Palliative care referrals in patients with advanced malignancies and the benefits of early showering in patients following cardiac surgery

This issue of the Annals of Palliative Medicine marks the return of the Message from the Editor-in-Chief. This standing column first appeared in the April 2014 issue of Annals of Palliative Medicine (1). Over the past 2 years, however, with a need to focus on numerous enhancements of the journal—including the initiation of reporting guidelines checklists, increased transparency of the peer review process, revamping of data sharing and conflict of interest policies, and partnership with Publons (2)—along with a transition of the journal to become a monthly publication (3), the Message from the Editor-in-Chief was temporarily halted.

Moving forward, the Message from the Editor-in-Chief will resume in earnest, and its content will relate to the prior month’s Annals of Palliative Medicine issue. For a focused issue or special series of articles within an issue of Annals of Palliative Medicine, the Message from the Editor-in-Chief will summarize the whole issue or the collection of articles, respectively. For issues of Annals of Palliative Medicine comprised of free articles without a focused issue or special series, such as the August 2022 issue, one or a few notable articles will be selected for a more detailed editorial commentary. The context of the articles will be exemplified for readers, and the importance of the studies and the roles that they play in changing or reaffirming the standard of care in a variety of fields of palliative medicine will be detailed.

Among the 18 original articles in the August 2022 issue of Annals of Palliative Medicine, two will be highlighted in this September 2022 Message from the Editor-in-Chief.

In the first, Chen et al. reported on longitudinal symptoms and temporal trends in palliative care in patients with metastatic cancer near the end of their lives. They performed an institutional analysis of 135 patients with metastatic cancer who received palliative radiotherapy and found that pain significantly predicted for patients receiving earlier specialty palliative care, whereas patients who had received at least two prior chemotherapy regimens were less likely to have received earlier specialty palliative care. In fact, specialty palliative care was most often engaged to address pain and also to discuss goals of care. Notably, 9.6% of patients received palliative radiation therapy, chemotherapy, or surgery within 30 days of death. This is in keeping with discordant expectations about prognosis commonly exhibited between clinicians and patients or their surrogate decision makers (4,5), and also that clinicians often overestimating the life expectancy of their cancer patients (6). Furthermore, nearly half of palliative radiotherapy visits and three-quarters of specialty palliative care visits among the cohort assessed by Chen et al. occurred in the last quarter of life from metastatic diagnosis to death.

This analysis is both quite revealing and novel, as it is the first study to assess longitudinal patterns of delivering palliative radiotherapy and specialty palliative care, as well as the distribution of symptoms over relative survival time from metastatic diagnosis. The investigators call for multidisciplinary efforts to manage longitudinal symptoms and offer goal-concordant care. They recommend clinicians—including radiation oncologists—initiate referrals to specialty palliative care at the time of palliative radiation oncology consultation. For too long, clinicians as well as patients and their families, have associated palliative care referrals with end-of-life or hospice care. This misperception may account, at least in part, for the delay in earlier initiation of specialty palliative care in this study (7), even despite the study team at Dana-Farber Cancer Institute/Brigham and Women’s Cancer Center having one of the strongest palliative care programs worldwide.

Early initiative of palliative care, however, is often critical for patients with metastatic cancer and has been associated with less use of chemotherapy in the final 2 months of life (8), improved quality of life and symptom burden (9,10), and even better overall survival (11). Early initiative of palliative care cannot be underscored enough and has been the subject of a prior focused issue within Annals of Palliative Medicine (12).

In an editorial in the same August issue of Annals of Palliative Medicine, Chan et al. similarly called on radiation oncologists to deliver general palliative care and to make referrals to supportive or specialty palliative care, while also managing patient symptom burden and delivering palliative radiation therapy. They cite structural inequities and lack of service models and training as reasons for the limited number of radiation oncology programs that have structured palliative care programs. It is encouraging, however, that palliative care is increasingly thought of as one of the most important clinical competencies for training in radiation oncology residency programs in the United States (13).

Next, Yoo and colleagues performed an institutional prospective observational study of 100 cardiac surgery patients who underwent early postoperative showers after drain removed. Patients showered at a mean of 6.0 days following sternotomy or minimally invasive surgery. In this cohort, no wound dehiscence, superficial wound infections, or deep wound infections were observed, and patient satisfaction was quantitatively assessed as high with early showering. These findings are noteworthy since surgical site infections are particularly morbid complications of cardiothoracic surgery that compromise quality of life, add costs of therapy, and can even be fatal when associated with mediastinitis (14,15).

While the findings of Yoo et al. are in keeping with prior reports (16-20) and even guidelines (21) supporting early initiation of postoperative showering, cardiothoracic surgeons still commonly advise patients to keep their wounds dry at least until suture removal and believe that early postoperative showering can increase the risk for infection due to direct wound opening or to residual moisture to enhance pathogen proliferation on the surgical site. Akin to the previous concern for the limited referrals to early palliative care despite its increasingly well-established benefits, there is a similar disconnect with many surgeons recommending against early showering despite its increasingly well demonstrated benefits and lack of additive infection risk. In fact, a recent questionnaire demonstrated that most surgeons recommended against water contact before suture removal (22).

As such, the study by Yoo et al. adds to the growing body of literature that is hoped to change practice patterns among surgeons. The authors call for future randomized trials assessing the safety and benefits of early showering and for further study to evaluate the impact of different skin closure techniques on wound complication rates after cardiac surgery.

In an Editorial in the same August issue of Annals of Palliative Medicine, Gupta and Aliter related the consideration of earlier initiation of showers to the consistent evolution of enhancing patient comfort and facilitating earlier recovery following surgical procedures. They stated that although limited, the sum of the evidence—which has now been bolstered significantly by findings by Yoo and colleagues—is conclusive enough to allow cardiac surgery patients to shower earlier, and Gupta and Aliter encouraged their surgical colleagues to evaluate their current postoperative practices and adopt evidence-based changes of earlier showering to improve patient comfort and potentially even outcomes.

Tsagkaris and Papadakis also wrote an editorial on the findings by Yoo and colleagues. They chronicled the identification and now more widespread use of early mobilization after cardiac surgery to improve patient satisfaction and reduce overall healthcare costs (23), and similar to early mobilization, they related early initiation of showering with empowering patients in their postoperative recovery.

Acknowledgments

Funding: None.

Footnote

Provenance and Peer Review: This article was commissioned by the editorial office, Annals of Palliative Medicine. The article did not undergo external peer review.

Conflicts of Interest: The author has completed the ICMJE uniform disclosure form (available at https://apm.amegroups.com/article/view/10.21037/apm-22-1080/coif). The author serves as the Editor-in-Chief of Annals of Palliative Medicine. The author has no other conflicts of interest to declare.

Ethical Statement: The author is accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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