Advance Care Planning before Major Surgery: A Podcast with Vicky Tang

Advance Care Planning before Major Surgery: A Podcast with Vicky Tang



welcome to the Jerry palbok yes this is Erik Whitner this is alex smith and alex who do we have in our studio today today we have woot woot she's doing the woot woot those of you are joining on youtube you can see this vicky tang is assistant professor in the division of geriatrics here at UCSF and she's very interested in the intersection of the geriatrics palliative care advanced care planning and surgery welcome to the Gerry pal podcast Vicki thank you thank you for having me and before we go into this topic including your recent JAMA surgery article on this we always ask every guest do you have an article art not an article Alex to warm us up with I do and it is the house of Rising Sun house the Rising Sun all right good song hopefully you'll sing so it's dedicated to anakata okay anyway who is yes she's a surgery resident who's worked a lot with ACP and surgery with me so I really appreciate her all right shout out to Anna there is a house anywhere they call the right buzzing son it's been the room oh boy and God [Applause] well do why did why did you pick that song for for anakata but is there a reason it was like what's the what's the reason is she from New Orleans or no but New Orleans is a really cool place ah yeah great so we're talking about advance care planning and surgery so maybe we should take a step back first and say what why is this an important topic and how did you get interested in it yeah so so I'm a geriatrician and I think we all understand how important advance care planning is especially in a venerable time for an older adult and so we one of those times is surgery especially high-risk surgery so we've done some work in the clinic at UCSF with prehab and we can talk a little bit more about that but the idea was that we incorporated advance care planning discussions before anything potentially bad happens so that the patients and the families are well prepared to make decisions yeah so if you it clinically had experiences that made you realize this is an important issue we I know some of my patients have gone had major surgery have not had engaged in advanced care planning things haven't gone well or I'm so glad we did that advance care planning discussion with this patient before that major surgery because boy if we hadn't done that we wouldn't have known how to proceed yeah that's I think we all have those stories and I think it's kind of crazy because now that I'm working in the prehab kind of like so this is a a Jerry surged clinic that's before actual surgery so in the pre-op setting and having patients come through that have already had major surgery and not having had covered these topics of what's most important to you who's going to make decisions for you if you can't for yourself kind of just blows my mind yeah right and prehab is a play on rehab right yes which is like pre rehabilitation is that what it's sort of yeah yeah yeah so so there's a fairly new concept maybe within the last decade and it there are several places throughout the u.s. there's the big one that I think about started in the UK actually with older adults before surgery and the idea is to get them physical therapy get them occupational therapy nutrition social support and all those other things and just basically prepare the patient before this major surgery so that their outcomes are better so the pre could be for prepare or prevent or for pre like before their there are many things the pre and the prehab could stand for so I've interpreted prehab to include advanced care planning right I think a lot of surgeons think of prehab as oh you get your patients you know that the physical therapy and the nutrition part and then I kind of you know sneak in there with advance care planning part and then you know find out that you know we had one case where the patients like oh I you know after this whole advanced care planning discussion say like oh I'm not sure how this surgery will actually get me to where I want to go in life you know or it's is this actually what I want to be doing spending my time my limited time that's left so definitely a serious kind of heavy hitter questions and discussions with patients and family members in this time period so leveraging the prehab and like the sexiness of physical therapy occupational therapy and nutrition with some acp right right it's like stealth geriatrics that's that's exactly right and when you when you look at like a CP like are we just talking about here's an advance directive go home fill it out talk to your lawyer if you have one bring back to me no so it so we definitely modeled our ACP discussion with from Rebecca so Dory's work for prepare for your care and really delve into what's most important to you and address that conversation that way versus like hey if your heart we're to stop do you want us to pound on it you know and resuscitate you so really trying to start with the big picture of who are you what do you live for and then you know I do a lot of coaching with the patients and the family members as to you know how to make decisions based on their goals and values because we can't you know you can go down the list of surgical complications of like oh yeah you may die you may bleed you may have you know pulmonary embolism this and that but you can't you know say all of them and anticipate all the potential additional operations or procedures that that the patient or the family will be offered or discussed you know afterwards so just to give them that kind of framework to work with I think is really important so starting off with less with preferences for individual decisions and more about big picture what's important to them what they're worried about what they're hoping for that's right and then sounds like also making recommendations on those individual preferences so from as a geriatrician I definitely recognize I'm not the surgeon and I can't say you know like oh this you know the risk of this