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Surgeons who provide care for patients with cancer are sometimes tasked with challenging conversations. Approaching difficult communications using a structured approach for delivering difficult news and exploring goals of care can help surgeons provide support to patients and their families.

In the 20 years since the American College of Surgeons outlined the first research agenda for surgical palliative care, there has been immense growth in the evidence. In this article, we briefly review the state of the science and priority research areas in surgical palliative care.

Surgeons who provide care for patients with cancer are sometimes tasked with challenging conversations. Approaching difficult communications using a structured approach for delivering difficult news and exploring goals of care can help surgeons provide support to patients and their families.

Given survival measured in months, metrics, such as 30-day mortality, are poorly suited to measure the quality of palliative procedures for patients with advanced cancer. Nationally endorsed process measures associated with high-quality PC include code-status clarification, goals-of-care discussions, palliative-care referral, and hospice assessment. The impact of the performance of these process measures on subsequent healthcare utilization is unknown. Administrative data and manual review were used to identify hospital admissions with performance of palliative procedures for advanced pancreatic cancer at two tertiary care hospitals from 2011 to 2016. Natural language processing, a form of computer-assisted abstraction, identified process measures in associated free-text notes. Healthcare utilization was compared using a Cox proportional hazard model. We identified 823 hospital admissions with performance of a palliative procedure. PC process measures were identified in 68% of admissions. Patients with documented process measures were older (66 vs. 63; p = 0.04) and had a longer length of stay (9 vs. 6 days; p

Palliative surgical procedures are frequently performed to reduce symptoms in patients with advanced cancer, but quality is difficult to measure.To determine whether natural language processing (NLP) of the electronic health record (EHR) can be used to (1) identify a population of cancer patients receiving palliative gastrostomy and (2) assess documentation of end-of-life process measures in the EHR.Retrospective cohort study of 302 adult cancer patients who received a gastrostomy tube at a single tertiary medical center.Sensitivity and specificity of NLP compared to gold standard of manual chart abstraction in identifying a palliative indication for gastrostomy tube placement and documentation of goals of care discussions, code status determination, palliative care referral, and hospice assessment.Among 302 cancer patients who underwent gastrostomy, 68 (22.5%) were classified by NLP as having a palliative indication for the procedure compared to 71 patients (23.5%) classified by human coders. Human chart abstraction took2600 times longer than NLP (28 hours vs. 38 seconds). NLP identified the correct patients with 95.8% sensitivity and 97.4% specificity. NLP also identified end-of-life process measures with high sensitivity (85.7%-92.9%,) and specificity (96.7%-98.9%). In the two months leading up to palliative gastrostomy placement, 20.5% of patients had goals of care discussions documented. During the index hospitalization, 67.7% had goals of care discussions documented.NLP offers opportunities to identify patients receiving palliative surgical procedures and can rapidly assess established end-of-life process measures with an accuracy approaching that of human coders.

Chronic pain after trauma is associated with serious clinical, social, and economic burden. Due to limitations in trauma registry data and previous studies, the current prevalence of chronic pain after trauma is unknown, and little is known about the association of pain with other long-term outcomes. We sought to describe the long-term burden of self-reported pain after injury and to determine its association with positive screen for posttraumatic stress disorder (PTSD), functional status, and return to work.Trauma survivors with moderate or severe injuries and one completed follow-up interview at either 6 months or 12 months after injury were identified from the Functional Outcomes and Recovery after Trauma Emergencies project. Multivariable logistic regression models clustered by facility and adjusting for confounders were used to obtain the odds of positive PTSD screening, not returning to work, and functional limitation at 6 months and 12 months after injury, in trauma patients who reported to have pain on a daily basis compared to those who did not.We completed interviews on 650 patients (43% of eligible patients). Half of patients (50%) reported experiencing pain daily, and 23% reported taking pain medications daily between 6 months and 12 months after injury. Compared to patients without pain, patients with pain were more likely to screen positive for PTSD (odds ratio [OR], 5.12; 95% confidence interval [CI], 2.97-8.85), have functional limitations for at least one daily activity (OR, 2.42; 95% CI, 1.38-4.26]), and not return to work (OR, 1.86; 95% CI, 1.02-3.39).There is a significant amount of self-reported chronic pain after trauma, which is in turn associated with positive screen for PTSD, functional limitations, and delayed return to work. New metrics for measuring successful care of the trauma patient are needed that span beyond mortality, and it is important we shift our focus beyond the trauma center and toward improving the long-term morbidity of trauma survivors.Therapeutic/Care management, level III.

Objectives To quantify preoperative illness burden in older adults undergoing emergency major abdominal surgery (EMAS), to examine the association between illness burden and postoperative outcomes, and to describe end‐of‐life care in the year after discharge. Design Retrospective study using data from Health and Retirement Study interviews linked to Medicare claims (2000–2012). Setting National population‐based dataset. Participants Medicare beneficiaries who underwent EMAS. Measurements High illness burden, defined as ≥2 of the following vulnerabilities: functional dependence, dementia, use of helpers, multimorbidity, poor prognosis, high healthcare utilization. In‐hospital outcomes were complications and mortality. Postdischarge outcomes included emergency department (ED) visits, hospitalization, intensive care unit (ICU) stay, and 365‐day mortality. For individuals discharged alive who died within 365 days of surgery, outcomes included hospice use, hospitalization, ICU use, and ED use in the last 30 days of life. Multivariable regression was used to determine the association between illness burden and outcomes. Results Of 411 participants, 57% had high illness burden. More individuals with high illness burden had complications (45% vs 28% p=0.00) and in‐hospital death (20% vs 9%, p=0.00) than those without. After discharge (n=349), individuals with high illness burden experienced more ED visits (57% vs 46%, P=.04) and were more likely to die (35% vs 13%, p=0.00). Of those who died after discharge (n=86), 75% had high illness burden, median survival was 67 days (range 21–141 days), 48% enrolled in hospice, 32% died in the hospital, 23% were in the ICU in the last 30 days of life and 37% had an ED visit in the last 30 days of life. Conclusion Most older adults undergoing EMAS have preexisting high illness burden and experience high mortality and healthcare use in the year after surgery, particularly near the end of life. Concurrent surgical and palliative care may improve quality of life and end‐of‐life care in these people. J Am Geriatr Soc 66:2072–2078, 2018.

