Improving Perioperative Communication in Urologic Serious Illness: A Team Approach For Goals of Care and Surgery

Outcomes 1. Identify opportunities to improve perioperative communication about goals for patients with urologic serious illness.2. Understand the value of having both Palliative Care Specialists and Urologists involved in preoperative conversations about patient goals. Key Message A joint Urology-Palliative Care team approach to navigating patient goals is warranted in advance of surgery for patients with urologic serious illness. In coordination, Urologists and PC can offer complementary contributions to different parts of a goals of care conversations, covering both goals of care generally and developing shared understanding of risks and realistic expectations of what surgery can achieve. Introduction Care for urologic serious illness often includes surgery; preoperative shared decision making about patient goals is often inadequately implemented in surgical settings. Objective To understand perspectives on improving perioperative communication about goals for patients facing urologic serious illness. Methods We conducted 37 semi-structured interviews with Palliative Care Physicians (PC) (11), Urologists (13) and interdisciplinary clinicians (13) at fourteen geographically distributed Veteran Health Administration (VHA) sites. The analytic approach relied on content analysis with dual review; analysis is conducted separately by provider type and triangulated. Results 1) In existing pre-operative workflows: “patients are not [always] aware that we might be able to palliate their symptoms without surgery” (URO). 2) Goal of surgery is often something patients really need help understanding, e.g. “It's gonna help temporarily, but it's not gonna help long term” (PC). 3) PC is not in the position to have the part of the goal of care conversation that clarifies the goal of the surgery: “it's very hard for non-surgeon to have a robust goals of care discussion with the patient who's co-managed with surgery unless surgery is able to give you a sense of what to expect.” (PC) 4) A team approach to clarifying and navigating patient goals is warranted: “how do we work together to sort of think about prognosis, how to plan ahead for care after the surgery and then setting sort of real realistic expectations and goals for after the surgery?”(PC). 5) In coordination, Urologists and PC can offer complementary contributions to different parts of a goals of care conversation: “the interventionists would better know how effective the intervention is going to be, but PC probably has much better perspective on how the patient is doing overall.” (URO) Conclusion Patients will benefit from a urology-PC team approach to clarifying goals of care and surgery. Keywords Shared Decision Making / Advance Care Planning / Surgical / Palliative Care