procedure will be this this and this but definitely helping the patient recognize you know this is what's most important to me and coaching them and saying like hey if you haven't had these discussions with your surgeon like you know go back and talk with them and you know I would contact the surgeon and you know request or Rock commend that they meet with the patient again so priming both the patients and the surgeons to have these yeah and I definitely want to give a shout out in a little endorsement for this geriatric surgery program I don't know if I should do it now or later geriatric surgery part yeah it's super cool it's called the geriatric surgery verification quality improvement program it can cool acronym gsv I can see that I can see that but it could be a really cool rap song too yeah but yeah so it started from the American College of Surgeons and it's supported by John a Hartford so we have a coalition for quality and geriatric surgery group the CQG s and so it's a bunch of surgeons I'm one of the geriatricians on it and we've basically gathered all the evidence for standards and figured out what the infrastructure needs to be for a health system to be able to provide good quality geriatric surgical care to older adults and so what's really neat is it's rolling out in July mid July the launch and then health systems can sign up for it I think in October but so one of the four big pieces of the standards includes goals of care discussions and surgical decision-making as one of their big kind of standards and so you know in the past patients will see the surgeon they'll see the pre-op anesthesiologist and then they'll roll into surgery and that's it and so in the standards now it says you know the patient should be offered up to the patient the family if they want to take take you know take them up on it but that they are offered a second visit with the surgeon or the surgical team to talk about any any other things that they want to talk about and that the surgery note needs to include a dis some sort of written documentation that that that they've had discussions with a patient about the goals of care with quotes from the patient so this is huge from you know in the past I know we'll talk about the Jama surgery paper in a little bit but you know what we had found going through some of the charts is that that there was like zero documentation about discussions about ACP in the surgery no it's prior to surgery and these are patients that died within a year of the surgery so so we're hoping that this program will definitely change care and I'm pretty sure well it's a tremendous amount in there but let me just back out a little bit so it's gonna be a red carpet launch of yeah geriatric surgery virus yes verification quality improvement in Washington DC next month in the middle of the month there's gonna be like a red carpet and you a song I did I was like can we we hire you guys to come yeah exactly exactly yeah so we've got tons of stakeholders coming cheri link from CMS is coming to give our keynote so it's gonna be a great big long yeah and then and then the hope is that health systems will actually buy into this quality program and that they will adopt the standards of the program as their own standards is that correct and attendance presumably there'll be some kind of monitoring and verification that they are being complying with those standards that's exactly right yeah so the program has four pillars one are the standards the second is the infrastructure so it gives you kind of a play-by-play on like what infrastructure you need and then the third part in terms of collecting robust data to make sure that you're you know following these guidelines you know for example you know they'll be chart reviews in terms of like how you know how many of these charts of a subset actually document goals of care or have had these conversations and then the and then the fourth part is having a lot of times it's surgeons but like other kind of external reviewers come to your location and do do a discussion to make sure that you're following the rules and this is you know ACS has got lots of other quality improvement programs so trauma for example has one Bariatrics cancer so we're just following along with that set up and it's been successful for those programs and so we're hopeful for this one and getting back to the advanced care planning part of what you talked about it sounds like that's going to be a big good portion of or at least some of what happens in this yeah yeah super excited about that can I go too you mentioned the Jama surgery article can we talk a little bit about that just so apparently it's not an open access yet do number it was it was published December 2018 and apparently in a year from that location access but it was titled advanced care planning and other adults with multiple chronic conditions undergoing high-risk surgery what did you what you do in this article yeah we were looking at one big healthcare system where we could get some advanced care planning documentation data as well as the patient data so we looked at one time point 2013 and 2014 and looked at basically older adults that had multiple chronic conditions and that had major surgery as defined by a risk of one or more percent likelihood of risk of death within 30 days of surgery so this is what's defined by surgeons as major surgery so these are things like with a beige or triple-a repair triple-a repair a soffit ejected me pancreatectomy so a lot of kind of serious big bad surgeries and so that's how we identified these patients and basically looked it whether they had advanced care planning in their in their chart prior to prior to surgery and it didn't even have to be within a year it was like anything anything anytime we were like it could even be you know the durable power of attorney it could be you know like that's directed exactly and it was pretty low I think it was like 30-some percent that we found and this is a healthcare system that had implemented this like clinical reminder for all the all the