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

Eric: This is Alex Smith.

Eric: Alex, who do we have in our studio today?

Alex: Today, we have, woot-woot … She’s doing the woot-boot. Good. Those of you who 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 geriatrics, palliative care, advanced care planning and surgery. Welcome to the GeriPal podcast, Vicky.

Vicky: Thank you. Thank you for having me.

Eric: Before we go into this topic, including your recent JAMA-Surgery article on this, we always ask every guest, do you have an article … or not an article.

Eric: A song. You have the article, but do you have a song for Alex to warm us up with?

Vicky: I do, and it is the House of the Rising Sun.

Alex: House of the Rising Sun. All right. Good song. Hopefully you’ll sing something.

Vicky: It’s dedicated to Anna Kata.

Alex: Good. Anyway, say who Anna is.

Vicky: She’s a surgery resident who’s worked a lot with ACP and surgery with me so I really appreciate her.

Alex: All right. Shout out to Anna. (singing)

Vicky: Awesome. Good job.

Alex: Thank you. I thought you were going to come in there in the middle and then nothing happened [laughter].

Vicky: I missed my cue. I’m sorry.

Eric: You have another chance at the end to sing along with Alex.

Vicky: Okay, will do.

Eric: Why did you pick that song?

Vicky: For Anna Kata.

Eric: Is there a reason? What’s the reason? Is she from New Orleans?

Vicky: No, but New Orleans is a really cool place. Does that count?

Eric: It’s just a dedication.

Alex: It’s close enough.

Vicky: It’s just a really good song.

Alex: Anna helped pick the song?

Vicky: Yeah.

Alex: Great. We’re talking about advanced care planning and surgery. Maybe we should take a step back first and say, why is this an important topic and how did you get interested in it?

Vicky: I’m a geriatrician, and I think we all understand how important advanced care planning is, especially in a vulnerable time for an older adult. One of those times is surgery, especially high-risk surgery. 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 advanced care planning discussions before anything potentially bad happens so that the patients and the families are well prepared to make decisions.

Alex: You clinically had experiences that made you realize this is an important issue. I know some of my patients have gone and had major surgery, have not had engaged in advanced care planning. Things haven’t gone well, or I’m so glad we did that advanced 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.

Vicky: Yeah. I think we all have those stories. I think it’s crazy because now that I’m working in the prehab, this is geri-surg clinic that’s before the actual surgery, so in the preop 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? It just blows my mind.

Alex: Prehab is a play on rehab, right, which is afterwards.

Vicky: Yes, that’s right.

Alex: This is like pre-rehabilitation. Is that what it’s-

Vicky: Yeah. Yeah. This is a fairly new concept maybe, within the last decade. There are several places throughout the US. There’s the big one that I think about started in the UK actually with older adults before surgery. 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.

Alex: The pre could be for prepare or for prevent or for pre like before. There are many things the pre and the prehab could stand for.

Vicky: I’ve interpreted prehab to include advanced care planning. I think a lot of surgeons think of prehab as, oh, you get your patients the physical therapy and the nutrition part and then they sneak in there with advanced care planning part and then find out that … We had one case where the patient, after this whole advanced care planning discussion, say like, “Oh, I’m not sure how the surgery will actually get me to where I want to go in life, or is this actually what I want to be doing spending my limited time that’s left?” Definitely serious, heavy-hitter questions and discussions with patients and family members in this time period. Leveraging the prehab and the sexiness of physical therapy, occupational therapy and nutrition with some ACP.

Alex: It’s like stealth geriatrics.

Vicky: That’s exactly right.

Alex: When you look at ACP, are we just talking about here’s an advanced directive, go home and fill it out, talk to your lawyer if you have one, bring it back to me?

Vicky: No. We definitely modeled our ACP discussion from Rebecca Sudore’s work for prepare for your care and really delved into what’s most important to you and address that conversation that way versus like, hey, if your heart were to stop, do you want us to pound on it and resuscitate you? Really trying to start with the big picture of who are you, what do you live for? I do a lot of coaching with the patients and the family members as to how to make decisions based on their goals and values because we can’t … You can go down the list of surgical complications of like, oh yeah, you may die, you may bleed, you may have pulmonary embolism, this and that. You can’t say all of them and anticipate all the potential additional operations or procedures that the patient or the family will be offered or discussed afterwards. Just to give them that framework to work with I think is really important.

Eric: Starting off less with the preferences for individual decisions and more about big picture, what’s important to them, what they’re worried about, what they’re hoping for.

Vicky: Yeah, that’s right.

Eric: It sounds like also making recommendations on those individual preferences, if there are some.

