Palliative care interventions for surgical patients: a narrative review

Introduction

Surgeons play an integral role in perioperative pain and symptom management, supporting patients through post-operative complications, and navigating end-of-life (EOL) decision making (1). Current literature has established that palliative care interventions reduce healthcare utilization (2-8), mitigate symptoms, improve EOL care planning (3,4,6), and allow for improved physician and patient communication among surgical patients with serious illness (9,10). Despite these known benefits, routine implementation of surgical palliative care is limited, and the body of evidence to support routine use of palliative care interventions for surgical patients remains sparse (11).

In 2003, the American College of Surgeons proposed seven areas of study in the realm of palliative care decision making for surgical patients: surgical decision making, EOL decision making, patient-centered decision making, symptom management, processes of care, communication, and surgical education regarding palliative care (12). Using these domains as a framework to categorize existing publications, Lilley et al. published the first systematic review of palliative care interventions for surgical patients in 2016. Twenty-five articles met criteria for inclusion, however most of the studies were of low quality. The authors concluded that additional research was needed in order to clarify which surgical patient populations most benefit from palliative care interventions, and how such interventions should be most effectively employed (13).

In 2018, acknowledging a need for focused research goals as well as the documented knowledge gaps in palliative care research for surgical patients, Lilley et al. published a national agenda to delineate priority areas for palliative care research in surgical patient populations. This agenda established three foundational domains for future study: (I) measuring outcomes that matter to patients; (II) communication and decision making; (III) delivery of palliative care to surgical patients (11). With these consensus research directives, we undertook the task of updating the literature and summarizing recent contributions in the space of surgical palliative care since the first systematic review published in 2016 (14). We present the following article in accordance with the Narrative Review reporting checklist (available at https://apm.amegroups.com/article/view/10.21037/apm-22-770/rc).

Methods

We performed a literature search for publications circulated between 01/01/2016 and 21/02/2022 that studied palliative care interventions for surgical patients (Table 1). Citations were pulled from the following databases: PubMed, EMBASE, PsychINFO, and CINAHL. There were no language limitations for full-text publications; perspective pieces, review articles, and scientific meeting abstracts were included in the initial review. Additional articles were included following a manual review of citations and publications from the Annals of Palliative Medicine special series on Palliative Care and Surgery. Given our limited scope of knowledge in other surgical subspecialties and indications for palliative care interventions outside our area of expertise, this review only included publications focusing on adult general surgical patients receiving palliative care interventions. Studies describing the experience of palliative care for pediatric patients with heart failure, patients with ear, nose, and throat-related disease, patients receiving cardiac surgery, patients receiving urological care, and patients receiving left ventricular assist devices were excluded from the analysis. Included and excluded studies were reviewed by two authors, KK and IF, for analysis and discussion. Once the manuscript was complete, the narrative review reporting checklist was saved and finalized.

Results

A total of 3,258 unique articles were identified through the PubMed, EMBASE, PsychINFO, and CINAHL databases, and an additional eight studies were identified from manual review (Figure 1). Three thousand and forty-three articles were excluded based on title review alone. Two hundred and fifteen abstracts were assessed in full and 22 articles were included in the final narrative review (Table 2). Of the 215 abstracts assessed, 88 were focused on palliative surgical interventions, 40 were perspective/opinion pieces or reviews, and 23 were retrospective series exploring (I) rates of palliative care consultation; (II) triggers for palliative care consultation; or (III) documentation of advanced care planning (ACP). Six reported palliative care education interventions for surgical providers and three publications were pre-study plans for ongoing trials. Eleven publications were available only as scientific meeting abstracts.

Figure 1 Flowchart of literature review strategies.

All studies included in the final review were mapped to the 2018 national “Priority Areas of Research” for palliative care for surgical patients (Figure 2) (11). As previously described, this publication laid out three broad domains for palliative care research for surgical patients: (I) measuring outcomes that matter to patients; (II) communication and decision making; (III) delivery of palliative care to surgical patients. These three domains were further subdivided into eight sub-domains: ‘Defining Outcomes that Patients Value’, ‘Measures to Evaluate High-quality Palliative Care in Surgery’, ‘Aligning Surgical Treatments with Patient-oriented Outcomes’, ‘Preoperative Advance Care Planning’, ‘Decision Making After Postoperative Complications or Critical Illness’, ‘Integrating Palliative Care Principles into Routine Surgical Practice’, ‘Developing Scalable Models of Primary Palliative Care Delivery for Surgical Patients’, and ‘Identifying Patients Who Would Benefit from Palliative Care Specialist Consultation’. The goal of categorizing the publications according to each Priority Area was to draw attention to the remaining knowledge gaps as well as to areas that had been satisfactorily addressed. We present the results below.