Periprocedural providers are encountering more patients with code status limitations (CSLs) regarding their preferences for resuscitation and life-sustaining treatment who choose to undergo palliative procedures. Surgical and anesthesia guidelines for preprocedural reconsideration of CSLs have been available for several years, but it is not known whether they are being followed in practice.We assessed compliance with existing guidelines for patients undergoing venting gastrostomy tube (VGT) for malignant bowel obstruction (MBO), serving as an example of a palliative procedure received by patients near the end of life.Code status was determined at admission and throughout the hospitalization by chart review. Documentation of code status discussions (CSDs) was identified from provider notes and compared with existing guidelines.An institutional database retrospectively identified patients who underwent VGT placement for MBO at two academic hospitals (2014-2015).We identified 53 patients who underwent VGT placement for MBO. Interventional radiologists performed 88% of these procedures. Other periprocedural providers involved in these cases included surgeons, gastroenterologists, anesthesiologists, and sedation nurses.CSLs were documented before the procedure in only 43% of cases, and a documented CSD with a periprocedural provider was identified in only 22% of CSL cases. Of all VGT placements performed in patients with CSLs before the procedure, only 13% were compliant with the guidelines of preprocedural reconsideration of CSLs.Increased compliance with guidelines published by the American Society of Anesthesiologists, the American College of Surgeons, and the Association of Perioperative Registered Nurses is necessary to ensure goal-concordant care of patients with CSLs who undergo a procedure. Efforts should be made to incorporate these guidelines into the training of all periprocedural providers.

Background Hospice improves quality and value of end of life care (EOLC), and enrollment has increased for older patients dying from chronic medical conditions. It remains unknown if the same is true for older patients who die after moderate to severe traumatic brain injury (msTBI). Methods Subjects included Medicare beneficiaries (≥65 years) who were hospitalized for msTBI from 2005 to 2011. Outcomes included intensity and quality of EOLC for decedents within 30 days of admission, and 30-day mortality for the entire cohort. Logistic regression was used to analyze the association between year of admission, mortality, and EOLC. Results Among 50,342 older adults, 30-day mortality was 61.2%. Mortality was unchanged over the study period (aOR 0.93 [0.87–1.00], p = 0.06). Additionally, 30-day non-survivors had greater odds of hospice enrollment, lower odds of undergoing neurosurgery, but greater odds of gastrostomy. Conclusion Between 2005 and 2011, hospice enrollment increased, but there was no change in 30-day mortality.

Objective Despite caring for patients near the end-of-life (EOL), surgeons and anesthesiologists report low confidence in their ability to facilitate EOL conversations. This discrepancy exists despite competency requirements and professional medical society recommendations. The objective of this systematic review is to identify articles describing EOL communication training available to surgeons and anesthesiologists, and to assess their methodological rigor to inform future curricular design and evaluation. Methods This PRISMA-concordant systematic review identified English-language articles from PubMed, EMBASE, and manual review. Eligible articles included viewpoint pieces, and observational, qualitative, or case studies that featured an educational intervention for surgeons or anesthesiologists on EOL communication skills. Data on the study objective, setting, design, participants, intervention, and results were extracted and analyzed. The Newcastle-Ottawa Scale was used to assess methodological quality. Results Database and manual search returned 2710 articles. A total of 2268 studies were screened by title and abstract, 46 reviewed in full-text, and 16 included in the final analysis. Fifteen studies were conducted exclusively in academic hospitals. Two studies included attending surgeons as participants; all others featured residents, fellows, or a mix thereof. Fifteen studies used simulated role-playing to teach and assess EOL communication skills. Measured outcomes included knowledge, attitudes, confidence, self-rated or observer-rated communication skills, and curriculum feedback; significance of results varied widely. Most studies lacked adequate methodological quality and appropriate control groups to be confident about the significance and applicability of their results. Conclusions There are few quality studies evaluating EOL communication training for surgeons and anesthesiologists. These programs frequently use role-playing to teach and assess EOL communication skills. More studies are needed to evaluate the effect of these interventions on patient outcomes. However, evaluating the effectiveness of these initiatives poses methodological challenges.

