuss our recommendations for incorporating palliative care into anesthesiology practice and for future research on this important topic.

Palliative Care Needs of the Frail Patient

There are eight main domains of palliative care according to the National Coalition for Hospice and Palliative Care Clinical Practice Guidelines.²¹ They are summarized and applied to frailty in Table 1. We will focus here on the four we feel are most relevant to anesthesia practice: complex symptom management, communication about medical decision-making (including goals of care discussion, advance care planning, and transitions of care from curative to comfort-focused), psychosocial support, and end-of-life care. These can be provided to a patient at any point in the course of his or her serious illness, beginning at diagnosis and continuing throughout the disease course until the end stage, when it overlaps with hospice.

Table 1.

Primary vs Specialty Palliative Care for Patients with Frailty³⁹

	When to use:
NHPC-NPC Domain		Primary Palliative Care	Specialty Palliative Care
Structure and Processes of Care	Interdisciplinary care	• Understand the role of an interdisciplinary team • Refer to ancillary services if indicated and available • Basic advance care planning	• Complex psychosocial needs • Spiritual distress
Symptom management16	Weight loss	• Encourage liberal diet • Consider high-calorie supplements • Consider nutrition referral	• >10% weight loss over 6 months • Consideration of artificial nutrition
	Weakness	• Consider rehab or physical therapy referral • Encourage strength and balance training	• Decline in functional status, especially loss of independence in ADLs
	Fatigue	• Investigate/treat underlying conditions • Discontinue contributing medications if possible • Encourage physical activity	• Symptoms refractory to primary palliative care interventions
	Falls	• Investigate/treat underlying conditions • Consider rehab or physical therapy referral • Refer for home safety evaluation • Encourage strength and balance training • Review medications for potential contributors	• Ongoing falls despite primary palliative care interventions • Complex decision-making or conflict regarding nursing home placement when indicated
	Pain	• Investigate/treat underlying conditions • Prescribe analgesics including non-opioid medications (acetaminophen, NSAIDs) or single-agent opioid therapy when indicated	• Symptoms refractory to primary palliative care interventions
Psychological and Psychiatric Care		• Screen routinely for depression • Explore patient/caregiver concerns and offer support • Refer for psychotherapy or psychiatry when indicated	• Refractory symptoms (e.g. anxiety, depression, suicidal ideation and PTSD) • Complex psychiatric issues
Social Support		• Explore availability of caregivers/social supports • Refer to social work when appropriate	• Complex psychosocial needs • Caregiver burnout
Spiritual, Religious, and Existential Care		• Recognize spiritual care needs and refer to chaplaincy if available	• Significant spiritual distress related to illness • Spiritual history that affects medical decision-making
Culturally Competent Care		• Use interpreter services when necessary • Recognize cultural influences on medical decision-making	• Primary team or patient/caregiver distress related to medical decision-making
End-of-Life Care		• Recognize hospice eligibility • Discuss code status • Discuss preferences for life-sustaining therapies	• Patients/caregivers with limited understanding of illness/prognosis • Patients unable to verbalize clear preferences • Family or team conflict
Ethical and Legal Concerns		• Assist patient to designate a healthcare agent and complete other advance directives • Identify legal surrogate decision maker if no designated healthcare agent	• Patient without capacity and no clear surrogate decision maker • Requests for non-beneficial treatments • Requests for physician aid in dying

Table 1 describes the eight domains of palliative care identified by the National Coalition for Hospice and Palliative Care-National Consensus Project Clinical Practice Guidelines and provides recommendations for associated primary palliative care interventions and indications for specialty palliative care referral in the frail patient. Bolded recommendations for primary palliative care are discussed in depth in the manuscript. Adapted with permission from Gelfman et al, 2017.⁴⁶

NCHPC-NCP: National Coalition for Hospice and Palliative Care-National Consensus Project; ADLs: activities of daily living; NSAIDs: non-steroidal anti-inflammatory drugs; PTSD: post-traumatic stress disorder.