Figure 2 Included studies, categorized according to 2018 Priority Area from Palliative Care in Surgery: Defining the Research Priorities (14).

Measuring outcomes that matter to patients

Defining outcomes that patients value

Two publications set out to evaluate the outcomes that matter most to surgical patients. Nabozny et al. convened focus groups with community-dwelling adults over age 60 to facilitate conversation around hypothetical high-stakes surgical decisions. The study found that seniors have strong fears that “living in a nursing home would lead to personal suffering, loneliness, depression and a downward trajectory toward the end of life” (15). Despite these deeply held worries, when presented with a hypothetical emergency surgical scenario, many participants favored surgical intervention, even if that decision yielded a feared or unwanted outcome. Bergenholtz et al. confirmed these findings (16). In this study, the coauthors characterized the priorities and preferences of medical and surgical patients who were in the palliative phase of their disease trajectory for diagnoses including cirrhosis, pancreatic cancer, colon cancer, renal failure, heart failure, and chronic obstructive pulmonary disease (COPD) (16). The authors found that patients were more concerned about the daily physical and social toll of advanced illness than about its implications on EOL planning. Similar to the study of Nabozny et al., the authors found vast diversity in patient and family expectations regarding the pertinence of in-hospital EOL discussions. For some, EOL considerations were noted to be a “sensitive and personal matter… rather than something they expected to be addressed in a hospital setting” (16). Others, conversely, expected EOL discussions to be initiated by hospital staff. Several were astonished that non-intervention was an option; these patients felt that “declining any life prolonging measure was [equivalent to] evading responsibility to live” (15). Other participants in the focus group setting felt that surgical intervention was not worthwhile if suffering was predicted; these people embraced the opportunity to dictate how they wished to die.

Measures to evaluate high-quality palliative care in surgery

Five studies discussed improvement to the delivery and measurement of high-quality palliative care for surgical patients. Lilley et al. (11) outlined three national priority areas for research in palliative care for surgical patients (as above). Yefimova et al. characterized EOL experiences of veterans who died within 90 days of a high-risk surgical operation by reporting family ratings of overall care in the last month of life (17). The researchers found that families of decedents who received palliative care were more likely to rate communication, support, and overall care at the EOL as ‘excellent’ compared with surgical patients who did not receive palliative care. Overall, the study found that of veterans who died after surgery, only 5.6% received a pre-operative palliative care consultation (17).

The three additional studies explored the use of natural language processing (NLP) to support the measurement and documentation of goals of care conversations, code status discussions, palliative care consultations and hospice eligibility assessment with a further goal of measuring goal-concordant treatment decisions (18-20). NLP identified palliative care delivery in 33% of admissions, as compared to 8% recorded through administrative coding, and was completed 50 times faster than manual review (18). When applied to surgical oncology patients, NLP was highly sensitive and specific relative to manual coding, and was 2,600 times faster in identifying patients undergoing palliative gastrostomy tube placement (20). Further work remains to enable timely assessment of palliative care process measures with the assistance of NLP technology.

Communication and decision making

Aligning surgical treatments with patient-oriented outcomes

No studies reported on best practices for aligning surgical treatments with patient-oriented outcomes.

Preoperative advance care planning

Two publications explored perioperative ACP (21,22). Robbins et al. summarized a retrospective cohort study of 29,132 patients undergoing inpatient elective procedures and demonstrated that preoperative palliative care consultation was associated with a higher likelihood of pre-operative completion of ACP paperwork (22). Despite these encouraging findings, the authors concluded that additional data is needed to optimize pre-operative screening metrics and clarify measures of ‘success’ in preoperative ACP in the surgical patient population. Aslakson et al. implemented ACP in the clinical setting and found that ACP educational videos could be safely and logistically integrated into a pre-operative surgical oncology clinic visit. Though viewing the ACP video did not impact the pre-operative surgical discussion in a substantive manner, patients found it to be helpful (21).

Decision making after postoperative complications or critical illness

A single novel study characterized an emerging model of unexpected, catastrophic, and often incapacitating illness: Sudden Advanced Illness (SAI) (23). The authors outlined this cognitive framework to help clinicians and families navigate unanticipated and devastating illness in the face of prognostic uncertainty and extreme grief (23). The authors anticipate that use of the SAI cognitive framework will assist medical providers of all types, including surgeons and palliative medicine specialists, in the care of patients diagnosed with unexpected, overwhelming, and emotionally-laden ailments.