Objective The objective of our study was to characterize providers' impressions of factors contributing to disproportionate rates of morbidity and mortality in emergency general surgery to identify targets for care quality improvement. Background Emergency general surgery is characterized by a high-cost burden and disproportionate morbidity and mortality. Factors contributing to these observed disparities are not comprehensively understood and targets for quality improvement have not been formally developed. Methods Using a grounded theory approach, emergency general surgery providers were recruited through purposive-criterion–based sampling to participate in semi-structured interviews and focus groups. Participants were asked to identify contributors to emergency general surgery outcomes, to define effective care for EGS patients, and to describe operating room team structure. Interviews were performed to thematic saturation. Transcripts were iteratively coded and analyzed within and across cases to identify emergent themes. Member checking was performed to establish credibility of the findings. Results A total of 40 participants from 5 academic hospitals participated in either individual interviews (n = 25 [9 anesthesia, 12 surgery, 4 nursing]) or focus groups (n = 2 [15 nursing]). Emergency general surgery was characterized by an exceptionally high level of variability, which can be subcategorized as patient-variability (acute physiology and comorbidities) and system-variability (operating room resources and workforce). Multidisciplinary communication is identified as a modifier to variability in emergency general surgery; however, nursing is often left out of early communication exchanges. Conclusion Critical variability in emergency general surgery may impact outcomes. Patient-variability and system-variability, with focus on multidisciplinary communication, represent potential domains for quality improvement in this field.

Introduction Developing an optimized and user-friendly mHealth application for patients and family members in the hospital environment presents unique challenges given the diverse patient population and patients' various states of well-being. Objective This article describes user-centered design methods and results for developing the patient and family facing user interface and functionality of MySafeCare, a safety reporting tool for hospitalized patients and their family members. Methods Individual and group usability sessions were conducted with specific testing scenarios for participants to follow to test the usability and functionality of the tool. Participants included patients, family members, and Patient and Family Advisory Council (PFAC) members. Engagement rounds were also conducted on study units and lessons learned provided additional information to the usability work. Usability results were aligned with Nielsen's Usability Heuristics. Results Eleven patients and family members and 25 PFAC members participated in usability testing and over 250 patients and family members were engaged during research team rounding. Specific themes resulting from the usability testing sessions influenced the changes made to the user interface design, workflow functionality, and terminology. Conclusion User-centered design should focus on workflow functionality, terminology, and user interface issues for mHealth applications. These themes illustrated issues aligned with four of Nielsen's Usability Heuristics: match between system and the real world, consistency and standards, flexibility and efficiency of use, and aesthetic and minimalist design. We identified workflow and terminology issues that may be specific to the use of an mHealth application focused on safety and used by hospitalized patients and their families.

To compare survival, readmissions, and end-of-life care after palliative procedures compared with medical management for malignancy-associated bowel obstruction (MBO).MBO is a late complication of intra-abdominal malignancy for which surgeons are frequently consulted. Decisions about palliative treatments, which include medical management, surgery, or venting gastrostomy tube (VGT), are hampered by the paucity of outcomes data relevant to patients approaching the end of life.Retrospective study using 2001 to 2012 Surveillance, Epidemiology, and End Results-Medicare data of patients 65 years or older with stage IV ovarian or pancreatic cancer who were hospitalized for MBO. Multivariate competing-risks regression models were used to compare the following outcomes: survival, readmission for MBO, hospice enrollment, intensive care unit (ICU) care in the last days of life, and location of death in an acute care hospital.Median survival after MBO admission was 76 days (interquartile range 26-319 days). Survival was shorter after VGT [38 days (interquartile range 23-69)] than medical management [72 days (23-312)] or surgery [128 days (42-483)]. As compared to medical management, patients treated with VGT had fewer readmissions [subdistribution hazard ratio 0.41 (0.29-0.58)], increased hospice enrollment [1.65 (1.42-1.91)], and less ICU care [0.69 (0.52-0.93)] and in-hospital death [0.47 (0.36-0.63)]. Surgery was associated with fewer readmissions [0.69 (0.59-0.80)], decreased hospice enrollment [0.84 (0.76-0.92)], and higher likelihood of ICU care [1.38 (1.17-1.64)].VGT is associated with fewer readmissions and lower intensity healthcare utilization at the end of life than do medical management or surgery. Given the limited survival, regardless of management, hospitalization with MBO carries prognostic significance and presents a critical opportunity to identify patients' priorities for end-of-life care.

Background Prior studies of Medicare beneficiaries with both neoplastic and non-neoplastic indications for cholecystectomy demonstrated a reduced risk of common bile duct (CBD) injury when intraoperative cholangiography (IOC) was used. We sought to determine the association between IOC and CBD injury during inpatient cholecystectomy for non-neoplastic biliary disease and compare survival among those with or without CBD injury. Methods Retrospective study of patients ≥66 who underwent inpatient cholecystectomy (2005–2010) for gallstones, cholecystitis, cholangitis, or gallbladder obstruction. The association between IOC and CBD injury was analyzed using multivariable logistic regression and survival after cholecystectomy was analyzed using multivariable Cox regression. Results Among 472,367 patients who underwent cholecystectomy, 0.3% had a CBD injury. IOC was associated with increased CBD injury (adjusted OR 1.41[1.27–1.57]). CBD injury was associated with increased hazards of death (adjusted HR 1.37[1.25–1.51]). Conclusions IOC in patients with non-neoplastic biliary disease was associated with increased odds of CBD injury. This likely reflects its selective use in patients at higher risk of CBD injury or as a confirmatory test when an injury is suspected.