Symptoms

In general, frailty is associated with a lower quality of life even in the absence of a major event, such as a hospitalization or procedure.²² Symptom burden is a key predictor of quality of life, and frail patients tend to have a higher symptom burden than the non-frail both at baseline and after an ICU admission or hospitalization.²³ In a study of 125 patients discharged from the ICU, as compared to non-frail patients, patients with frailty had significantly higher distress scores in the week after transfer to the regular hospital floor; patients with frailty were also significantly more likely to have fatigue, dyspnea, drowsiness, and anorexia, among other symptoms at one month follow-up.²⁴ In general, weight loss, weakness/slowness, fatigue, depression, falls, and pain, are among the most prominent, modifiable symptoms in frail patients.¹⁶

Communication Needs

Along with symptom management, communication of difficult news and identifying patients’ goals of care are key skills in palliative medicine. They are particularly relevant in frailty when it comes to decision-making surrounding surgery, in light of the significant associated morbidity and mortality.^6,8,25 A scoping review of communication needs also found that frail older adults report wishing to discuss measures to improve or prevent disease progression, potential complications, and prognosis.²⁶ Of note, another theme included valuing interpersonal skills over medical expertise. Experts recommend having a goals of care conversation as soon as a patient is recognized as frail, based on anticipated progression of disease and the potential for the types of adverse outcomes previously discussed.²⁷

Psychosocial Burden

Psychosocial support from an interdisciplinary team is another critical component of palliative care. Frailty is associated with high emotional and psychosocial distress and low perceived social support, even in comparison with patients with amyotrophic lateral sclerosis (ALS), chronic obstructive pulmonary disease (COPD), and end stage renal disease (ESRD).^28,29 Some frailty screening tools therefore include questions addressing social activities, support systems, and loneliness.³⁰

End-of-Life Issues

The spectrum of palliative care also includes end-of-life care and hospice transitions. In a systematic review of the end-of-life care needs of frail patients, Stow et al found they had pain and emotional distress comparable to patients with advanced cancer.²⁹ Prognostication and identifying the end-of-life phase can be difficult in patients with frailty.³¹ However, the electronic frailty index (eFI) has been used to estimate 12 month mortality and described three distinct frailty trajectories that may be of use.³² Additionally, the National Hospice and Palliative Care Organization (NHPCO) has published guidelines for identifying poor prognosis in chronic diseases and which may be applied to frailty.^16,33 They suggest that clinical features suggestive of a poor prognosis include multiple emergency department visits or hospitalizations over a six month period; recent decline in functional status; and unintentional progressive weight loss of more than 10% over the prior six months. Any of these situations should likely prompt exploration of a patient’s goals and consideration of hospice eligibility, even as the underlying cause is evaluated and treated. Hospice is a Medicare benefit available to patients at the end of life and offers support for physical, psychological and existential distress caused by an illness. Like palliative care, it is provided by interdisciplinary teams in a variety of settings and its primary aim is to improve quality of life for seriously ill patients and families. Unlike palliative care, it is limited to patients with a life expectancy of six months or less who have chosen to forego life-prolonging treatments.³⁴ Hospice care is associated with higher patient and caregiver satisfaction, lower healthcare utilization and costs, and lower likelihood of dying in the hospital.³⁵

Primary Palliative Care and Specialty Palliative Care Applied to Anesthesiology

Palliative care can be divided broadly into primary palliative care and specialty palliative care.³⁶ The former can be provided by healthcare practitioners of any specialty and consists of symptom management and basic discussions around advance care planning including prognosis, goals of treatment, and code status. The World Health Assembly issued a statement in 2014 calling for palliative care to be integrated into treatment of any serious illness, as part of “the ethical duty of health care professionals.”³⁷ For anesthesiology providers, primary palliative care interventions may include timed or structured goals of care discussions in the ICU or perioperative settings (see “Settings of Care” below). When palliative care needs cannot be met by a patient’s primary team, specialty palliative care referral should be considered. Specialty palliative care is provided by an interdisciplinary team with advanced training, including physicians who have completed a one-year palliative medicine fellowship or certification, nurses, social workers, and chaplains.²¹ It is generally recommended for any patient with refractory symptoms, uncertain prognosis, requests for non-beneficial treatments, and significant emotional and spiritual distress, among other indications.^38–40 Specialty palliative care has expanded from most commonly hospital-based to include community-based services, including outpatient practices and home-based care.³⁶ The broader scope of these services has been shown to improve quality of life outside of the hospital setting,^41,42 and reduce hospital admissions.⁴³ Figure 1 shows our suggested timing for providing primary palliative care, specialty palliative care, and hospice, and how each can improve care for these patients. Figure 2 depicts the typical illness trajectory of a frail patient,⁴⁴ with our suggestions for when each type of palliative care can be considered.