Delivery of palliative care to surgical patients

Integrating palliative care principles into routine surgical practice

Twelve manuscripts explored the delivery of palliative care to surgical patients. Of these, nine fell into the domain of integrating palliative care principles into routine surgical practice. A systematic review and mixed methods analysis evaluated 2,589 publications characterizing the role of U.S. surgeons in the provision of palliative care and found that surgeons have limited knowledge of and comfort introducing palliative care concepts to their patients (24). Per Suwanabol et al., “a persistent theme across studies was the difficulty of communicating realistic estimates of risk and benefit to patients and families who were struggling with decision making for high-risk surgery and surgery at the end of life” (24). Many studies highlighted the prevalence of surgeon discomfort with communicating to patients and families regarding prognosis and goals of care. Bateni et al. confirmed, as others have, that surgeons have fewer hours of palliative care training compared to other specialists (25) and Marterre et al. offered a synthesis of core competencies for surgeons interested in gaining palliative care skills and knowledge (26). In order to facilitate the integration of palliative care principles into routine use by surgeons, Lee et al. convened a 12-member expert advisory panel to develop a serious illness definition for surgical patients (27). A consensus definition was reached and includes the following variables: American Society of Anesthesiology (ASA) risk score, age, presence of absence of advanced cancer, pulmonary disease, heart disease, cirrhosis, renal disease, frailty, severe traumatic injury, and place of residence. A consensus definition of serious illness in surgery offers clinical guidance to practicing providers, and facilitates the uniform inclusion of surgical patient populations in studies focused on palliative care processes.

Two publications studied communication approaches for surgical patient populations facing emergent or high-risk surgeries. The first analyzed use of the Best Case/Worst Case (BC/WC) tool to establish goal-concordant care in high-risk surgical patients (28). The researchers found that physician-patient dyads using this framework were better equipped to navigate complex surgical decision-making (28). Patients and families, in particular, felt that the use of the BC/WC tool helped surgeons clearly outline treatment choices and prepare for possible adverse events (28). The second publication focused on pre-operative communication and defined 9 components of communication with elderly patients facing surgical emergencies: (I) discussing a prognosis, (II) creating a personal connection with the patient, (III) contextualizing the acute problem in the greater scheme of the patient’s overall illness, (IV) creating a common understanding of the patient’s condition, (V) creating space for silence to cope with emotion, (VI) identifying surgical and palliative treatment plans, (VII) identifying patient priorities and goals, (VIII) recommending a care plan, and (IX) encouraging ongoing support for the patient and family (29). The aim of this structured approach to communication is to ensure goal-concordant care as well as candid discussion of likely outcomes.

The sustainability of palliative care principles in the surgical intensive care unit is discussed in an article by Cralley et al. This publication confirms prior conclusions that interventions such as implementing standardized palliative care documentation in the electronic medical record, integrating palliative care goals in daily rounding ICU checklists, and offering special education about palliative care is associated with increased identification of surrogate decision makers in the surgical ICU (30). The authors highlight the importance of a strong working relationship between surgeons and palliative care clinicians as one of the keys to sustained success.

Regarding access to care, Lee et al. characterized barriers to palliative care referral for surgical patients in the state of Michigan (31). They found four main barriers as perceived by surgical residents at all stages of training: (I) difficulties with prognostication; (II) communication barriers not only with patients and families, but also with other providers; (III) respect for the surgical hierarchy and getting permission from superiors; and (IV) surgeon mentality including both unrealistic hope that patients will recover, and that most problems are ‘fixable’. More work is required to surmount these barriers and to characterize the existing problems that limit access to palliative care for surgical patients.

In their 2022 paper, Rowe et al. review disparities in access to specialty palliative care services among racial/ethnic and rural populations (32). The authors offer an overview of provider, institutional, and geographic factors that influence access to care and health resources. Further research is needed to clarify the extent of the current disparities in access to palliative care and how such disparities might be mitigated in order to offer all patients appropriate and indicated consultations, referrals, and resources to palliative therapy in the setting of advanced illness.

