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Abstract

Background:

Palliative care should be delivered alongside surgical care for adults with serious illness. Yet, most do not routinely integrate palliative principles in their surgical practices.

Objectives:

This study aims to examine barriers to integration of palliative care in surgery using a socio-ecological framework.

Design:

A qualitative study using semi-structured, video-based interviews was conducted.

Methods:

Qualitative interviews were conducted between April and July 2023 in a tertiary academic center in Singapore. Surgeons were purposively sampled across various surgical subspecialty teams. The interview guide was informed by the socio-ecological model (SEM), exploring individual, interpersonal, community, organizational, and policy level barriers to surgical palliative care, that is, the integration of palliative care principles in surgical care. Reflexive thematic analysis was used to analyze the data.

Results:

Fourteen surgeons (50% male, with an average of 12 years of practice) participated in this study. Three themes were constructed, based on the SEM framework. At the individual level, inadequate palliative care training and a misalignment between the surgeon’s professional identity and their understanding of palliative care impede the delivery of surgical palliative care. At the interpersonal and community level, poor intra- and inter-teamwork act as barriers. At the organizational and policy level, subspecialization, lack of incentives, and organizational support further inhibit the practice of surgical palliative care.

Conclusion:

Barriers to the integration of palliative care in surgery exist at multiple levels of the SEM. Our findings highlight opportunities for targeted interventions to improve the delivery of palliative care for adults with serious illness in surgery.

Keywords

palliative care surgery surgical palliative care serious illness barriers

Introduction

Globally, approximately 20 million adults in developed countries are diagnosed with serious illness each year.¹ Serious illness is the presence of any life-limiting condition that can negatively impact function, quality of life of patients and exerts an excessive strain on caregivers.^2,3 It includes the adults with dementia, advanced cancer, end-stage renal or heart disease, oxygen-dependent pulmonary disease, and other life-limiting diseases.⁴ Up to 40% of adults with serious illness undergo surgery, and they represent a vulnerable group, at risk of greater pain and depressive symptoms, and with higher functional and caregiving needs.^5
–7

As adults with serious illness have life-limiting conditions and are near end-of-life, professional surgical bodies have recommended for the provision of palliative care alongside life-prolonging treatments such as major surgery in this group.⁸ Palliative care is medical care aimed at improving quality of life, relieving physical, psychological, social, and spiritual suffering, and can be delivered in any care setting by both specialist and non-specialist (e.g., surgeons, primary care) clinicians.^9,10 In the context of surgery, palliative care has been shown to improve post-operative pain and other symptoms in adults with serious illness.¹¹ There is also evidence that palliative care during acute hospitalizations decreases downstream healthcare utilization, including fewer hospital days, intensive care unit stays, and emergency department visits.^12,13

Despite recommendations and the known benefits of integrating palliative care practices in surgical patients, adherence remains low: the completion rate for goals of care conversations, an important aspect of palliative care was just 18.7%, and advanced care planning was documented in only 11.9% of seriously ill adults planned for major surgery.^14
–16 In a recent survey of surgical oncologists, most expressed a lacked confidence in delivering palliative care. This was attributed to inadequate palliative care education opportunities during surgical training.^7,11,17 This knowledge gap, together with misconceptions about palliative care among surgeons, are known barriers to the integration of palliative care in surgery.^18,19

However, it is crucial to recognize that obstacles to surgical palliative care go beyond the levels of individual surgeons and may include interpersonal, community, institutional, and policy-related factors.⁸ As such, there is a need for a comprehensive assessment of factors on multiple levels that either facilitate or impede a surgeon’s practice of palliative care using a theoretical framework.⁹ In this study, we adopted the socio-ecological model (SEM) to ground our exploration of barriers within a theoretical lens, allowing a deeper understanding and enabling the recognition of intricate interconnections and potential causal relationships.²⁰ This integration enhances the precision and depth of the analysis, allowing for a more nuanced comprehension of the multifaceted challenges that surgeons face in their efforts to incorporate palliative care. Consequently, this approach not only illuminates the barriers themselves but also sheds light on possible strategies to overcome them.

As such, this theory-informed study aims to explore surgical perspectives in the practice of surgical palliative care. We hope to gain an understanding of these barriers to facilitate the future development of surgeon-specific palliative care education programs.

Methods

Study design

This study employed a qualitative descriptive study design based on the COREQ (Consolidated Criteria for Reporting Qualitative Studies).^10,21 Semi-structured interviews were conducted to determine the perceived barriers and enablers to surgical palliative care, that is, the integration of palliative care principles in surgical practice.