Figure 1.

Indications and key components of each of the three categories of palliative care.³⁶

Figure 2.

The illness trajectory of a frail patient with surgical needs. Purple = opportunities for primary palliative care; yellow= opportunities for specialty palliative care; blue = consideration of hospice, if in line with goals and values. Adapted from Lynn and Adamson, 2003.⁴⁴

Multiple models exist for integrating primary and specialty palliative care into the management of a patient’s illness.⁴⁵ These include the “linkage model,” wherein the primary team does much of the primary palliative care and refers for specialty consultation at his or her discretion; the “coordinated model,” also called the “trigger model,” wherein there are predetermined criteria for specialty palliative care consultation; and the “integrative model,” wherein a palliative care specialist is fully embedded in the primary clinical setting. In the context of anesthesia care, these models have primarily been applied in the ICU and perioperative settings.

Settings of Care

No model of palliative care delivery is “one size fits all,” and there is a growing body of literature surrounding tailored approaches for specific diseases (such as heart failure⁴⁶ and COPD⁴⁷) and settings of care (such as emergency departments,^48,49 cancer centers,⁵⁰ and nursing homes).^51,52 For anesthesiology providers, ICU admissions^53,54 and perioperative encounters⁵⁵ have been studied as potential opportunities to improve delivery of palliative care. These studies are reviewed below.

Palliative Care in the Intensive Care Unit (ICU)

Frailty has been identified in up to 30% of patients upon admission to the ICU and is associated with poor outcomes.²³ Frail patients are at risk for higher mortality and a higher burden of symptoms during and after the ICU stay.²³ They are also more likely to be disabled, require nursing home care,⁵⁶ and have worse health-related quality of life than non-frail individuals in the months following ICU admission.⁵⁷ In a general ICU population, as many as one in seven patients meets criteria for palliative care consultation as determined by the Project IMPACT screening tool for unmet palliative care needs.⁵⁸ This number increased to one in five patients when multiple screening tools were used together; based on baseline symptom burden among frail patients, it is expected that even a higher fraction of ICU patients with frailty would meet these criteria. Efforts have been made to systematically address the palliative care needs of ICU patients via primary palliative care interventions that are part of the ICU team workflow and alternatively by establishing criteria for specialty palliative care consultations.⁵⁴

Multiple interventions incorporating primary palliative care in the ICU have been studied, including protocols for early family meeting (led by the ICU team without specialty palliative care consultation),^59–61 routine palliative care assessment as part of a daily checklist,^62–64 embedding a trained provider into the ICU team specifically to address palliative care needs,^65,66 increasing education for ICU team members, and improving education and support for family members of ICU patients.^66–70 Individual interventions have been associated with such benefits as increased clinician understanding of patient goals^{59,62,63,68,69,71} and improved caregiver perception of communication.^61,64 Specific to the end of life in the ICU, Cook et al instituted the 3 Wishes Project, which seeks to honor dying patients by fulfilling their own wishes or those of their caregivers and clinical team members on their behalf.^72,73 Participants in the project scored favorably on the Quality of End-of-Life Care–10 instrument.⁷³

Increasing specialty palliative care involvement in the ICU often relies on the use of a needs assessment tool and predetermined triggers for a consultation.^71,74–76 The screening tools take into account factors such as length of stay, age, comorbid conditions, and severity of admitting diagnosis, and are meant to identify patients at highest risk of morbidity and mortality, signaling that an earlier discussion of goals of care is warranted.⁵⁸ In one example, the CAPC IPAL-ICU project screened medical and surgical ICU (SICU) patients for palliative care needs, with positive screens being reviewed for possible specialty consult.⁷⁵ The authors found an increase in palliative care consults by 113% in the MICU and 51% in the SICU during the nine-month pilot period of the tool.

In terms of outcomes, a review of 30 primary and specialty palliative care interventions by Aslakson et al found that most resulted in decreased ICU length of stay and/or hospital length of stay overall, with no difference in mortality associated with the intervention.⁵⁴ Additional benefits identified include improved agreement between family members and providers about the patient’s care plan and disposition,^71,77 decreased family distress (though without improved family satisfaction),⁶¹ and decreased utilization of mechanical ventilation and artificial nutrition/hydration.^78–80 It is not yet clear which model – structured primary vs specialty palliative care – has the greatest benefit to patient outcomes in terms of symptom control, receipt of medical care aligned with treatment preferences, satisfaction, caregiver burden, length of stay, and health care costs and utilization (particularly non-beneficial treatments and those not aligned with patients’ goals and values). Certain unique cultural features of the ICU may also present barriers to increased palliative care interventions, regardless of delivery model.

