Integrating Surgical Palliative Care Into the Full Spectrum of Medical Education

In 2005, the American College of Surgeons called upon surgeons to provide high quality palliative care to all surgical patients with serious illnesses, not just those approaching the end of their life. ¹ This care includes, but is not limited to, guiding difficult decisions, defining goals of care, explaining the impact of serious surgical problems on a patient’s quality of life and facilitating transitions to end-of-life care.^2,3 The combination of serious illness communication and symptom management provided by the treating surgeon is known as primary palliative care and is increasingly being viewed as an essential part of quality surgical care.^4-6 The sheer volume of medical knowledge to master in Undergraduate and Graduate Medical Education (UME and GME, respectively) coupled with a pivot to virtual and asynchronous didactics makes instruction in principles of primary palliative care increasingly challenging to provide.

This article describes our institutional approach to incorporating surgical palliative care education into the UME, GME, and Continuing Medical Education (CME) space, as a model to help guide similarly interested educators.

We first began with a general educational needs assessment, building on national calls for increasing the quality and quantity of surgical palliative care and several published needs assessments describing the vast educational need.^7-10 While single institutions have reported on initial approaches to serious illness communication and there are a variety of asynchronous educational options available, including the American College of Surgeons Residents Guide to Surgical Palliative Care and the Surgical Council on Resident Education (SCORE)® curriculum, the need vastly outstrips available educational options.^11-14

At our institution, a specific educational needs assessment demonstrated that only slightly more than half of the surgical residents felt comfortable leading goals of care conversations, transitioning patients to comfort focused care and delivering bad news. In support of this, over 90% of the surgical faculty felt that chief residents needed additional training in palliative care principles and 85% of the surgical residents wanted a formal palliative curriculum. ⁸ These data were obtained in spite of an already established Ethics and Professionalism Curriculum, which consisted of 8 hours of content per post-graduate year. We therefore aimed to improve our surgical palliative care education, building from the base of this curricula. Our existing curriculum included current surgical literature, case studies, and focused discussions on topics including informed consent, truth-telling and disclosing medical error, professional obligations, maintenance of competence, self-regulation, delivering difficult news, end-of-life decisions, surrogate decision making, advanced directives, shared decision making, maintenance of hope, conflict among specialists, and the effect of lawsuits on surgeons. We grew from here.

Our approach to surgical palliative care curriculum development was focused across the UME, GME, and CME spectrum and began at our first main interaction with medical students. In 2019, we developed a medical student surgical palliative care curriculum for our 3rd year medical students. This was integrated into the surgical clerkship and included four one-hour long sessions: ¹ an introductory lecture on the intersection between surgery and palliative care, ² an didactic and simulation based introduction to surgical consent and capacity assessment, ³ a mid-clerkship session dedicated to serious illness communication, and debriefing after a major complication or patient death, and ⁴ a wrap-up session bringing these principles together. Asynchronous modules during the clerkship include readings and responses on: informed consent, surrogate decision making, and ethical issues at the end of life.

We next focused on the GME curriculum development with a 4 week surgical palliative care rotation for categorical general surgery PGY-1 residents. ¹⁵ Each categorical intern spends time on the interdisciplinary inpatient consultative palliative care service as well as time in the outpatient clinic and in the operating room with one of the authors (TS) who is board certified in General Surgery as well as Hospice and Palliative Medicine (HPM). This focus on surgical palliative care allows the interns to build their clinical exposure to the fundamental aspects of palliative care as they pertain to surgical practice across the continuum of healthcare settings. Communication around serious illness, complicated decision making, complex pain and symptom management, withdrawal of life-sustaining treatment, and end-of-life care are all integral parts of the rotation. The rotation has been very favorably received by the residents, with 92% describing the rotation as “extremely valuable.” They were much more comfortable treating nausea, pain, and dyspnea upon completion of the rotation, and the impact on the culture of the department has been tremendous as well. The structured approach we took to designing this rotation is provided; including goals and objectives and the weekly schedule, make this rotation easily replicable in other residency programs.

In 2022, we developed and implemented a Mastering Tough Conversations course, powered by Vital Talk©. This included two 2-hour sessions with simulated patients in the spring of the intern year, followed by two 2-hour sessions in the fall of the PGY-2 year. These focused sessions reinforce and extend principles from the surgical palliative care rotation. Initial feedback from the residents has been very positive and enthusiastic. These principles will again be reinforced and extended during two 2-hour sessions with simulated patients during the PGY-4 year.

Our GME focus on surgical palliative care extends into fellowship training, as our surgical critical care fellows can elect to spend 2 weeks on the inpatient Palliative Care consult team, working closely with the surgical Palliative Care attending. We also hold a difficult conversations dinner for these fellows, where guided reading underlies an in-depth discussion of the principles of serious illness communication. These principles are put into practice with scheduled and impromptu debriefings in the Intensive Care Unit (ICU) after major complications, deaths, and other high-stress events as well as entrustment of critical care fellows to lead high stakes family meetings. Death debriefs outside of the ICU are also routine and similarly facilitated.

We have extended our educational reach into the CME domain with routine Department of Surgery Death Rounds. ¹⁶ Scheduled in lieu of departmental Grand Rounds and distinct in focus from Morbidity and Mortality (M&M) review, these are a specific time where deaths that are difficult for non-medical (emotional, psychological, social etc.) reasons are reviewed and discussed in a facilitated fashion. There has been outstanding participation from faculty and principles introduced and reinforced during Death Rounds have had a profound impact on departmental morale, such as improving wellbeing and decreasing physician burnout among other reported benefits. In addition, this program has been associated with the routine and intentional embedding of palliative care concepts into our department M&M conference. The Department of Surgery Peer Support program is robust and focuses on maintaining a culture of wellness and concern for others’ wellbeing in the face of difficult patient outcomes. Surgical Palliative Care Journal Club, held quarterly, has allowed for the dissemination of the latest pertinent literature across specialties in the Department of Surgery.