Theoretical framework

The socio-ecological model (SEM) was employed as the theoretical framework, which served as a basis for our analysis, enabling us to comprehensively explore the multifaceted factors that hinder or facilitate the integration of palliative care principles into a surgeon’s practice.^22
–24 By adopting the SEM, we acknowledged the intricate interplay of factors at multiple levels, including the individual surgeon, interpersonal interactions, community dynamics, institutional policies, and broader healthcare system influences.^8,22 This holistic approach allowed us to gain deeper insights into the complex landscape surrounding palliative care in surgery, ultimately enhancing our understanding of the challenges and opportunities within the surgical community.

Participant selection

A total of 14 surgeons based at the Singapore General Hospital and National Cancer Centre Singapore were recruited for this study. We included surgeons whose practices involved the care of seriously ill adults. To ensure a comprehensive representation of experience levels within the field of surgery, participants were purposively selected, reflecting a diverse spectrum of expertise and background. This deliberate approach to participant selection enhanced the richness and depth of perspectives, enabling a more nuanced analysis of the factors influencing the integration of palliative care principles into surgical practices.

Data collection

One-on-one semi-structured video interviews were conducted with each participant by a qualitative trained researcher (D.W.K.J.), each lasting between 45 and 60 min. The semi-structured format allowed for a flexible yet focused approach to explore the participants’ thoughts and experiences regarding palliative care integration. Interviews were conducted virtually, utilizing video conferencing tools, to accommodate participants’ geographical locations and scheduling preferences. The interview sessions were recorded with participants’ consent to ensure accurate data capture and transcriptions. Decisions to stop data collection were based on Braun and Clarke’s (2017) recommendations.²⁵ Specifically, using the criteria of the depth of data generated from each participant and the perspectival diversity in that data, we determined when we had collected enough data to tell a rich and multifaceted research story about what had prevented or encouraged participants to incorporate palliative care into their practices.

Interview guide

A comprehensive interview guide was developed based on the study’s aims and research questions as shown in Supplemental Material 1. The guide encompassed open-ended questions that explored participants’ perceptions, experiences, and perceived barriers to integration of palliative care principles into their surgical practice. The guide also explored perceived needs and deficiencies when providing care palliative care and probed into practical challenges and adequacies of support systems in place. The guide was developed by the principal investigator (J.S.M.W.) and her research team in consult with a qualitative research expert (Y.Y.F.) and a specialist palliative care physician (A.C.P.Y.). The guide was piloted among surgical co-authors for usability prior to formal data collection.

Data analysis

The recorded interviews were transcribed verbatim and reviewed for accuracy and de-identified prior to analysis. While our study was informed by the SEM, we adopted reflexive thematic analysis as described by Braun and Clarke (2017) because of its flexibility to accommodate both inductive and deductive analytic strategies. This adaptability allows researchers to use theoretical frameworks to inform coding while remaining open to new insights grounded in the participants’ lived experiences. In phase I, D.W.K.J. and J.S.M.W. repeatedly read the transcripts and then wrote familiarization notes based on the transcripts. In phase II, the data process was sensitized by the SEM and coded at both semantic (descriptive) and latent (interpretive) levels. In phase III, they constructed candidate themes, which in phase IV and V, they reviewed and finalized using central organizing concepts. Team meetings were held with the rest of the authors. We brought our different perspectives as surgeons from different subspecialty teams and at varying levels of surgical training (N.H.S., S.H.X.C., G.C.A.T., J.Y.T., Y.G.T., M.Z.C., J.C.J.S., JCAO, CSC, JSMW), anesthesiologist (S.A.L.), specialist palliative care physician (A.C.P.Y.), and qualitative education researcher (Y.Y.F.) to enrich the analysis process.

Results

Participant characteristics

Of the 14 surgeons interviewed, 50% were male, and all were of Asian ethnicity. Most were general surgeons (35.7%), and the mean age was 35 (range 26–50). Further details are shown in Table 1.

Table 1.

Self-reported characteristics of surgeons participating in interviews on palliative care in surgery (N = 14).

Characteristics	Number	%
Gender
Female	7	50.0
Years in practice
0–5	8	57.1
6–10	2	14.2
>10	4	28.6
Surgical subspecialty
General	5	35.7
Surgical oncology	4	28.6
Hepato-pancreato-biliary	1	7.1
Colorectal	1	7.1
Vascular	1	7.1
Urology	1	7.1
Head and neck	1	7.1

Themes

We constructed three themes, which explored the barriers in surgical palliative care. They are: (1) Inadequate palliative care training and a misalignment between the surgeon’s professional identity and their understanding of palliative care at the individual level; (2) Poor intra- and inter-teamwork at the interpersonal and community levels; and (3) Subspecialization and lack of incentives and support at the organizational and policy levels. Figure 1 shows how the socio-ecological model informs our data analysis, and Supplemental Material 2 provides illustrative quotes with these themes.

Figure 1.