The National Academies of Sciences, Engineering, and Medicine (formerly the Institute of Medicine) recently recommended inclusion of postdischarge health-related quality of life (HRQoL) and patient-reported outcomes (PROs) metrics to benchmark the quality of trauma care. Currently, these measures are not routinely collected at most trauma centers. We sought to determine the feasibility and value of adding such long-term outcome measures to trauma registries.As part of the FORTE (Functional Outcomes and Recovery after Trauma Emergencies) project, we included patients with an Injury Severity Score of 9 or greater, admitted to the Brigham and Women's Hospital in Boston, MA, who were identified retrospectively using the institutional trauma registry and contacted 6 or 12 months after injury to participate in a telephone survey evaluating HRQoL (Short Form 12 [SF-12]), PROs (Trauma Quality of Life), posttraumatic stress disorder, return to work, residential status, and health care utilization.Data were collected for 171 of 394 eligible patients: 85/189 (45%) at 6 months and 86/205 (42%) at 12 months; 25%/29% (6/12 months) patients could not be contacted, 15%/16% (6/12 months) declined to participate, and 15%/13% (6/12 months) were interested in participating at another time but were not reached again. Approximately 20% patients screened positive for posttraumatic stress disorder, and half had not yet returned to work. There were significant reductions in SF-12 physical composite scores relative to population norms (mean, 50 [SD, 10]) at 6 months (mean, 44; 95% confidence interval [CI], 41-47) and 12 months (45; 95% CI, 42-47); no difference was noted in the SF-12 mental composite scores (6 months: 51 [95% CI, 48-54]; 12 months: 50 [95% CI, 46-53]).Trauma patients reported considerable impairment 6 and 12 months after injury. Routine collection of PROs and HRQoL provides important data regarding trauma outcomes beyond mortality and will enable the development of quality improvement metrics that better reflect patients' postinjury experiences. Improved and alternate methods for collection of these data need to be developed to enhance response rates before widespread adoption across trauma centers in the United States.Prognostic/epidemiologic, level II; Therapeutic, level III.

Background: Natural language processing (NLP), a form of computer-assisted data abstraction, rapidly identifies serious illness communication domains such as code-status confirmation and goals of care (GOC) discussions within free-text notes, using a codebook of phrases. Differences in the phrases associated with palliative care for patients with different types of illness are unknown. Objective: To compare communication of code-status clarification and GOC discussions between patients with advanced pancreatic cancer undergoing palliative procedures and patients admitted with life-threatening trauma. Design: Retrospective cohort study. Setting/Subjects: Patients with in-hospital admissions within two academic medical centers. Measurements: Sensitivity and specificity of NLP-identified communication domains compared with manual review. Results: Among patients with advanced pancreatic cancer (n = 523), NLP identified code-status clarification in 54% of admissions and GOC discussions in 49% of admissions. The sensitivity and specificity for code-status clarification were 94% and 99% respectively, while the sensitivity and specificity for a GOC discussion were 93% and 100%, respectively. Using the same codebook in patients with life-threatening trauma (n = 2093), NLP identified code-status clarification in 25.9% of admissions and GOC discussions in 6.3% of admissions. While NLP identification had 100% specificity, the sensitivity for code-status clarification and GOC discussion was reduced to 86% and 50%, respectively. Adding dynamic phrases such as “ongoing discussions” and phrases related to “family meetings” increased the sensitivity of the NLP codebook for code status to 98% and for GOC discussions to 100%. Conclusions: Communication of code status and GOC differ between patients with advanced cancer and those with life-threatening trauma. Recognition of these differences can aid in identification in patterns of palliative care delivery.

Palliative care (PC) is associated with lower-intensity treatment and better outcomes at the end of life. Trauma surgeons play a critical role in end-of-life (EOL) care; however, the impact of PC on health care utilization at the end of life has yet to be characterized in older trauma patients.This retrospective cohort study using 2006 to 2011 national Medicare claims included trauma patients 65 years or older who died within 180 days after discharge. The exposure of interest was inpatient PC during the trauma admission. A non-PC control group was developed by exact matching for age, comorbidity, admission year, injury severity, length of stay, and post-discharge survival. We used logistic regression to evaluate six EOL care outcomes: discharge to hospice, rehospitalization, skilled nursing facility or long-term acute care hospital admission, death in an institutional setting, and intensive care unit admission or receipt of life-sustaining treatments during a subsequent hospitalization.Of 294,665 patients who died within 180 days after discharge, 2.1% received inpatient PC. Among 5,693 matched pairs, inpatient PC was associated with increased odds of discharge to hospice (odds ratio [OR], 3.80; 95% confidence interval [CI], 3.54-4.09) and reduced odds of rehospitalization (OR, 0.17; 95% CI, 0.15-0.20), skilled nursing facility/long-term acute care hospital admission (OR, 0.43; 95% CI, 0.39-0.47), death in an institutional setting (OR, 0.34; 95% CI, 0.30-0.39), subsequent intensive care unit admission (OR, 0.51; 95% CI, 0.36-0.72), or receiving life-sustaining treatments (OR, 0.56; 95% CI, 0.39-0.80).Inpatient PC is associated with lower-intensity and less burdensome EOL care in the geriatric trauma population. Nonetheless, it remains underused among those who die within 6 months after discharge.Therapeutic/Care management, level III.

Objective: The aims of the study were to evaluate the amount and contentof data patients and care partners reported using a real-time electronicsafety tool compared with other reporting mechanisms and to understandtheir perspectives on safety concerns and reporting in the hospital.Methods: This study used mixed methods including 20-month preimplementation and postimplementation trial evaluating MySafeCare, a web-basedapplication, which allows hospitalized patients/care partners to report safetyconcerns in real time. The study compared MySafeCare submission ratesfor three hospital units (oncology acute care, vascular intermediate care, medical intensive care) with submissions rates of Patient Family Relations (PFR)Department, a hospital service to address patient/family concerns. The studyused triangulation of quantitative data with thematic analysis of safety concern submissions and patient/care partner interviews to understand submission content and perspectives on safety reporting.Results: Thirty-two MySafeCare submissions were received with an average rate of 1.7 submissions per 1000 patient-days and a range of 0.3 to4.8 submissions per 1000 patient-days across all units, indicating notablevariation between units. MySafeCare submission rates were significantlyhigher than PFR submission rates during the postintervention period onthe vascular unit (4.3 [95% confidence interval = 2.8–6.5] versus 1.5[95% confidence interval = 0.7–3.1], Poisson) (P = 0.01). Overall trendsindicated a decrease in PFR submissions after MySafeCare implementation. Triangulated data indicated patients preferred to report anonymouslyand did not want concerns submitted directly to their care team.Conclusions: MySafeCare evaluation confirmed the potential value ofproviding an electronic, anonymous reporting tool in the hospital to capturesafety concerns in real time. Such applications should be tested further aspart of patient safety programs.