The next step in a full spectrum surgical palliative care curriculum is a surgical palliative care curriculum that is fully integrated with the 5 clinical years of surgical residency. The proposed educational goals and year-specific objectives as outlined in Tables 1 and 2. In the near future, we hope to establish a Surgical Palliative Care Service, a hybrid of the Emergency General Surgery and the Inpatient Palliative Care Services, where both non-operative and interventional consultations will be available from the same team. The horizon also holds the potential for a dedicated track for surgeons in our Palliative Care Fellowship, as well as the development of an accelerated path to board certification in HPM, a variant of the Experiential Pathway to HPM board eligibility for practicing surgeons.

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Table 1.

Curriculum Goals for an Integrated Surgical Palliative Care Focus.

5-year curriculum goals
Cognitive	• Describe to patients and colleagues the role of different advanced care planning documents (POLST, advanced directive etc.) in their surgical practice
	• Describe the unique skill sets of subspecialty palliative care providers
	• Identify the role that the subspecialty palliative care service will have in their surgical practice
	• Explain different approaches of symptom management for end-of-life care
	• Discuss ethical considerations as related to surgical palliative care
Psychomotor	• Demonstrate primary palliative care skills in the surgical setting
	• Practice shared decision making with interdisciplinary team
	• Lead a goals of care meeting in the pre-operative and ICU settings
	• Transition a patient from recovery-focused care to comfort-measures-only care and assure their comfort at the end of life
	• Express empathic communication
	• Evaluate their own risk assessment and prognostication skills
Affective	• Arrange a debriefing session with learners and direct team members following a difficult patient outcome, providing support for their team and themselves
	• Reflect on personal and professional growth as related to longitudinal experience with surgical palliative care
	• Integrate wellness practices to mitigate burnout and to build emotional resilience, introspection, and awareness following difficult patient outcomes and discussions

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Table 2.

Surgical Palliative Care Educational Objectives, Divided by Appropriate Training Level.

PGY-1 learning objectives
Cognitive	• Define differences between documents related to goals of care, such as advanced directive, POLST, etc
	• Explain patient capacity and the role of the surrogate decision maker when patient is unable to make medical decisions
	• Identify the need for child life specialist in the care of patient’s family
	• Identify patients who would benefit from primary palliative care assessment
Psychomotor	• Demonstrate the best case/worst case communication tool in the pre-operative setting and identify when this tool is unable to be utilized
	• Follow a structured approach (eg, GUIDE and REMAP mnemonic) for planning family meetings
	• Demonstrate use of language that is accessible to patient and family
	• Assess capacity of the patient and/or surrogate decision maker
Affective	• Prioritize patient-centered care in code discussions

PGY 2-3 learning objectives
Cognitive	• Identify patients who would benefit from subspecialty palliative care consult
	• Distinguish the different roles of subspecialty teams as related to end-of-life care, such as subspecialty palliative care, hospice, pain management, etc
	• Identify their own limitations in primary palliative care delivery and the need for subspecialty palliative care consultation
Psychomotor	• Demonstrate the best case/worst case communication tool in the ICU setting and identify when this tool is unable to be utilized
	• Create the proper environment (physical, emotional, and intellectual) for palliative care discussions in the ICU, inpatient ward, and outpatient clinic
	• Communicate early and frequently with patient and/or patient’s family support system regarding clinical status changes and goals of care
	• Participate thoughtfully in palliative care discussions, including demonstrating active listening skills and empathic attendance to emotion
	• Recognize reception of information by patient and family, shifting meeting tone, and structure as needed
	• Deliver unexpected news to patient and family in a compassionate way
	• Work within interdisciplinary teams to understand a patient’s goals and provide goal concordant care
Affective	• Attend to individual spirituality in palliative care discussions
	• Verbalize how unconscious bias may impact patient care
	• Align patient & provider expectations of realistic outcomes
	• Prioritize the establishment of patient–provider relationship with value-congruent surgical planning

PGY 4-5 learning objectives
Cognitive	• Explain the similarities and differences between treatment plans and how they are concordant with patient’s underlying values
	• Identify when psychosocial, spiritual, or emotional care is lacking in patient’s current care
	• Describe different approaches of symptom management for end-of-life care
	• Describe the various components of a multi-disciplinary debriefing following a patient death
Psychomotor	• Initiate palliative care discussion with patient and/or family
	• Lead palliative care discussions with empathy and efficiency in the pre-operative and ICU settings
	• Identify examples of positive and negative communication styles in goals of care discussions
	• Explain all aspects of care—not just surgical intervention, but also expectations of possible postoperative outcomes and alternatives as related to independence, ADLs, quality of life, physical and emotional suffering, loss of physical and cognitive function, financial loss, etc.
	• Determine when a time-limited trial may be warranted, and institute time-limited trial once understood by and agreed upon by family
	• Make value-congruent treatment recommendations
	• Demonstrate common interventions for symptom control as related to end-of-life care and recognize when a specialty care provider should be consulted for complex symptom control
	• Lead a multi-disciplinary debriefing following a difficult patient outcome
Affective	• Assess provider’s uneasiness when final decision is not consistent with provider goals, but consistent with patient values
	• Assess their own prognostication skills
	• Reflect on their own wellness practices and available support

Since the number of surgeons in the United States who are board certified in both Surgery and HPM is well under 100, the development of a national surgical palliative care curriculum is essential. This is a focus of numerous national committees and we anticipate significant progress on a national level in the coming year. As national guidelines and curricula develop, we hope that our approach to the continuum of UME, GME, and CME surgical palliative care education can be a model for implementation across the country.