Advanced Care Planning and Quality of Symptom Management in Men with Advanced Urologic Malignancies Treated in an Integrated Urology/Palliative Care Clinic
Aaron A. Laviana1,2, Jon Bergman1,2, Christopher S. Saigal1,2, Josemanuel Saucedo2, Carol J. Bennett2
Background: A critical mass of research has isolated the two variables that decrease cost and improve quality at the end of life: addressing patient goals and integrating palliative care early into the management of patients with advanced malignancies. Quality indicators endorse formalizing patient preferences with either an advance directive or a Physician Orders for Life-Sustaining Treatment (POLST). Integration of palliative care has yet to be studied in a surgical setting. We hypothesized that building a multidisciplinary palliative care/urology clinic would lead to higher-than-average levels of patient preference assessment and quality-endorsed symptom management.
Research Design: We partnered with patients, families, and palliative care clinicians to develop an integrated urology-palliative care clinic for patients with metastatic urologic malignancies. In an interim analysis, we abstracted medical records for the first 28 patients enrolled to assess advanced care planning and quality of symptom management, using previously validated indicators for quality of care in advanced cancer. We compared this with a representative national sample of patients in the Veterans’ Administration (VA).
Results: Our cohort was old (mean age, 76 years), male (100%), and had high comorbidity (mean Charlson Index Score, 6). The majority of men (86%) had metastatic prostate cancer, while the remaining had metastatic bladder (10%) or penile (4%) cancer. The patient’s primary care physician was integrated into the management of care in all cases. As shown in the table, advanced care planning was excellent, as measured by completion of either an advance directive or POLST (83%) and by timely assessment of individual goals of care (93%).
Conclusions: Advanced care planning and symptom management were excellent compared with a national VA sample. Efforts to implement similar interventions broadly within surgery are warranted.