BACKGROUND/OBJECTIVES: Prior research suggests that high illness burden (HIB) is a proxy for palliative care needs in older adults. Increasing numbers of older adults are undergoing emergent major abdominal surgery (EMAS); however, illness burden in this population is unexamined. Our objectives were to 1) quantify preoperative illness burden among older EMAS patients; 2) examine the association between illness burden and postoperative outcomes; and 3) describe end-of-life care among decedents in the year after discharge. DESIGN: Retrospective study using data from Health and Retirement Study interviews linked to Medicare claims (2000-2012). SETTING: National population-based dataset. PARTICIPANTS: Medicare beneficiaries who underwent EMAS. EXPOSURE: HIB, defined as ≥2 of the following vulnerabilities: functional dependence, dementia, use of helpers, multimorbidity, poor prognosis, high healthcare utilization. MEASUREMENTS: In-hospital outcomes were complications and mortality. Post-discharge outcomes included emergency department (ED) visits, hospitalization, intensive care unit (ICU) stay, and 365-day mortality. Among patients discharged alive who died within 365 days of surgery, outcomes included hospice utilization, hospitalization, ICU and ED use in the last 30 days of life. Multivariable regression was used to determine the association between illness burden and outcomes. RESULTS: Among 411 patients, 57% had HIB. More HIB patients had complications (45% vs. 28% P< 0.01) and in-hospital death (20% vs. 9%, P< 0.01). Post-discharge (n=349), HIB patients experienced more ED visits (57% vs. 46%, P=0.04) and higher mortality (35% vs. 13%, p

Palliative surgical procedures are often performed for patients with limited survival. Quality measures for processes of care at the end of life are appropriate in palliative surgery, but have not been applied in this patient population. In this paper, the authors propose 4 quality measures for end-of-life care in a palliative surgery, and then demonstrate the utility of natural language processing for implementing these measures.

Objective To study preoperative counseling in patients undergoing salvage total laryngectomy (STL). Study Design Case series with chart review. Setting Tertiary care academic hospital. Subjects and Methods We reviewed charts of patients ≥18 years undergoing STL between 2005 and 2015. Fifty-eight patients were identified. Notes written within 2 months prior to surgery by head and neck surgical oncologists, radiation oncologists, medical oncologists, speech-language pathologists, social workers, and nurse practitioners were extracted and coded into 4 categories. Coded content was then analyzed using a simple tally within content areas. Results Nonphysicians documented patient values and priorities, exclusive of treatment desires, more frequently. These topics included apprehension about family obligations, fear about communication, questions regarding quality of life, and anxiety regarding job continuation. Physician notes documented priorities regarding preferences for surgical treatment. No patients were seen by palliative care preoperatively, and only 14% (n = 8) patients had documentation of an end-of-life discussion. Conclusions Preoperative counseling for STL patients that included nonphysicians had a higher frequency of discussion of patients' priorities. This suggests including these types of providers may lead to more patient-centered care. A prospective study evaluating patient and physician perceptions of preoperative counseling can better identify where discrepancies exists and help conceptualize a framework for preoperative counseling in STL patients and other patients undergoing high-risk surgery.

The surprise question is a validated tool for identifying patients with increased risk of death within one year who could, therefore, benefit from palliative care. However, its utility in surgery is unknown.We sought to determine whether the surprise question predicted 12-month mortality in older emergency general surgery patients.This was a prospective cohort study.Emergency general surgery attendings and surgical residents in or beyond their third year of training at a single tertiary care academic hospital from January to July 2014.Surgeons responded to the surprise question within 72 hours of evaluating patients, ≥65 years, hospitalized with an acute surgical condition. Patient data, including demographic and clinical characteristics, were extracted from the medical record. Mortality within 12 months of initial evaluation was determined by using Social Security death data.Ten attending surgeons and 18 surgical residents provided 163 responses to the surprise question for 119 patients: 60% of responses were "No, I would not be surprised" and 40% were "Yes, I would be surprised." A "No" response was associated with increased odds of death within 12 months in binary logistic regression (OR 4.8 [95% CI 2.1-11.1]).The surprise question is a valuable tool for identifying older patients with higher risk of death, and it may be a useful screening criterion for older emergency general surgery patients who would benefit from palliative care evaluation.