Developing scalable models of primary palliative care delivery for surgical patients

Two studies discuss scalable models of primary palliative care delivery for surgical patients. Lee et al. performed a systematic review of quality indicators in surgical palliative care and generated guidelines for palliative care quality in surgical patients (33). The literature review identified and abstracted quality indicators from patient populations ranging from patients with advanced cancer, vulnerable elders, critically ill patients admitted to the ICU, and geriatric and trauma patients. Ultimately, their work to catalog quality indicators for surgical palliative care was published in the Annals of Surgery as an original article (34). This foundational work is crucial to ensuring that palliative care interventions for surgical patients can be tracked and monitored and analyzed over time.

Identifying patients who would benefit from palliative care specialist consultation

Given the considerable number of publications on the subject of ‘triggers’ for palliative care consultation, we adopted the Lilley et al. inclusion criteria which indicated that a patient-oriented outcome must be measured for review and inclusion in this analysis (13). Only one study met these criteria and is included for discussion. The authors of the included publication found that inpatient palliative care consultation for patients with moderate to severe trauma reduced healthcare utilization at the EOL (35).

Discussion

The body of literature exploring the implementation of palliative care for surgical patients remains limited in scope. This analysis has identified 22 manuscripts published since 2016 that have studied the implementation of palliative care interventions for seriously ill surgical patients. We categorized our findings according to the 2018 priority guidelines for research in palliative care for surgical patients (Figure 2) and found that although progress has been made over the last six years, additional work is still needed to standardize and refine the delivery of palliative care interventions to surgical patients.

The majority of the publications circulated since 2016 focus on the mechanisms of palliative care delivery to surgical patients. As a whole, these projects emphasize the importance of implementing standardized palliative care documentation in electronic medical records, offer recommendations on how to define critical illness, and provide guidelines on how to engage in conversations centered around palliative care. Progress towards measuring the success of studied interventions is evolving with the implementation and use of NLP. The remaining gap in the literature centers around the ideal timepoint to incorporate palliative care principles into the care of surgical patients, and whether palliative care specialists or surgeons would be better equipped to offer this type of care for a particular patient.

The projects exploring the outcomes most valued by patients found that hospitalized patients with serious illness fear functional debility and experience more unease about burdening loved ones than about controlling decisions about their medical care. These findings support previous research in other clinical contexts (36,37). Additional progress is needed to help surgeons and palliative care providers tailor value-concordant recommendations that focus on the day-to-day impact of potential interventions for surgical patients facing serious illness, and to recognize that patients facing high-stakes surgical decisions are prone to paradoxical decision making.

Contributions to the literature in the realm of communication and decision making were quite limited, with only three new publications circulated since 2016. These projects outlined cognitive frameworks for navigating unanticipated critical illness and demonstrated the importance and intricacies of initiating perioperative ACP conversations with seriously ill surgical patients. Additional work is needed to document outcomes for surgical patients who have completed preoperative ACP versus those that have not, and if preoperative ACP impacted the timeliness or quality of palliative care discussions.

No publications identified in this narrative review offer insight into the current practice of aligning surgical treatments with patient-oriented outcomes, the epitome of palliative care research. In the presented studies, palliative care or hospice referral/consultation was viewed as ‘success’ without confirming concordance of treatment goals. As such, additional inquiry is needed to explore reliable mechanisms to facilitate goal-concordant care for surgical patients. As the data supporting palliative care interventions for surgical patients grows, albeit slowly, and as multidisciplinary models of patient care continue to become the norm, we are hopeful that surgeons and palliative care specialists can continue to foster both clinical and research relationships. Surgeons and palliative care specialists can find common ground in supporting patient autonomy while offering realistic hope regarding anticipated clinical outcomes.

As with any narrative review, our study has limitations including potentially missed publications despite a comprehensive search of multiple databases and citation searching with manual review of select high-yield journals. The inclusion of expert guidance statements (27,29) helps to establish benchmarks for additional research in this area but is not itself objectively evidence-based. Bias (38) and quality ratings of the included studies were not formally assessed and had the potential to influence the conclusions of the studies included in this analysis.

Conclusions

As therapies to support seriously ill surgical patients continues to evolve, it is essential to establish guidelines and best-practices to achieve goal-concordant care. Despite calls for continued research in this patient population, the existing body of literature remains lacking and more work is needed to clarify which surgical patient populations benefit most from palliative care interventions, and how such interventions can be most effectively employed.

Acknowledgments

Funding: None.

Footnote

Reporting Checklist: The authors have completed the Narrative Review reporting checklist. Available at https://apm.amegroups.com/article/view/10.21037/apm-22-770/rc

Peer Review File: Available at https://apm.amegroups.com/article/view/10.21037/apm-22-770/prf

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://apm.amegroups.com/article/view/10.21037/apm-22-770/coif). FMJ serves as an unpaid Editorial Board Member of the Annals of Palliative Medicine from February 2022 to January 2024.The other authors have no conflicts of interest to declare.

