This talk describes a journey investigating supportive and palliative care as a potential tailored intervention for patients referred for major surgery. It considers findings from a workshop addressing palliative surgery and palliative care in surgery with patients and professionals, proposes a pilot study of perioperative supportive care and introduces some of the key unpublished findings from the Lancet Value of Death Commission which considers rebalancing our approach to death- and in so doing aims to realign over- and undertreatment in healthcare.
Nearly one-third of Medicare beneficiaries have an operation during their last year of life. Patients undergoing surgery are older and more multi-morbid than in the past. Framing decision making for major surgery needs to encompass the complexity of potential longevity gains, with patient goals for life and quality of life. Surgical shared decision making has been positively embraced by patients and surgeons as an opportunity to improve patient knowledge of the risks and benefits of a procedure and provide greater comfort in decision making. The use of the multidisciplinary team within an integrated pathway perioperatively has also shown improved patient satisfaction, reduced pain, anxiety and fatigue and reductions in length of stay and overall healthcare utilisation and even potential survival gains. A quality improvement program in the US found the use of risk assessments pre-operatively combined with palliative care consultations improved patient survival. Striking the balance between surgery, which enhances length and/or quality of life and potentially non-beneficial treatment at the end of life is not always clear. Optimising perioperative supportive care for patients undergoing major surgery with elements of shared decision making, integrated care, risk assessments and supportive and palliative care perioperatively holds a number of uncertainties. What kind of perioperative intervention, how and who best to deliver it needs to be established.