Vicky: As a geriatrician, I definitely recognize I’m not the surgeon and I can’t say like, oh, the risk of this procedure, we’ll need this, this and this. Definitely helping the patient recognize 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, go back and talk with them. I would contact the surgeon and request or recommend that they meet with the patient again.

Alex: Priming both the patients and the surgeons to have these conversations.

Vicky: Yeah. I definitely want to give a shout out and a little endorsement for this geriatric surgery program. I don’t know if I should do it now or later.

Alex: Let’s do it.

Eric: What is this geriatric surgery program?

Vicky: Yeah, it’s super cool. It’s called the Geriatric Surgery Verification Quality Improvement Program.

Eric: Very cool acronym. That’s too long.

Vicky: It’s GSV.

Eric: GSV.

Vicky: That’s the way I say it.

Eric: Is that an infectious disease?

Vicky: I could see that, but it could be a really cool rap song too. It started from the American College of Surgeons, and it’s supported by John A. Hartford. We have a Coalition for Quality and Geriatric Surgery Group, the CQGS. It’s a bunch of surgeons. I’m one of the geriatricians on it. 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. 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.

Vicky: One of the four big pieces of the standards includes goals of care discussions and surgical decision-making as one of their big standards. In the past, patients will see the surgeon. They’ll see the preop anesthesiologist, and then they’ll roll into surgery. That’s it. In the standards now, it says the patient should be offered, up to the patient and family if they want to take them up on it, but that they are offered a second visit with the surgeon or the surgical team to talk about any other things that they want to talk about. The surgery note needs to include some written documentation that they’ve had discussions with the patient about the goals of care with quotes from the patient.

Vicky: This is huge from in the past … I know we’ll talk about the JAMA-Surgery paper in a little bit. What we had found going through some of the charts is that there was zero documentation about discussions about ACP in the surgery notes prior to surgery. These are patients that died within a year of the surgery. We’re hoping that this program will definitely change care. I’m pretty sure it will.

Alex: It’s a tremendous amount in there. Let me just unpack that a little bit. There’s going to be a red carpet launch of the geriatric surgery virus, GSV.

Vicky: Verification Quality Improvement Program.

Alex: Verification Quality Improvement Program in Washington DC next month, in the middle of the month, and it’s going to be like a red carpet. You asked me if I had any songs that were-

Vicky: I did. I was like, can we hire you guys to come out there? [laughter]

Alex: Interview everybody.

Eric: A podcast.

Vicky: Exactly. We’ve got tons of stakeholders coming. Shari Ling from CMS is coming to give our keynote. It’s going to be a great launch.

Alex: Big launch event.

Vicky: Yeah.

Alex: 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?

Vicky: Correct.

Alex: Presumably there’ll be some monitoring and verification that they are indeed complying with those standards.

Vicky: That’s exactly right. Yeah. The program has four pillars. One are the standards. The second is the infrastructure. It gives you a play by play on what infrastructure you need. The third part in terms of collecting robust data to make sure that you’re following these guidelines. For example, there’ll be chart reviews in terms of how many of these charts of a subset actually document goals of care or have had these conversations? The fourth part is having, a lot of times it’s surgeons, but other external reviewers come to your location and do a discussion to make sure that you’re following the rules. ACS has got lots of other quality improvement programs. Trauma, for example, has one; bariatrics, cancer. We’re just following along with that set up and it’s been successful for those programs. We’re hopeful for this one.

Eric: Getting back to the advanced care planning part of what you talked about, it sounds like that’s going to be a good portion or at least some of what happens in this project.

Vicky: Yeah. I’m super excited about that.

Eric: You mentioned the JAMA-Surgery article. Can we talk a little bit about that?

Vicky: No.

Eric: No? [laughter]

Vicky: Read it. [laughter]

Eric: Alex, do you want to finish us with a song?

Vicky: Apparently it’s not an open access yet. It’s due December 2019.

Eric: It was published December 2018, and apparently in a year from that notification date is open access, but it was titled Advanced Care Planning in Older Adults with Multiple Chronic Conditions Undergoing High-risk Surgery.

Vicky: That’s right.

Eric: What did you do in this article?

Vicky: We are looking at one big healthcare system where we could get some advanced care planning documentation data as well as the patient data. 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 a risk of death within 30 days of surgery. This is what’s defined by surgeons as major surgery.

Alex: These are things like … What would that be, CABG or AAA repair?

Vicky: AAA repair, esophagectomy, pancreatectomy, so a lot of serious, big, bad surgeries. That’s how we identified these patients and basically looked whether they had advanced care planning in their chart prior to surgery. It didn’t even have to be within a year. It was like-

Alex: Anything.

Vicky: Anything, anytime. We were like, it could even be the durable power of attorney. It could be like-

Alex: Advanced directive — anything like that.