Concepts and themes of barriers to palliative care in surgery within the constructs of the socio-ecological model.

Inadequate palliative care training and a misalignment between the surgeon’s professional identity and their understanding of palliative care at the individual level

This theme explores how at the individual level of the SEM, several factors emerged as barriers to surgical palliative care for adults with serious illness.

A lack of knowledge and training in basic palliative principles was common, with many surgeons expressing difficulties in the following areas,

(1) Managing pain and other symptoms:

Symptom management, because right now, pharmacologically as surgeons we let our pharmacology things fall by the wayside.‬ So beyond Panadol, Tramadol, sometimes we’re often not very comfortable giving some of the medicines [stronger opioids] anymore. (P14 – Surgical Oncology)

(2) Difficult conversations during serious illness:

I think the communication issue is also difficult for most people. How to communicate end of life issues, properly elicit their goals and expectations is not easy. I would not be confident doing it, also due to lack of practice, I guess. (P3 – Vascular)

(3) Discharge and hospice planning:

The other main issue is placement. . .It’s very difficult to place patients. . .We really are very ill equipped on what to do when the hospital is no long the right place. (P3 – Vascular)

(4) Providing social and emotional support:

And emotional stuff. Especially when it comes to the social issues of the patients, I think they plague the patient a lot more than we think. And we as surgeons are not trained, I guess to even have a simple conversation on that. (P4 – Surgical Oncology)

There is also a misperception that palliative care falls outside the professional role of a surgeon. A common mindset among participants was that the professional role of the surgeon is to perform surgery rather than deliver palliative care:

Honestly, I do not see myself doing what the palliative medicine guys are currently doing, because there is so much else to do, and I am still a surgeon, so my main role is devoted to being a surgeon. (P1 – Hepato-pancreato-biliary and Transplant);

As surgeons. If you come to me, my job is to palliate your symptoms. So, I will tell you, can I operate on you to improve your symptoms? If I cannot, then I’ll pass you on to the next best person to manage your symptoms. (P9 – Urology)

Such mindsets often led to the prioritization of the development of surgical skills and technical expertise over palliative care knowledge and skills.

Furthermore, most surgeons perceive surgery as the best and often the sole solution to their patients’ problems, such that the delivery of palliative care, which prioritizes comfort, and quality of life over more aggressive surgical approaches is discouraged.

In the eyes of a surgeon. . .when they [adults with serious illness] come with a symptom, it is very hard to shake the “Number 1, what kind of surgery can I possibly give them that may possibly give them a chance.” That was how we were trained to think. And when we don’t offer it, it feels like we are holding back and not offering our best. . .that is a personality that is ingrained through our training. (P1 – Hepato-pancreato-biliary and Transplant);

I think it’s very difficult to imagine all surgeons providing palliative care because what we are brought up and trained to do, is not this [palliative care]. While I see the significance and importance of providing palliative care to patients, it is very different to what I am called to do as a surgeon. We are brought in to do surgery as surgeons right? (P4 – Surgical Oncology)

Poor intra- and inter-teamwork at the interpersonal and community levels

Within the interpersonal and community domains of the SEM, barriers to integration of palliative care in surgery centers around the dynamics and interactions among surgeons themselves and their relationship with other healthcare providers. Misalignment of priorities and goals was common among members of the surgical team, and disagreements would often arise when palliative care was advocated in the care of adults with serious illness:

Your palliative treatment [can be] easy or difficult, it’s just a matter of which team you are in. The thinking and all [towards palliative care in surgery]. Some team have colleagues that would not understand. I have been those teams before, then you are greatly limited as to what you can do, even if you believe in this whole pal[palliative] care thing, you are not going to be able to do it without the support. (P4 – Surgical Oncology);

You can try to organize . . .[a] palliative procedure for a patient, but then it may be controversial in your team. People may not be exactly in agreement with your plans. When you work in a team, it then stops there when you don't have majority agreement. (P8 – General Surgery)

The care of adults with serious illness in surgery often requires input from a multi-disciplinary team including anesthetists, medical oncologists, and other healthcare providers. Inter-disciplinary conflict and disagreements also posed as a significant barrier to the successful delivery of palliative care to surgical patients:

I think that there are stereotypes. . .. [most other healthcare providers believe that] the surgeons only want to chop [do surgery, without considering other treatment options]. The oncologist wants to . . .[administer] palliative chemo [chemotherapy]. . .. [it is difficult to have a] conversation without the accusations flying. (P1 – Hepato-pancreato-biliary and Transplant);

The ICU [intensive care unit, referring to anaesthesiologists] guys tend to accuse us of being trigger happy [with offering high risk surgery for adults with serious illness] and we accuse them of playing God and executioner at the same time. (P1 – Hepato-pancreato-biliary and Transplant)