Ethical Statement: The authors are 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/.

References

1. Lilley EJ, Cooper Z. The High Burden of Palliative Care Needs among Older Emergency General Surgery Patients. J Palliat Med 2016;19:352-3. [Crossref] [PubMed]
2. Axelsson B, Christensen SB. Evaluation of a hospital-based palliative support service with particular regard to financial outcome measures. Palliat Med 1998;12:41-9. [Crossref] [PubMed]
3. Hall RI, Rocker GM, Murray D. Simple changes can improve conduct of end-of-life care in the intensive care unit. Can J Anaesth 2004;51:631-6. [Crossref] [PubMed]
4. Lamba S, Murphy P, McVicker S, et al. Changing end-of-life care practice for liver transplant service patients: structured palliative care intervention in the surgical intensive care unit. J Pain Symptom Manage 2012;44:508-19. [Crossref] [PubMed]
5. Mallery L, Moor-House P. Palliative and therapeutic harmonization. Healthc Manage Forum 2014;27:37-45. [Crossref] [PubMed]
6. Mosenthal AC, Murphy PA, Barker LK, et al. Changing the culture around end-of-life care in the trauma intensive care unit. J Trauma 2008;64:1587-93. [Crossref] [PubMed]
7. Tan KY, Tan P, Tan L. A collaborative transdisciplinary "geriatric surgery service" ensures consistent successful outcomes in elderly colorectal surgery patients. World J Surg 2011;35:1608-14. [Crossref] [PubMed]
8. Holloran SD, Starkey GW, Burke PA, et al. An educational intervention in the surgical intensive care unit to improve ethical decisions. Surgery 1995;118:294-8; discussion 298-9. [Crossref] [PubMed]
9. Committee on Approaching Death: Addressing Key End of Life Issues; Institute of Medicine. Dying in America: Improving Quality and Honoring Individual Preferences Near the End of Life. Washington (DC): National Academies Press (US); March 19, 2015.
10. National Institute of Nursing Research Report. Building momentum: the science of end-of-life and palliative care. A Review of Research Trends and Funding, 1997-2010. The National Institutes of Health, the National Institute of Nursing Research, 2013.
11. Lilley EJ, Cooper Z, Schwarze ML, et al. Palliative Care in Surgery: Defining the Research Priorities. Ann Surg 2018;267:66-72. [Crossref] [PubMed]
12. Surgeons Palliative Care Workgroup. Office of Promoting Excellence in End-of-Life Care: Surgeon's Palliative Care Workgroup report from the field. J Am Coll Surg 2003;197:661-86. [Crossref] [PubMed]
13. Lilley EJ, Khan KT, Johnston FM, et al. Palliative Care Interventions for Surgical Patients: A Systematic Review. JAMA Surg 2016;151:172-83. [Crossref] [PubMed]
14. Siddaway AP, Wood AM, Hedges LV. How to Do a Systematic Review: A Best Practice Guide for Conducting and Reporting Narrative Reviews, Meta-Analyses, and Meta-Syntheses. Annu Rev Psychol 2019;70:747-70. [Crossref] [PubMed]
15. Nabozny MJ, Kruser JM, Steffens NM, et al. Constructing High-stakes Surgical Decisions: It's Better to Die Trying. Ann Surg 2016;263:64-70. [Crossref] [PubMed]
16. Bergenholtz H, Missel M, Timm H. Talking about death and dying in a hospital setting - a qualitative study of the wishes for end-of-life conversations from the perspective of patients and spouses. BMC Palliat Care 2020;19:168. [Crossref] [PubMed]
17. Yefimova M, Aslakson RA, Yang L, et al. Palliative Care and End-of-Life Outcomes Following High-risk Surgery. JAMA Surg 2020;155:138-46. [Crossref] [PubMed]
18. Lee KC, Udelsman BV, Streid J, et al. Natural Language Processing Accurately Measures Adherence to Best Practice Guidelines for Palliative Care in Trauma. J Pain Symptom Manage 2020;59:225-232.e2. [Crossref] [PubMed]
19. Lilley EJ, Lindvall C, Lillemoe KD, et al. Measuring Processes of Care in Palliative Surgery: A Novel Approach Using Natural Language Processing. Ann Surg 2018;267:823-5. [Crossref] [PubMed]