One possible cultural challenge is the phenomenon of “clinical momentum” described by Kruser et al.⁸¹ They define clinical momentum as the “accrual of multiple interventions” triggered by an initial, automatic response to an abnormal clinical sign, symptom, or diagnosis in the ICU and which continues despite progressively decreasing likelihood of a good outcome for the patient. These authors posit that clinical momentum leads to unwanted care. Similarly, the idea of the “surgical rescue mission” in the surgical ICU has been described as a commitment by surgeons and surgical patients to do whatever it takes to get through the postoperative period, regardless of complications and prolonged or uncertain recovery.⁵³ ICU teams interested in implementing a palliative care program should take into account the baseline needs of their patient population, the capacity and resources of both the ICU and specialty palliative care staff, and less tangible factors such as clinical momentum to determine what will be most sustainable in their unit.

Palliative Care in the Perioperative Period

As previously noted, frail patients are at increased risk of perioperative complications compared with non-frail surgical patients: a recent retrospective cohort study by Shinall et al found that preoperative frailty is associated with significantly increased mortality at 30, 90, and 180 days postoperatively across all levels of operative stress.⁶ Even at the lowest level of operative risk, the authors found that risk of mortality increased with degree of frailty: 90-day mortality after low-risk surgery was approximately 5% in frail patients and 23% in the very frail; for higher-risk surgeries, mortality increased to 13% in the frail and 34% in the very frail (mortality remained under 1% in the non-frail at these same levels of operative risk). Frail patients have double the risk of major postoperative morbidity, as well as both six times higher risk of short-term mortality and three times increased risk of long-term mortality following major abdominal surgery.¹⁵ Even for ambulatory surgery patients, there is a stepwise increase in risk of serious complication with worsening frailty.¹⁴ Although efforts have been made to develop “pre-habilitation” programs to improve the functional status of frail patients prior to surgery, there is no clear evidence that these can mitigate risk of perioperative complications.⁸² These findings suggest that primary palliative care interventions and potentially specialty palliative care referral could play a role in preoperative assessment of the treatment goals of frail patients.

A recent systematic review of palliative care interventions for surgical patients in general (not limited to frail patients) revealed a paucity of high-quality evidence in this area, but suggested that perioperative decision-making programs may improve mortality, symptom control, quality of life, communication, and health care utilization.⁵⁵ The twenty-five reviewed interventions were heterogeneous in design and mostly consisted of small, single-center studies ranging from structured communication tools to interdisciplinary team consultations to informational handouts for patients and families.^83–99 Only two studies specifically focused on frail patients. In a sample of 150 frail patients referred for a structured decision-making intervention, previously scheduled for surgery, hemodialysis, or other procedural interventions, 75% ultimately declined the procedure, suggesting that many patients are undergoing treatments that are not aligned with their goals of care.⁸⁹ Another study of 310 patients at one Veterans Affairs Medical Center found that following implementation of preoperative frailty screening, palliative care consultations for surgical patients increased and an increased proportion of those consultations were done preoperatively rather than postoperatively. In the same study, mortality was significantly reduced even when controlling for whether or not surgery was completed.⁸⁵ Another recent randomized trial by Schwarze et al found that use of a question prompt list for older patients considering major surgery was not associated with patient engagement or wellbeing outcomes; they suggest that having clinicians initiate conversations about decision-making, rather than having patients independently review the question prompts as was done in the trial, would be more likely to have an effect.¹⁰⁰ The interventions described vary in terms of time and resources necessary for implementation, so feasibility and sustainability are important considerations for hospitals wishing to institute this type of program.