Vicky: Exactly. It was a pretty low. I think it was like 30% – some that we found. This is a healthcare system that had implemented this clinical reminder for all the clinics. If there’s a patient that hasn’t completed the ACP that they would be prompted to. Even with that, maybe, I don’t know, maybe there’s that trigger fatigue or clinical reminder fatigue as part of the problem, but it was pretty low, 30% or so.

Eric: I’m seeing about 26% had ACP documented preop, and then among those who died within a year of surgery, so 14% died within a year of surgery, only 30% had documentation of advanced care planning, so less than one out of three.

Vicky: Yeah. These are people obviously that were really sick or likely to have died in a year or so.

Eric: It sounds like what you’re doing right now is trying to target that, try to increase advanced care planning for this population.

Vicky: Yeah.

Eric: Go ahead. You were going to say something to steal the show.

Vicky: I was going to steal the show. [laughter]

Eric: Steal. Take it away.

Vicky: I was going to say absolutely, and I think we are doing that from a surgical standpoint. I would say the ideal situation, the ideal, putting on my geri hat of ideal, this needs to happen even before surgery enters the picture. It needs to happen in the PCP office. It needs to happen as a public health push to help older adults or just anybody, even me, 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 and then bring that conversation to the surgical team to express those things.

Eric: Let me ask you about this because you were talking about the current process. It’s the surgeon to the anesthesiology team. How is that relationship between the person who’s doing that advanced care planning and the surgeon? Because this could also just be a barrier to getting surgery. You have these goals of care discussions, and like you mentioned, oh, will this surgery actually achieve my goals? Maybe not. Especially in a fee-for-service system potentially, are the surgeons receptive to this?

Vicky: I feel like I’ve surrounded myself with surgeons that absolutely believe in ACP. I can’t speak for maybe a subset that are concerned. The thing that I would say is I’d like to think, and this is true for all kinds of clinicians, is that we want to do what’s best for our patient. If that’s the case, which I believe surgeons want, they don’t want to do something that would be harmful or not aligned with the patient’s goal, then they would be supportive of such an endeavor. Does that answer the question?

Eric: I think so. I think just the thing about the receptiveness of this collaboration with surgeons because I think it’s something that … Go ahead.

Vicky: I do have to say Zara Cooper and Gretchen Schwarze, along with Emily Finlayson, 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. I think that’s very powerful.

Alex: That’s terrific. It takes a multipronged approach to change advanced care planning. We can’t just mandate to set standards that they should engage in advanced care planning without teaching them, giving them the skills and tools to engage in those conversations in a high-quality, skillful 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? Does it do anything? What would we expect it to do?

Vicky: There’s been several studies that have come out about prehab. Unfortunately, these models are very different depending on the place that it’s been created in. For example, in Michigan, they’ve done even home prehab in the sense that patients are receiving material to do on their own in terms of physical therapy. There’s a psychological component. That’s one model. They’ve shown positive outcomes. There’s the Duke Model, which there’s a geriatrician, there’s a social worker, they cover the comprehensive geriatric assessment and may have physical therapy called in as a consultative 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 psychologist actually and the geriatrician.

Vicky: There’s a whole bunch of different models. They’ve all turned out positive. I haven’t seen a negative prehab model, but we’re still very early and how do you compare?

Alex: It’s still pretty early. Right.

Vicky: I would say, for example, the Michigan model isn’t specifically for the 80, 90-year-olds. For example, the model we have here currently is only for ortho patients. I think there’s still a bunch of different … a lot of good work.

Alex: Different models, different mechanisms of delivery, different patient populations, different surgeries. It’s early yet, but the evidence … To date, it’s somewhat promising.

Vicky: Yeah.

Alex: What kind of outcomes are we talking about?

Vicky: We’re talking about re-admission, 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 decreased rates of delirium as well. Granted, their model has … and their model is called POSH, which is really cool.

Alex: That’s a good acronym.

Vicky: Better than-

Alex: GSV. I’m going to go to the POSH Clinic. Yeah, POSH.

Vicky: They also have an inpatient geriatric service that’s dedicated to geriatric surgery. Every model is different, and they’re all publishing on it.

Eric: I also hear a lot about frailty with these models. Is that a big component, the assessment of frailty and thinking of that?

Vicky: Yeah. I think surgeons are very interested in looking at frailty, and some even within at UCSF, Anne Suskind has started implementing a Timed Up and Go as their frailty measurement in her clinic. It’s definitely happening. The Timed Up and Go is the go-to for surgeons because it’s fast and easily assessable.

Eric: Jack’s paper just came out looking at frailty assessment and the tests that they recommended, which are some of the most practical, quickest to do was chair rise.