56 Background: Despite high post-discharge mortality among older patients with metastatic cancer who undergo emergency general surgery (EGS), little is known about the impact of EGS on the type of end-of-life care received. We sought to examine the association between EGS and established markers of high intensity or poor quality end-of-life care for cancer patients. Methods: This retrospective cohort study used 2001-2013 Surveillance, Epidemiology, and End Results-Medicare to identify beneficiaries 65 years or older, diagnosed initially with stage IV cancer (lung, colorectal, breast, ovarian, pancreatic, or melanoma), who received one of the seven highest-burden EGS operations, and died within 180 days of surgery. Non-EGS controls were exact-matched by age, sex, race, cancer type, and cancer diagnosis date then assigned a pseudo-exposure date corresponding to the EGS date. Conditional logistic regression adjusting for region and Charlson score was performed among pairs discharged alive to compare location of death (facility or home/hospice), healthcare utilization (hospitalization, intensive care unit (ICU) stay, emergency department (ED) visit) in the last 30 days of life, and hospice use (death in hospice, hospice enrollment less than three days from death). Results: Among 1,129 matched pairs, EGS patients had higher odds of death in facility (OR [95% CI]: 1.29 [1.05 - 1.58]) as well as hospitalization (1.83 [1.54 - 2.18]), ICU stay (2.05 [1.66 - 2.53]) or ED visit (1.76 [1.47 - 2.10]) in the last 30 days of life compared to non-EGS patients. EGS patients had higher odds of dying in hospice (1.22 [1.02 - 1.45]), but also experienced higher odds of hospice enrollment less than three days from death (1.72 [1.20 - 2.46]). Conclusions: Older patients with metastatic cancer who survive EGS experienced higher intensity end-of-life care than similar non-EGS patients. Such EGS patients may benefit from targeted interventions during the emergent hospitalization to improve the end-of-life care received.

The Eastern Association for the Surgery of Trauma (EAST) recommends that clinicians consider limiting further aggressive treatment in geriatric patients with severe traumatic brain injury (TBI) who do not improve in 72 hours (nonresponders) owing to their poor prognosis. However, little is known about how these guidelines are followed in practice. This study compared mortality and patient care among geriatric patients with severe TBI classified as "responders" and "nonresponders" 72 hours after injury.Retrospective review of patients 65 years or older at a Level I trauma center with severe TBI (GCS8) from 2011 to 2014. We compared in-hospital mortality, end-of-life (EOL) decision making, discharge functional status, and 12-month survival in responders (GCS8 at 72 hours) and nonresponders (GCS ≤ 8 at 72 hours).Of 90 patients, 29 (32%) died within 3 days of injury, 29 (32%) were nonresponders, and 32 (34%) were responders. An additional 19 patients (21%) died before hospital discharge, of whom 17 (89%) were nonresponders. Nonresponders had higher odds of in-hospital death (odds ratio, 31.8; 95% confidence interval [CI], 3.71-272.9; p = 0.002). Family meetings to discuss goals of care were more common in the nonresponder group (p0.001) and fewer nonresponders were full code at discharge or death (p0.001). There were no significant differences in functional status at discharge. Among patients discharged alive, there were no differences in 12-month survival.The responder/nonresponder dichotomy identifies patients with higher in-hospital mortality outcomes and is associated with differences in EOL decision making. However, functional impairment and poor survival were prevalent, irrespective of neurologic status at 72 hours.Prognostic/epidemiologic study, level III; therapeutic study, level IV.

According to the National Research Corporation, 1 in 5 Americans use social media sites to obtain healthcare information. Patients can easily access information on medical conditions and medical professionals; however physicians may not be aware of the nature and impact of this information. All physicians must learn to use the Internet to their advantage and be acutely aware of the disadvantages. Surgeons are in a unique position because, unlike in the primary care setting, less time is spent developing a long-term relationship with the patient. In this literature review, we discuss the impact of the Internet, social networking websites, and physician rating websites and make recommendations for surgeons about managing digital identity and maintaining professionalism.

Background Although high absolute hospital geriatric trauma volume (GTV) is associated with improved outcomes among geriatric trauma patients, the actual geriatric trauma proportion (GTP) may be a better predictor of outcomes. Methods Adult trauma admissions were identified in the California State Inpatient Database, 2007-2011. Hospital characteristics were extracted from the American Hospital Association database. The annual trauma volume of patients 65 years and older (GTV) was calculated. The GTP was derived by dividing the GTV by the overall adult trauma volume and hospitals were categorized into tertiles of GTP. Outcomes were hospital mortality, failure to rescue (FTR) and 30-day readmission in geriatric trauma patients. Independent risk factors were assessed with clustered multivariate logistic regression models adjusted for patient and hospital characteristics. Results There were 61,915 geriatric trauma patients included from 63 trauma centers. Hospital mortality, FTR, and 30-day readmission rates were 4.99%, 16.07% and 12.03% respectively. The adjusted Odds Ratio and 95% Confidence Intervals for in-hospital mortality and FTR per 100 patient increase in GTV were 0.91 (0.83-1.00) and 1.01 (0.90-1.14) respectively. As compared to hospitals in the lowest tertile, adjusted odds of mortality and FTR in the highest tertile were 0.71 (0.54-0.94) and 0.67 (0.48-0.92) respectively. None of the hospital factors measured was significantly associated with readmission. The Wald test revealed that GTP played a larger role than GTV in predicting hospital mortality (P=0.018 vs. P=0.048) and FTR (P=0.015 vs. P=0.985). Conclusions Treatment at hospitals with higher GTP is associated with lower hospital mortality and FTR among geriatric patients. These findings suggest that creation of specialized services for geriatric trauma care may improve outcomes among geriatric trauma patients.