Analogous to the “surgical rescue mission,” the concept of “surgical contract” may present a challenge to development of feasible perioperative palliative interventions: Schwarze et al describe the surgical contract as an expectation on the part of surgeons that patients will “buy in” to a certain amount or duration of postoperative care, including life-prolonging interventions that may not be in line with the patient’s goals and values.¹⁰¹ In a nationwide study of 912 U.S. surgeons, the same group found that up to two thirds of respondents sometimes or always refuse to operate on a patient requesting limitations on life-sustaining therapies.¹⁰² However, in 2005, the American College of Surgeons endorsed the importance of palliative care in the treatment of surgical patients¹⁰³ and the field of surgical palliative care continues to evolve.¹⁰⁴ Given their close collaboration with surgeons in the perioperative setting, it may be possible for anesthesiology providers to play a role in eliciting a patient’s care preferences and developing a treatment plan aligned with them.

Primary Palliative Care Recommendations for Anesthesiology providers

As reviewed above, frail patients have substantial palliative care needs that are particularly relevant to anesthesiology providers in the perioperative and critical care settings. In this section, we propose ways for anesthesiology providers to address the palliative care needs of their frail patients, either through coordination with other providers or through discussion of goals of care (see Table 1).

First, given the high prevalence of frailty in older adults, we recommend that patients over the age of 60 be screened for it at the time of preoperative assessment or admission to the ICU.¹⁰⁵ Identifying the syndrome may represent an opportunity for anesthesiology providers to provide the early care coordination that is often lacking for patients with multiple comorbidities, such as the frail,¹⁰⁶ by notifying primary care providers and surgeons (where applicable). When appropriate (see Table 1), they can also initiate a referral to specialty palliative care.

Primary palliative care may fall less frequently into the scope of anesthesiology. However, communication about goals of care may be particularly relevant in discussing the risks and benefits of anesthesia, code status during and after procedures, and preferences regarding ICU-level care and related life-prolonging interventions. The overarching aim of these conversations is to integrate the biomedical facts of a patient’s condition with his or her core values to help guide decision-making.¹⁰⁷ We recommend covering the following topics: identification of a surrogate decision maker or completion of an advance directive assigning one (health care proxy, durable power of attorney for healthcare or medical surrogate); eliciting a patient’s goals and values related to healthcare; and discussion of prognosis. Initiating these conversations can be challenging, particularly when it comes to prognosis and end-of-life issues,¹⁰⁸ but evidence suggests that patients generally wish to have them addressed.¹⁰⁹ Patients and families vary in their preferences regarding amount and detail of information, but they consistently express a desire for direct and honest communication. One tool we suggest using is a semi-structured script developed by Nakagawa et al to identify patients’ goals and values prior to left ventricular assist device (LVAD) implantation that may be a useful guide for anesthesiology providers and surgeons.¹¹⁰ The script elicits the patient’s goals and expectations for the procedure, such that information gaps can be filled based on the patient’s understanding. It also prepares the patient and/or family for the potential complications and prompts patients to discuss what would be most important to them should a devastating complication occur. This script could be adapted to other non-emergent surgical procedures by anesthesiology providers and would require little institutional investment. Two commonly-used, more general communication tools include “ask-tell-ask”¹¹¹ for opening a goals of care conversation, and NURSE statements for responding empathetically to the emotions of patients and caregivers.^112–114 These are summarized and applied to the frail patient in Table 2. When done effectively, this type of patient-centered communication is associated with improved satisfaction for both patients and providers, decreased psychological distress, and greater adherence to recommended therapies.^115–117

Table 2.

Key Palliative Care Communication Skills for Patients with Frailty¹¹³

Context	Tool	Details
Opening a conversation	Ask-Tell-Ask	Ask: ask patient/caregiver their understanding of the situation (disease, treatment options) “What have doctors told you about this illness/hospitalization/surgery?” Tell: summarize the information and fill in missing pieces/correct misinformation, without jargon Ask: have patient/caregiver re-state the information in their own words “I’ve given you a lot of information. To make sure I explained it well, can you tell me what you heard?”
Responding to emotion	NURSE	Naming: name the emotional response you see from the patient “I can see how frustrating it is to be getting weaker.” “It can be very frightening to talk about the risks associated with this procedure.” Understanding: show that you are listening “I am hearing that your biggest worry is needing a ventilator for a long time.” Respect: honor the role of the patient/caregiver in managing the disease “You have been working so hard to prepare for surgery.” “I am very impressed with how you’ve traveled here every day to support your loved one in the ICU.” Support: remind the patient/caregiver you are still going to continue helping them “I will be with you every step of the way” Explore: ask the patient/caregiver to articulate what they are feeling “Could you tell me more about what worries you about this procedure?”