Vicky: That would be faster.

Eric: I think it was times five. We’ll include a link to that article on our GeriPal website.

Alex: Is there a link to the new GSV or GVS, what is it?

Eric: CVS pharmacy.

Alex: Geriatric-

Vicky: Now you got me confused. It’s GSV. [laughter]

Alex: The GSV. Is there a website up for that?

Vicky: Yes. I will give that link.

Alex: Awesome. Last question from me, is there evidence for advanced care planning prior to major surgery impacting outcomes that people care about or health systems care about?

Vicky: How has Rebecca Sudore answered this question?

Alex: You mean for advanced care planning in general?

Vicky: In general, yeah. Not that I know of. I know 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. Also thinking about from being offered the surgery, thinking about like, hey, does this fit within my goals? I would think that they would feel either more like, yeah, this surgery is going to get me to my grandson’s graduation or say like, hey, this surgery actually doesn’t fit with what I wanted to do with the rest of my time that I possibly have. From that standpoint, yes, but in terms of like, oh, it’s prevented, I don’t know, length of stay increases, I don’t have that.

Eric: From a practical standpoint, when you have these advanced care planning discussions, do discussions about … I know the big picture goes to care, but do discussions about life-sustaining treatments, code status, intubation, do they come up with a person who’s having this, the geriatrician, and how do you handle that with the surgeon and the anesthesiologist if they do come up?

Vicky: I think you’re referring to there’s this thing about how surgeons or anesthesiologists like to request the reversal of a DNR.

Eric: Yeah. I think every surgeon is a little bit different. Some, again depending on the type of surgery, would only want to do it on somebody who is full code and maybe reverse it, but how long do you reverse it for? There are all these questions about how to think about these life-sustaining treatments, including how long until … If somebody doesn’t want to be kept alive on breathing machines, how long postsurgery 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?

Vicky: I really follow Rebecca Sudore’s model. She has, in her prepare for your care, ask more broad questions of like do I agree with one of these statements? I would want to be kept alive even if I’m in pain or suffering or I would value quality of life even though it means that my life may be limited. I don’t usually get into the nitty-gritties of like if your heart were to stop, do you want us to resuscitate you? I give them the advanced directive if they haven’t had one to fill out. It’s definitely in there.

Vicky: I don’t think surgeons are having the in-depth conversations that you’re talking about. I know that there is a culture around like, let me say your DNR needs to be full code, at least throughout the surgery because whatever … If your heart were to stop by that point, it’s reversible, whatever may be causing it. That may be their thinking in terms of changing it to full code and then saying we’ll change it back to DNR once you come out of surgery. In terms of how long to keep the full code for, I’ve not been in that situation, but I’d love to hear if you guys have seen that.

Alex: We’ve certainly seen circumstances where surgeons feel like, and Gretchen Schwarze has written about this, they have a compact somewhat, sometimes unspoken, unwritten with patients.

Eric: A covenant.

Alex: Covenant, that’s the right word.

Vicky: Yeah, that’s right.

Alex: An agreement that if you have this surgery, we’re going to get you through not just the surgery but all the whole recovery period afterward, and that means you’re going to do everything I tell you to do. We’re going to get you through it, and you’re not going to change your mind about this.

Vicky: I can see where they’re coming from because they see … A lot of times, as geriatricians or palliative care docs, we only see them at that time period of they’re crashing, they’re not doing well. The surgeon, they’ve seen them in the pre-op clinic. They’ve seen them function. I 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 going to get you through this. I absolutely understand that feeling but also recognize it’s patient autonomy and we need to respect their wishes.

Alex: That’s great.

Eric: Great. A couple other names that we mentioned here. Gretchen Schwarze, we’ve done a podcast with her that we’ll have a link to. Rebecca Sudore with prepare for your care, I think we’ve done two podcasts with Rebecca. We’ll have links for that on our GeriPal website.

Vicky: You’ve done Zara Cooper as well.

Eric: Yeah, Zara Cooper. Please check out those podcasts. With that, we’ll end with a little bit of more of, what’s the song called again?

Alex: House of the Rising Sun.

Vicky: House of the Rising Sun.

Alex: Vicky is going to come in this time.

Vicky: I will.

Alex: Are you ready?

Vicky: I’m ready.

Alex: I don’t know what it’s going to be.

Vicky: It might be a woot. We’ll see.

Alex: (singing)

Alex: Vicky, thank you for joining us.

Vicky: Thank you, guys.

Alex: Thank you so much, Vicky.

Vicky: Thank you.

Eric: Thank you for everybody who’s listening for joining us on this week’s GeriPal podcast. Join us next week.

Alex: Until next week, folks. Bye.

Vicky: Bye.