More than 80% of older patients die or are seriously impaired within 1 year after severe traumatic brain injury (TBI). Given their poor survival, information about end-of-life care is a relevant marker of high-value trauma care for these patients. In-hospital mortality is commonly used to measure quality of trauma care; however, it is not known what type of end-of-life care hospitals with the best survival outcomes provide to those who die.To determine whether end-of-life care for older patients with TBI is correlated with in-hospital mortality.A retrospective cohort study using 2005-2011 national Medicare claims from acute care hospitals was conducted. Medicare beneficiaries aged 65 years or older who were admitted with serious or severe TBI were included. Transferred patients, those treated at low-volume hospitals, and those who died on the date of admission were excluded. Low-mortality hospitals were those in the lowest quartile for in-hospital mortality using standardized mortality rates adjusting for age, sex, race/ethnicity, comorbidity, and injury severity. Patients at low-mortality hospitals were compared with patients at all other hospitals. The study was conducted from January 2005 to December 2011. Data analysis was conducted between August 2016 and February 2017.End-of-life care outcomes for patients who died in hospital or 30 days or less after discharge included gastrostomy and tracheostomy placement during the TBI admission and enrollment in hospice.Of 363 hospitals included in the analysis, 91 (25.1%) were designated as low-mortality. The cohort included 34 691 patients (median age, 79 years; interquartile range, 72-84 years; 40.8% women). Of these patients, 55.8% of those at low-mortality hospitals and 62.5% at all other hospitals died in the hospital or 30 days or less after discharge (P .01). Among patients who died in the hospital (n = 16 994), end-of-life care was similar at low-mortality hospitals and all other hospitals. For patients who survived the TBI admission and died 30 days or less after discharge (n = 4027), those at low-mortality hospitals underwent fewer gastrostomy (15.9% vs 24.0%; adjusted OR, 0.61; 95% CI, 0.52-0.72) or tracheostomy (18.2% vs 24.9%; adjusted OR, 0.71; 95% CI, 0.60-0.83) procedures and received more hospice care (66.3% vs 52.5%; adjusted OR, 1.72; 95% CI, 1.50-1.96).For older patients with serious or severe TBI, hospitals with the lowest in-hospital mortality perform fewer high-intensity treatments at the end of life and enroll more patients in hospice without increasing cumulative mortality 30 days or less after discharge.

7 Background: Natural Language Processing (NLP) presents a novel method of extracting text-embedded information from the electronic health record (EHR) to improve routine assessment of palliative quality metrics such as timely advance care planning (ACP), palliative care provision (PC), and hospice referral. Methods: We identified cancer patients (ICD-9-CM codes 140-209) who received a gastrostomy tube (ICD-9-CM 43.11, 43.19, 44.32; CPT code 49440) from Jan 1, 2012, to Mar 31, 2016 at an academic medical center. We used NLP to identify palliative indication for gastrostomy tube placement by labeling clinical notes from the EHR containing the key word “venting” near the time of the procedure. Documentation of ACP, PC, and hospice referral was identified by NLP using a validated key term library. The sensitivity and specificity of the NLP method was determined by comparing outcome identification to manual chart abstraction performed by two clinicians. All NLP code was written in the open-source programming language Python. Results: NLP was performed for 75,626 documents. Among 305 cancer patients who underwent gastrostomy, 75 (24.6%) were classified by NLP as having a palliative indication for the procedure compared to 72 patients (23.6%) classified by human coders. Manual chart abstraction took > 2,600 times longer than NLP (28 hrs vs. 38 seconds). NLP identified the correct patients with high precision (0.92) and recall (0.96). ACP was documented during the index admission for 89.3% of patients. PC was documented for 85.7% and hospice referral was documented for 64.3% of these patients with advanced cancer during the index hospitalization. NLP identified ACP, PC and hospice referral with high precision (0.88-1.0) and recall (0.92-1.0) compared to human coders. Median survival was 37 days following gastrostomy tube procedure. Conclusions: NLP can greatly speed the assessment of established palliative quality metrics with an accuracy approaching that of human coders. These methods offer opportunities for facilitate quality improvement in palliative care for patients with advanced cancer.

Although involvement of geriatricians in the care of older trauma patients is associated with changes in processes of care and improved outcomes, few geriatrician consultations were ordered on our service.Mandatory geriatric consults were initiated in September 2013 for all trauma patients 70 years and older admitted to our hospital. We prospectively collected data on patients admitted from October 2013 through September 2014 (postintervention) and compared their data with those of patients admitted from June 2011 through June 2012 (preintervention). We collected data on processes of care (DNR and do not intubate status, delirium, and referral for cognitive evaluation) and patient outcomes (mortality, readmission, and length of stay). Descriptive statistics and post-hoc power analyses were performed.There were 215 and 191 patients included in the preintervention and postintervention cohorts, respectively. After the intervention, geriatric consults increased from 3.26% to 100%. Patients with DNR and do not intubate status increased from 10.23% to 38.22% (p0.01). Referral for formal cognitive evaluation increased from 2.33% to 14.21% (p0.01) and delirium documentation increased from 31.16% to 38.22% (p = 0.14). In-hospital mortality and 30-day mortality in the pre- and postintervention periods were 9.30% vs 5.24% (p = 0.12) and 11.63% vs 6.81% (p = 0.10), respectively. Intensive care unit readmission rate was 8.26% preintervention and 1.96% postintervention (p = 0.06). There were no changes in 30-day hospital readmission and length of stay. Power analyses showed more patients were needed to show statistically significant outcomes.The initiation of mandatory geriatric consults on our trauma service was associated with improved advance care planning and increased multidisciplinary care. Ensuring involvement of geriatricians can aid in reducing adverse outcomes among geriatric trauma patients.

