As vascular surgeons, we strive to practice comprehensive vascular surgery care. This entails the medical and surgical management of patients with a wide range of vascular diagnoses. Patients with advanced vascular disease experience significantly reduced quality of life and high healthcare utilization. Palliative care principles are interwoven into the care of these patients. As a vascular surgeon striving to practice comprehensive vascular surgery care, it is essential to be knowledgeable about these topics to provide better patient care.
This article aims to answer several important questions to define what surgical palliative care is, explore the current research literature, redefine misconceptions regarding surgical palliative care, and apply these concepts to the care of vascular surgery patients.
So, what is surgical palliative care? And how can you integrate surgical palliative care principles to improve the care of your vascular surgery patients? Surgical palliative care was defined by Dr. Red Hoffman, an acute care surgeon and associate hospice medical director at Mission Health in Asheville, North Carolina, as “the attention to suffering in all of its manifestations of the patient and the family under surgical care.”1 The tenets of surgical palliative care extend beyond surgical interventions to encompass medical management of vascular disease and social support such as exercise programs, smoking cessation resources, and wound care. Surgical palliative care sees the whole unique person and all aspects of their suffering, to include physical, psychological, social and spiritual.
Although vascular surgeons often implement palliative care through goals-of-care discussions, there remain further opportunities to engage mental health experts, chaplains, social workers and community resources in our approach. Even engagement with advance directives, healthcare proxy documentation, or inpatient/outpatient hospice referral can further our impact. Active implementation of surgical palliative care principles is ultimately a skill that must be learned through understanding available hospital and community resources, but it can ultimately have an immense impact on the lives of our patients.
What does the current research literature say about surgical palliative care in the vascular surgery patient population? One study examined hospital patients who died after vascular surgery, and only 25% received palliative care consultation, with a median interval of only 10 hours between consultation and patient death. Only 14% of patients in this study cohort had a documented advance directive.2 This is extremely low when put into the context that an estimated 36.7% of the U.S. population has a documented advance directive.3 A single-institution, retrospective chart review of all patients who underwent open aortic surgery showed 16.7% of patients had advance care planning documentation prior to open aortic surgery. Palliative care involvement was close to patient death, with a median interval of five (interquartile range [IQR] 2–13) days.4
In the context of peripheral arterial disease (PAD), Dr. Mimmie Kwong and colleagues studied 111 patients who received below-knee amputation for chronic limb-threatening ischemia (CLTI). One-year mortality was 21.9%. The median interval between palliative consultation and amputation was 26 days, whereas the median interval between palliative consultation and death was nine days.5 This study demonstrates a pattern of consulting palliative care closer to death than earlier evaluation after amputation.
Current studies have further demonstrated that when surgical palliative care was utilized in the care of patients with CLTI, patients had less emotional distress and less uncertainty regarding the expected course of their illness.6 Integrating palliative care was also associated with a lower likelihood of in-hospital death and increased likelihood of discharge to hospice (odds ratio [OR] 0.248, p=0.0167; OR 1.283, p<0.001) in patients after major amputation.7
The research literature on this topic is growing, and the current research defines clear opportunities for improvement in our patient care.
What are some misconceptions regarding surgical palliative care? “Why would we consult palliative care? The patient isn’t going to die anytime soon”: as a visiting medical student, I remember this response when a resident suggested consulting palliative care for a patient with debilitating chronic pain and wounds, and no great revascularization option. I was surprised by how many healthcare providers equate palliative care with end-of-life care, or only for geriatric patients. Palliative care is not only for when death is imminent or for those entering the last stages of life. Palliative care is appropriate for any patient with a serious life-limiting illness, or significant pain or distress, to improve quality of life.
Another misconception of palliative care is that consultation is admitting that there is nothing more we can do. Patients with surgical options should not be excluded from the benefit palliative care can provide. We must accept that many of our interventions are ultimately of a palliative nature and may not ultimately extend the life of our patients. However, in situations where there is room to improve our patients’ quality of life and reduce their suffering, palliative care can assist in furthering our impact.
As we progress as a field, it is imperative that we integrate surgical palliative care principles into vascular surgery practice. Enriching our current literature with more studies on multidisciplinary practice and the use of hospital/community resources in vascular-specific pathologies could help us understand how to best serve our patients and provide more comprehensive surgical care.
References
- Fox, M. New Surgical Palliative Care Society Aims to Build Community, Alleviate Suffering. American College of Surgeons, Dec. 3, 2021, www.facs.org/for-medical-professionals/news-publications/news-and-articles/bulletin/2021/12/new-surgical-palliative-care-society-aims-to-build-community-alleviate-suffering/
- Wilson DG, Harris SK, Peck H et al. Patterns of Care in Hospitalized Vascular Surgery Patients at End of Life. JAMA Surg. 2017;152(2):183–190. doi:10.1001/jamasurg.2016.3970
- Yadav, Kuldeep N et al. Approximately one in three US adults completes any type of advance directive for end-of-life care. Health Affairs, vol. 36, no. 7, July 2017, pp. 1244–1251, https://doi.org/10.1377/hlthaff.2017.0175
- Barrera-Alvarez A, Brittenham GS, Kwong M. Missed Opportunities for use of Advanced Care Planning and Palliative Care in Open Aortic Surgery. Ann Vasc Surg. 2025 Jan;110(Pt A):205–216. doi: 10.1016/j.avsg.2024.08.005. Epub 2024 Sep 27. PMID: 39343365
- Kwong M, Curtis EE, Mell MW. Underutilization of Palliative Care for Patients with Advanced Peripheral Arterial Disease. Ann Vasc Surg. 2021 Oct;76:211–217. doi: 10.1016/j.avsg.2021.07.003. Epub 2021 Aug 14. PMID: 34403753
- Cattermole TC, Schimmel ML, Carpenter RL, Callas PW, Gramling R, Bertges DJ, Ferranti KM. Integration of palliative care consultation into the management of patients with chronic limb-threatening ischemia. J Vasc Surg. 2023 Aug;78(2):454–463. doi: 10.1016/j. jvs.2022.12.069. Epub 2023 Apr 23. PMID: 37088444
- Morton C, Hayssen H, Kawaji Q, Kaufman M, Blitzer D, Uemura T, Kheirbek R, Nagarsheth K. Palliative Care Consultation is Associated with Decreased Rates of In-Hospital Mortality Among Patients Undergoing Major Amputation. Ann Vasc Surg. 2022 Oct;86:277–285. doi: 10.1016/j.avsg.2022.05.005. Epub 2022 May 18. PMID: 35595211
Tara Zielke, MD, is a PGY-2 integrated vascular surgery resident at Indiana University School of Medicine in Indianapolis.