clinics like you know if there's a patient that hasn't completed the ACP that they would be prompted to so even with that maybe I don't know maybe there's that trigger fatigue or you know clinical reminder fatigue as part of the problem but it was pretty low 30 percent or so yeah I'm seeing about 26% had ACP documented pre-op and then among those who died within a year of surgery so 14 percent died within a year surgery only 30% had documentation of advanced care planning so less than one out of three yeah and these are people obviously that were really sick or likely to have died in a year so so yeah so it sounds like what you're doing right now is is trying to target that try to increase advanced care planning for this population yeah go ahead you were going to say I was gonna steal the show as you say like absolutely and I think we are you know are doing that from a surgical standpoint but I would say you know like the ideal situation the ideal kind of like putting on my jerry hat of ideal this needs to happen even before surgery enters the picture right and so it needs to happen in the pcp office and needs to happen as like a public health kind of push you know to figure to help older adults or just anybody even me like figure out like hey what's most important to me what am i living for so that when there is something like oh you might need to undergo some major surgery I'll already have that thought about for a while you know and then bring that conversation to the surgical team to express those things so let me ask you about this because you were talking about the current process like it's the surgeon – the anesthesiology team like does any how is that relationship which mean the person who's doing that advance care planning and the surgeon because this could also just be a barrier to getting surgery like you have these goals of care discussions and like you mentioned like oh like will this surgery actually achieve my goals maybe not like especially in like a fee-for-service system potentially like how are cert are the surgeons receptive to this so I feel like I've surrounded myself with surgeons that absolutely believe in ACP so I can't speak for maybe a subset that are concerned but you know I the thing that I would say is I think I'd like to think you know and this is true for all kind of clinicians is that we want to do what's best for our patients yeah and so if that's the case which I believe you know surgeons want they don't want to do something that would be harmful or not aligned with the patient school then they would be supportive of such a such an endeavor yeah does that answer the question I think so okay I think just the thing about the receptiveness of this collaboration with with surgeons because I think it's something that they're good and I do have to say you know like you know Sarah Cooper and got Gretchen schwarzy have like along with Emily Finley's in it a lot of other surgeons are working on trying to improve and educate surgeons on communication around goals of care discussion I've gone to several surgery conferences with good attendance from surgeons that want to learn how to have these conversations and I think that's very powerful that's terrific and it takes a multi-pronged approach to change advanced care planning we can't just you know mandate you know it set standards that they they should engage in an advanced care planning without teaching them giving them the skills and tools to have engaged in those conversations in a high-quality you know skilful manner with older adults having serious high-risk surgery I wanted to ask you returning to the prehab is there any evidence for prehab period I guess expected to do yeah so um so there's been several studies that have come out about prehab fortunately unfortunately you know these models are very different depending on the place that it's been created and so for example in Michigan they've done even home prehab in the sense that you know patients are receiving material to do on their own in terms of you know physical therapy there's a psychological component so so that's one model and they've shown positive outcomes so then there's like the Duke model which you know they do you know there's a geriatrician there's a social worker they cover the geriatric comprehensive geriatric assessment and may have physical therapy called in if there's as a consultative kind of model we've got one here actually at the VA that sits within hospital medicine where we have physical therapy see the patient as well as occupational therapy and psychology pain psychologists actually in the geriatrician so there's a whole bunch of different models they've all turned out positive I haven't seen a negative prehab model but you know we're still very early and like how do you so pretty and I would say like so for example the Michigan model isn't specifically for the 8090 year olds right so and that you know for example the the model we have here currently is only for ortho patients so I think there's still a bunch of different work different mechanisms of delivery different patient populations different surgeries it's early yet but their evidence so to date is somewhat promising yeah and what kind of outcomes are we talking about so we're talking about readmission length of stay I'm trying to remember the specifics but I know for Duke they had a decrease of length of stay and I think they also showed that they had decrease rates of delirium as well granted they're their model has a and there there are models called posh but they also have an inpatient geriatric service that's dedicated to geriatric surgery right so so every model is different and they're all publishing on it but I also hear a lot about frail to you with these models is that a big component like the assessment of frailty and yeah yeah and I think surgeons are very interested in looking at frailty and some even within at UCSF and Susskind has just started implementing a timed up and go as their frailty measurement in her clinic and so so it's definitely happening the timed up and