Invited Commentary
May 10, 2023
Surgical Palliative Care—Who, When, and Why?
Jason Michael Johanning, Ana Berlin, Pringl Miller
JAMA Surg. 2023;158(7):755. doi:10.1001/jamasurg.2023.1406
Palliative care services for patients with inoperable cancer and end-stage chronic medical conditions have been shown to improve quality of life, reduce consumption of medical services, and overall increase long-term survival.1 In surgical populations, palliative care has grown in use, demonstrating improvement in outcomes with advocates suggesting that surgeons themselves should be proficient in primary palliative care skills for their patients.2
Yet many questions remain unanswered when it comes to which populations would benefit from primary vs specialty palliative care services and who is best to provide those services. In this issue of JAMA Surgery, the study by Shinall et al3 identified a clear and distinct surgical population—namely, patients with resectable cancer undergoing major operations with curative intent. The trial was well designed and faithfully executed. Palliative care specialist teams were clearly engaged to a high standard throughout the care pathway for patients randomized to the intervention. Thus, in the setting of a gold-standard randomized clinical trial with a very homogenous population, there was absence of significant benefit for routine specialty palliative care consultation.
This is an important study despite the demonstrated absence of significant impact for routine palliative care consultation because it begs multiple fundamental questions. Clearly one may ask based on the current study and for future work: (1) What elective surgical populations are likely to benefit most from perioperative palliative care? For instance, rather than patients undergoing nonpalliative operations, should we ideally be targeting patients who are likely not to be cured from surgical therapy, where the burdens of disease are greatest and the gains of operative intervention are most uncertain? (2) Who should be providing palliative care to the surgical patient? Is a palliative care specialist too far removed? Could it be the primary surgeon or is that person too ill-equipped or too close to the surgical care to provide the optimal support? Would a surgical palliative care specialist be more effective? (3) How to best facilitate the delivery of palliative care support to high-risk surgical patients—either by surgeons themselves or by hybrid surgeon-hospice and palliative care experts or hospice and palliative care specialist consultants? (4) What metrics are most meaningful for determining the impact and potential benefit of palliative care delivery for surgical patients? Is it possible that quantitative quality of life scales and other quantitative measures are less well suited to the study of this intervention than, for example, qualitative measures?
Ultimately Shinall et al3 have given us pause to reconsider the role of routine perioperative-specialist palliative-care consultation in surgical oncology for curative intent. But rather than throwing the baby out with the bathwater, their work helps define important questions to be addressed by further investigations. The surgical community must now focus on optimal patient selection, who and when best to provide optimal palliative care support, and how best to measure the impact of palliative care delivery in the surgical setting.
