Defining Serious Illness Among Adult Surgical Patients

J Pain Symptom Manage. 2019 Nov;58(5):844-850.e2. doi: 10.1016/j.jpainsymman.2019.08.003. Epub 2019 Aug 9.

Abstract

Context: Palliative care (PC) for seriously ill surgical patients, including aligning treatments with patients' goals and managing symptoms, is associated with improved patient-oriented outcomes and decreased health care utilization. However, efforts to integrate PC alongside restorative surgical care are limited by the lack of a consensus definition for serious illness in the perioperative context.

Objectives: The objectives of this study were to develop a serious illness definition for surgical patients and identify a denominator for quality measurement efforts.

Methods: We developed a preliminary definition including a set of criteria for 11 conditions and health states. Using the RAND-UCLA Appropriateness Method, a 12-member expert advisory panel rated the criteria for each condition and health state twice, once after an in-person moderated discussion, for validity (primary outcome) and feasibility of measurement.

Results: All panelists completed both rounds of rating. All 11 conditions and health states defining serious illness for surgical patients were rated as valid. During the in-person discussion, panelists refined and narrowed criteria for two conditions (vulnerable elder, heart failure). The final definition included the following 11 conditions and health states: vulnerable elder, heart failure, advanced cancer, oxygen-dependent pulmonary disease, cirrhosis, end-stage renal disease, dementia, critical trauma, frailty, nursing home residency, and American Society of Anesthesiology Risk Score IV-V.

Conclusion: We identified a consensus definition for serious illness in surgery. Opportunities remain in measuring the prevalence, identifying health trajectories, and developing screening criteria to integrate PC with restorative surgical care.

Keywords: Delphi methods; RAND-UCLA Appropriateness Method; Surgical palliative care; quality improvement; quality measurement; serious illness.

Publication types

  • Research Support, N.I.H., Extramural