20. Lindvall C, Lilley EJ, Zupanc SN, et al. Natural Language Processing to Assess End-of-Life Quality Indicators in Cancer Patients Receiving Palliative Surgery. J Palliat Med 2019;22:183-7. [Crossref] [PubMed]
21. Aslakson RA, Isenberg SR, Crossnohere NL, et al. Integrating Advance Care Planning Videos into Surgical Oncologic Care: A Randomized Clinical Trial. J Palliat Med 2019;22:764-72. [Crossref] [PubMed]
22. Robbins AJ, Beilman GJ, Ditta T, et al. Mortality After Elective Surgery: The Potential Role for Preoperative Palliative Care. J Surg Res 2021;266:44-53. [Crossref] [PubMed]
23. Barnett MD, Williams BR, Tucker RO. Sudden Advanced Illness: An Emerging Concept Among Palliative Care and Surgical Critical Care Physicians. Am J Hosp Palliat Care 2016;33:321-6. [Crossref] [PubMed]
24. Suwanabol PA, Kanters AE, Reichstein AC, et al. Characterizing the Role of U.S. Surgeons in the Provision of Palliative Care: A Systematic Review and Mixed-Methods Meta-Synthesis. J Pain Symptom Manage 2018;55:1196-1215.e5. [Crossref] [PubMed]
25. Bateni SB, Bold RJ, Meyers FJ, et al. Comparison of common risk stratification indices to predict outcomes among stage IV cancer patients with bowel obstruction undergoing surgery. J Surg Oncol 2018;117:479-87. [Crossref] [PubMed]
26. Marterre B, Kopecky K, Miller P. Primary palliative care for surgeons: a narrative review and synthesis of core competencies. Ann Palliat Med 2022;11:885-906. [Crossref] [PubMed]
27. Lee KC, Walling AM, Senglaub SS, et al. Defining Serious Illness Among Adult Surgical Patients. J Pain Symptom Manage 2019;58:844-50.e2. [Crossref] [PubMed]
28. Kruser JM, Taylor LJ, Campbell TC, et al. "Best Case/Worst Case": Training Surgeons to Use a Novel Communication Tool for High-Risk Acute Surgical Problems. J Pain Symptom Manage 2017;53:711-9.e5. [Crossref] [PubMed]
29. Cooper Z, Koritsanszky LA, Cauley CE, et al. Recommendations for Best Communication Practices to Facilitate Goal-concordant Care for Seriously Ill Older Patients With Emergency Surgical Conditions. Ann Surg 2016;263:1-6. [Crossref] [PubMed]
30. Cralley A, Madsen H, Robinson C, et al. Sustainability of Palliative Care Principles in the Surgical Intensive Care Unit Using a Multi-Faceted Integration Model. J Palliat Care 2022;37:562-9. [Crossref] [PubMed]
31. Lee CW, Vitous CA, Silveira MJ, et al. Delays in Palliative Care Referral Among Surgical Patients: Perspectives of Surgical Residents Across the State of Michigan. J Pain Symptom Manage 2019;57:1080-8.e1. [Crossref] [PubMed]
32. Rowe JT, Johnston FM. Surgical palliative care disparities. Ann Palliat Med 2022;11:862-70. [Crossref] [PubMed]
33. Lee KC, Sokas CM, Streid J, et al. Quality Indicators in Surgical Palliative Care: A Systematic Review. J Pain Symptom Manage 2021;62:545-58. [Crossref] [PubMed]
34. Lee KC, Walling AM, Senglaub SS, et al. Improving Serious Illness Care for Surgical Patients: Quality Indicators for Surgical Palliative Care. Ann Surg 2022;275:196-202. [Crossref] [PubMed]
35. Lilley EJ, Lee KC, Scott JW, et al. The impact of inpatient palliative care on end-of-life care among older trauma patients who die after hospital discharge. J Trauma Acute Care Surg 2018;85:992-8. [Crossref] [PubMed]
36. Rubin EB, Buehler AE, Halpern SD. States Worse Than Death Among Hospitalized Patients With Serious Illnesses. JAMA Intern Med 2016;176:1557-9. [Crossref] [PubMed]
37. Heyland DK, Dodek P, Rocker G, et al. What matters most in end-of-life care: perceptions of seriously ill patients and their family members. CMAJ 2006;174:627-33. [Crossref] [PubMed]
38. Higgins JP, Altman DG, Gøtzsche PC, et al. The Cochrane Collaboration's tool for assessing risk of bias in randomised trials. BMJ 2011;343:d5928. [Crossref] [PubMed]