Appropriateness in surgical decision-making necessitates that surgical treatments are aligned with patients' goals and values for care. To arrive at informed decisions for surgery, patients must have an understanding of post-operative recovery, the impact on quality of life, and expected functional outcomes. This article describes an illustrative case of an older patient who experienced a decline in health, functional status, and quality of life in the months following a major surgical operation that was not clearly aligned with her personal goals and priorities. Palliative care needs that arose during the course of the patient's treatment are identified and described, revealing opportunities for better integration between palliative and postoperative care. A conceptual framework for measuring appropriateness in surgery, which incorporates patients' goals, values and preferences for medical treatments, is proposed.

Throughout history, changes in the relationship between a college and its students have reflected their respective changes in American society. Violence on campus has become a pressing problem for the modern university. To understand the current state of the mental health crisis on campus, one must understand the history of American higher education and student rights. This chapter will provide a review of mental health concerns on college campuses, describe key legal cases regarding the college’s role and responsibilities, frame the ethical issues surrounding patient privacy and public safety, and provide recommendations to colleges and mental health practitioners for managing the student in crisis.

Background Impaired capacity of patients necessitates the use of surrogates to make decisions on behalf of patients. Little is known about surrogate decision-making in the surgical intensive care unit, where the decline to critical illness is often unexpected. We sought to explore surrogate experiences with decision-making in the surgical intensive care unit. Methods This qualitative study was performed at 2 surgical intensive care units at a single, tertiary, academic hospital Surrogate decision-makers who had made a major medical decision for a patient in the surgical intensive care unit were identified and enrolled prospectively. Semistructured telephone interviews following an interview guide were conducted within 90 days after hospitalization until thematic saturation. Recordings were transcribed, coded inductively, and analyzed utilizing an interpretive phenomenologic approach. Results A major theme that emerged from interviews ( N = 19) centered on how participants perceived the surrogate role, which is best characterized by 2 archetypes: (1) Preferences Advocates, who focused on patients' values; and (2) Clinical Facilitators, who focused on patients' medical conditions. The primary archetype of each surrogate influenced how they defined their role and approached decisions. Preferences Advocates framed decisions in the context of patients’ values, whereas Clinical Facilitators emphasized the importance of clinical information. Conclusion The experiences of surrogates in the surgical intensive care unit are related to their understanding of what it means to be a surrogate and how they fulfill this role. Future work is needed to identify and manage the informational needs of surrogate decision-makers.

Health care disparities (differential access, care, and outcomes owing to factors such as race/ethnicity) are widely established. Compared with other groups, African American individuals have an increased mortality risk across multiple surgical procedures. Gender, sexual orientation, age, and geographic disparities are also well documented. Further research is needed to mitigate these inequities. To do so, the American College of Surgeons and the National Institutes of Health–National Institute of Minority Health and Disparities convened a research summit to develop a national surgical disparities research agenda and funding priorities. Sixty leading researchers and clinicians gathered in May 2015 for a 2-day summit. First, literature on surgical disparities was presented within 5 themes: (1) clinician, (2) patient, (3) systemic/access, (4) clinical quality, and (5) postoperative care and rehabilitation-related factors. These themes were identified via an exhaustive preconference literature review and guided the summit and its interactive consensus-building exercises. After individual thematic presentations, attendees contributed research priorities for each theme. Suggestions were collated, refined, and prioritized during the latter half of the summit. Breakout sessions yielded 3 to 5 top research priorities by theme. Overall priorities, regardless of theme, included improving patient-clinician communication, fostering engagement and community outreach by using technology, improving care at facilities with a higher proportion of minority patients, evaluating the longer-term effect of acute intervention and rehabilitation support, and improving patient centeredness by identifying expectations for recovery. The National Institutes of Health and American College of Surgeons Summit on Surgical Disparities Research succeeded in identifying a comprehensive research agenda. Future research and funding priorities should prioritize patients’ care perspectives, workforce diversification and training, and systematic evaluation of health technologies to reduce surgical disparities.

Importance Inpatient palliative care improves symptom management and patient satisfaction with care and reduces hospital costs in seriously ill patients. However, the role of palliative care in the treatment of patients undergoing surgery (surgical patients) remains poorly defined. Objective To characterize the content, design, and results of interventions to improve access to palliative care or the quality of palliative care for surgical patients. Evidence Review This systematic review was conducted according to PRIMSA guidelines. Articles were identified through searches of PubMed, PsycINFO, EMBASE, and CINAHL as well as manual review of references. Eligible articles included experimental, quasi-experimental, and observational studies published in English from January 1, 1994, through October 31, 2014, in which patient outcomes of palliative care interventions for adult surgical patients were reported. Data on the study setting, design, intervention, participants, and results were extracted from the final study set and analyzed from December 22, 2014, to February 7, 2015. Findings A total of 3838 abstracts were identified and screened by 2 reviewers, 77 articles were reviewed in full text, and 25 articles (22 unique interventions involving 8575 unique patients) met the study criteria. Interrater agreement was good (κ = 0.78). Nine single-institution retrospective cohort studies, 7 single-institution prospective cohort studies, 7 single-institution randomized clinical studies, and 2 multicenter randomized clinical studies were included. Nineteen of the 23 single-site studies were performed at academic hospitals. Given the heterogeneity of study methods and measures, meta-analysis was not possible. Preoperative decision-making interventions were associated with decreased mortality in 4 studies. Three studies reported improved quality of communication; 4, improved symptom management; and 7, decreased use of health care resources and decreased cost. However, many studies were small, performed in academic settings, and methodologically flawed and did not measure clinically meaningful outcomes. Conclusions and Relevance The sparse evidence regarding interventions to introduce or improve palliative care for surgical patients is further limited by methodologic flaws. Rigorous evaluations of standardized palliative care interventions measuring meaningful patient outcomes are needed.