Table 2 provides an overview of the Ask-Tell-Ask and NURSE statement communication tools, with examples of phrasing that might be used during goals of conversations with frail patients and/or their caregivers.

For clinicians wishing to gain in-depth primary palliative care skills, there are resources available: VitalTalk is a non-profit organization that teaches evidence-based communication skills in settings ranging from online courses to in-person seminars;¹¹⁸ the Education in Palliative and End-of-Life Care Program (EPEC) creates and disseminates primary palliative care curricula adapted to the needs of different specialties and settings;^119,120 and the End-of-Life Nursing Education Consortium (ELNEC) is a program that prepares nursing educators to teach end-of-life care skills.^121,122

Future Directions

Additional research is needed to determine the optimal framework for addressing the palliative care needs of frail patients. Frailty is unique in that patients who have it may vary significantly in their comorbidities, and the diagnosis may be under-recognized in the absence of a consensus definition. One priority is to increase identification of frailty when patients come into contact with the healthcare system, especially at moments of great vulnerability to uncontrolled symptoms and acute decompensation, such as ICU admissions and during the perioperative period. As described above, a few studies have sought to both improve recognition of frailty and act upon it by implementing communication and decision-making interventions, but larger and more generalizable trials are needed. Aslakson et al are currently conducting one such clinical trial comparing a surgeon-palliative care co-management team to a surgeon alone with respect to quality of life in patients with upper gastrointestinal cancer undergoing curative-intent surgery.¹²³

There are also no clearly defined roles for various providers in addressing the palliative care needs of frail patients once the syndrome has been diagnosed. A second priority is to improve primary palliative care skills for providers, including anesthesiology providers, who will frequently come into contact with frail patients at these times. At present, there are no established guidelines for primary palliative care education for anesthesiology providers, although the American College of Graduate Medical Education and American Board of Anesthesiology include communication skills in their core competencies for anesthesia training.¹²⁴ In a recent systematic review, Bakke et al note that surgeons and anesthesiologists historically report low confidence in holding end of life discussions, despite frequently caring for patients at high risk of mortality.¹⁰⁸ They reviewed sixteen studies of educational interventions to improve this skill in surgery and anesthesiology, and found that in general confidence did improve, along with knowledge about communication and symptom management. Research is needed to design a feasible, standardized palliative care curriculum for anesthesiology trainees that is applicable to all patients with serious illness, including those with frailty. Finally, appropriate referral criteria for specialty palliative care should be developed. Lessons on a stepwise approach to developing palliative care models for chronic disease may be drawn from the literature on heart failure and chronic obstructive pulmonary disease, each of which has a growing evidence base.^46,47

Conclusions

Frailty is a significant and growing issue as the population of older adults grows. It affects the patient population cared for by anesthesiology providers, particularly in intensive care and perioperative settings, and furthermore, impacts symptom burden, morbidity and mortality. We propose that anesthesiology providers can play an important role in providing primary palliative care and referring to specialty palliative care when needed for these vulnerable patients. In a variety of settings ranging from perioperative or pain management clinics to the ICU, they may have an opportunity to recognize and respond to frailty-specific symptoms such as weight loss, functional impairment, mood symptoms, and pain. We also recommend routine identification of a surrogate decision-maker, either by helping patients complete a health care proxy, health care power of attorney, or advance directive, or by becoming familiar with local laws addressing surrogacy. Anesthesiology providers can also engage patients and families about goals of care, particularly as they relate to procedures or intensive care interventions. This may take the form of in-depth family meetings to discuss major medical decisions in the ICU, or of a more focused conversation in the outpatient setting, perhaps using the script developed by Nakagawa et al¹¹⁰. Even simply posing the questions, “What are you hoping will be the outcome of this treatment?” and “What if things did not turn out as you hope?” can give the provider valuable insights into a patient’s health-related beliefs and values.^125,126 In response to the Shinall study,⁶ Shellito et al assert that in addition to discussing risk of post-operative mortality, all patients should be asked, “What matters most to you?”¹²⁷ Ultimately, we believe that both primary and specialty palliative care have the potential to help improve quality of life and satisfaction for frail patients and their families, reduce unwanted or non-beneficial treatments and hospitalizations, and in turn, decrease health care costs.