go is the kind of for surgeons because it's fast and easily accessible Jax paper just came out looking at like frailty assessment and the tests that they recommended which was the most practical quickest to do was chair eyes I think it was times five I will include a link to that article on our Terry pal website is there a link to the new GSV Gorge EVs what is it cheap CBS check that you got me confused its GSB is your website up for that yes yeah I will give that link okay awesome and then it okay I'm last question for me is there evidence for advanced care planning prior to major surgery impacting outcomes that people care about or health systems care about how has Rebecca sue Dorie answered this question do you mean for advanced care planning in general yeah so not that I you know not that I know of I know from from a clinical standpoint having done some advanced care planning discussions having patients come out from that discussion one being more informed about who they are what their needs are and for the caregiver to know this information but then also thinking about from a surgical from the being offered the surgery you know thinking about like hate does this fit within my goals you know and I would think that they would feel more calm either more like yeah you know this surgery's gonna get me to my grandsons like you know graduation or you know say like hey you know the surgery actually doesn't fit with what I want to do with the rest of my time that I possibly have so from that standpoint yes but in terms of like oh it's permitted you know I don't know length of stay you know increases I don't have that sorry and then from a practical standpoint when you have these advanced care planning discussions do discussions about I know the big picture goes to care but discussions about life-sustaining treatment the code status intubation do they come up with the person who's having this like the geriatrician and how do you handle that with the surgeon and anesthesiologist that they do come up oh are you so I think you're referring to there's this thing about how surgeons our anesthesiologist like to request the reversal of a DNR I think every surgeons a little bit different some like you know again depending on the type of surgery like would only want to do it on somebody who's full code and maybe reverse it but how long do you reverse it for and like there's all these questions about how to think about these life-sustaining treatments including how long that like if somebody doesn't want to be kept alive on like breathing machines how long post-surgery do they have to be kept alive I'm just wondering how you would navigate that as a geriatrician talking about this or do you even talk about life-sustaining treatments when you're having these goals of care discussions so I you know I really follow Rebecca surgeries model and so she has you know in her prepare for your care kind of more broad questions of like you know do I agree with one of these statements like I would want to be kept alive even if I'm in pain or suffering or you know or I would value quality of life even though it means that my life may be limited so I don't usually get into the nitty gritties of like if your heart we're to stop like do you want us to resuscitate you right like I give them the advance you know directive if they haven't had one to fill out so it's definitely in there I don't think surgeons are having the kind of in-depth conversation is that you're talking about I know that there is a kind of culture around like let me say like your DNR needs to be full code at least throughout the surgery because whatever like if your heart were to stop by that point like it's reversible whatever you know may be causing it so that kind of their thinking in terms of changing it to full code and then saying like we'll change it back to DNR once you you know come out of surgery but in terms of how long to keep the full code for like I have not been in that situation I'd love to hear if you guys have have seen the hut we've certainly seen circumstances where surgeons feel like and Gretchen's forces written about this they have a compact somewhat sometimes unspoken unwritten with patients that's right yeah that's right you know an agreement that if you have this surgery we're gonna get you through not just the surgery but all the whole recovery period afterward and that means you're gonna do everything kind of I tell you to do yeah and we're gonna get you through it and we you're not gonna change your mind about this and yeah I can see where they're coming from because they've seen a lot of times like as geriatricians or palliative care Doc's we only see them at that time period of like they're they're crashing you know they're not doing well but the surgeon has they've seen them in the pre-op clinic they've seen them you know function they feel like maybe that's where it's coming from where they're like oh I can get that patient back to that state we're not giving up I'm your cheerleader I'm gonna get you through this so I absolutely understand that feeling but also recognize like you know it's patient autonomy in we need it you know respect their wishes it's great right so we'll also a couple other names that we mentioned here Gretchen schwarzy we've done a podcast with her that we'll have a link to Rebecca sue Dory with a prepare for UK I think we've done two podcasts with Rebecca we'll have links for that on our Jerry PAL website so please check out those podcasts and with that we'll end with a little bit of more of what's the song called again Rising Sun and Vicki's gonna come in on this time I well I was already it might be a would we'll see Oh mother to your children not to do have done spend your life since in misery in the house of the rise thing son wha-wha-wha wha-wha-wha Vicki thank you for joining us thank you guys thank you so much yeah thank you for everybody who's listening for joining us on this week's Jerry pal podcast join us next week until next week folks bye-bye

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