Care Coach-led Integrated Palliative Surgical Oncology and Rehabilitation Care Model for Advanced Cancer Patients

Summary

Advanced cancer is a life-limiting condition that can negatively impact quality of life and function. Patients often suffer from physical, emotional, social, spiritual, and decision-making issues. As such, most would benefit from basic palliative care (PC) which includes establishing goals of care through serious illness conversations (SIC), managing basic pain and other symptoms and addressing psychosocial needs, among others. Patients with advanced cancer are also at higher risk of functional decline due to receiving multiple concurrent treatments. Yet, among patients with advanced cancer undergoing major surgery, there has been little consideration of PC and functional needs. The palliative surgical care model is a care model in which PC educated surgical oncology teams deliver basic PC, allowing sustainable PC provision to an increasing number of patients living with advanced cancer. In a local pilot palliative surgical care model, it was found that a care coach-led palliative surgical oncology (PSO) care model significantly increased palliative care delivery, ensuring more consistent and comprehensive support for patients. In addition, cancer rehabilitation delivered by rehabilitation professionals addresses functional impairments during the cancer journey, restoring and/or maintaining function and improving quality of life. It also plays a preventive role before surgery, a restorative role during treatment, and a supportive role during cancer progression. Therefore, to address longitudinal PC and functional needs, an integrated care coach-led palliative surgical oncology rehabilitation (PSO+R) care model involving PC-trained care coaches, surgical oncology teams, rehabilitation professionals, supported by specialist palliative care (SPC) physicians who will provide PC and cancer rehabilitation throughout the patient's advanced cancer journey, is proposed.

Eligibility

Inclusion Criteria:

(i) Patients:

1. Aged 21 and above,
2. Diagnosis of advanced cancer, i.e. stage 3 or 4 solid organ cancer or diagnosed with cancer that requires complex surgery,
3. Planned for elective major surgery (Table of Surgical Procedures (TOSP) table code 4 or more or surgery involves more than one surgical discipline,
4. Able to speak and read English or Chinese

(ii) Caregivers:

1. Age 21 and above,
2. Unpaid family or informal caregiver who takes direct care of the patient's day-to-day and healthcare needs, or ensures provision of care to meet the needs, or who is the decision maker with regard to the patient's needs and healthcare,
3. Able to speak and read English or Chinese.

(iii) Healthcare Providers (Qualitative interview only):

1. Age 21 and above,
2. Currently working as a Healthcare professional at SGH or NCCS and involved in this study.

Exclusion Criteria:

(i) Patients:

1. Patient refusal,
2. Have complex PC needs requiring specialty palliative care (SPC) intervention before surgery,
3. Active mental illness or severe dementia and certified unfit to make medical decision by a specialist physician,
4. Scheduled for Emergency surgery.

(ii) Caregivers:

1\. Unwilling to participate in the study.

(iii) Healthcare Providers (Qualitative interview only):

1\. Unwilling to participate in the Qualitative interview.

Conditions2

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