Subspecialization, lack of incentives, and support at the organization and policy level

At the organization level of the SEM, barriers to integration of palliative care in surgery include an organizational culture that encourages subspecialization in healthcare delivery. The involvement of multiple subspecialty teams in the care of adults with serious illness often result in care that is fragmented and compartmentalized, with surgical and palliative care teams working in isolation:

The care has become very fragmented because of. . . [sub]specializations. So, everyone . . .sees one doctor for one condition. . .So you are probably not going to be efficient under this current model of care to care for the palliative needs of your patients when you are a surgeon in a surgical department because the care is split up. This goes here, that goes here. (P9 – Urology)

At the policy level, there is also a lack of incentive to encourage surgeons to engage in palliative care practices. Current reimbursement policies and performance indicators fail to acknowledge nor remunerate surgeons who go the extra mile to provide palliative care for adults with serious illness:

As surgeons, we have other KPIs [Key Performance Indicators which affect salary and bonus disbursements] . . .one of it is how many [surgical] cases we do. . .how many patients I see. . .having these tough end of life conversations, they take a while and you set aside the time. . . . [instead of performing one end of life conversation] I can see six to 10 other patients in the clinic. (P1 – Hepato-pancreato-biliary and Transplant);

I think the most glaring thing are like KPIs [Key Performance Indicators, including] Hospitalization, length of stay, post-op[erative] mortality, mortality . . . palliative care [patients with] . . . prognosis of less than three months. The very cases of these patients go against the KPIs that we are measured upon. (P4 – Surgical Oncology)

Finally, the absence of a robust and accessible support system for surgeons who are keen to practice palliative care hinders its widespread adoption. In fact, following training and education in palliative care, most surgeons expressed the need for supervision and mentorship by specialist palliative care teams to ensure the optimal delivery of palliative care:

Some on the ground guidance for the first few patients we manage may be helpful. . .for example, if after I do [a palliative care] course and get back to my clinical work, the first two to three referrals for [seriously ill] patients . . .[it will be] helpful if, [there’s] someone managing the patient and the care together with me. . .to make sure that I’m applying these [palliative principles] correctly and in an appropriate way. (P6 – Surgical Oncology);

A team that’s out there to provide multidisciplinary opinion on the care and [I don’t have to] try to manage these patients alone. . .because end of life care is complex. (P8 – General Surgery)

Discussion

In this qualitative study exploring barriers in the operationalization of palliative care in surgery using the socio-ecological model, we found multiple challenges at the individual, interpersonal, community, organization, and policy levels. At the individual level, inadequate palliative care training and a misalignment between the surgeon’s professional identity and their understanding of palliative care impedes surgical palliative care. At the interpersonal and community level, poor intra- and inter-teamwork among providers caring for adults with serious illness poses a challenge. At the organization and policy levels, subspecialization and the lack of incentivizing policies and a robust support system for surgeons represent key barriers.²⁶

In 2017, the American College of Surgeons Trauma Quality Improvement Program published the palliative care best practice guidelines, recommending the delivery of palliative care during surgical episodes for adults with serious illness.²⁷ Yet, adherence to palliative care practices remain low.²⁸ In a large retrospective cohort study of adults with serious illness, Pierce et al. found that only 25% of adults had documented goals of care discussions, an important measure for palliative care delivery, during surgical trauma admissions.²⁹ Dismal rates of palliative care delivery in surgery were also found in other academic centers, with Lee et al. reporting that code status clarification, goals of care discussions, palliative care consults, and hospice assessment occurred in 27%, 18%, 4%, and 4%, respectively, among adults with life-threatening illness.³⁰ The current study, through an in-depth qualitative exploration of the barriers to palliative care in surgery, we identified modifiable factors that may be targeted to address the suboptimal delivery of palliative care best practices for adults with serious illness in surgery.

At the individual level, inadequate palliative care training and exposure underlies the inability of surgeons to successfully integrate palliative care principles into surgical care. In a survey of members of the American Society of Colon and Rectal Surgeons, 76% reported no formal education in palliative care, including communication regarding end-of-life issues and symptom management.⁶ Among surgeons who received palliative care training, median training duration was 10 h, as compared with the 50 h of training received by medical intensivists.^31
–33 In Asia, similar challenges exist, with healthcare providers expressing difficulties in providing emotional support, managing social issues and family expectations during end-of-life for adults with serious illness in surgery.³⁴ Most attributed these deficiencies to a lack of under- and postgraduate training opportunities in palliative care. This is consistent with our findings, where participants voiced discomfort in providing various aspects of end-of-life care, including pain and symptom management, providing social and emotional support and communication.

Within the surgical community, the widely held belief that the main professional role of a surgeon is to perform surgery, and surgical attempts by “doing everything” provides the best chance of success for patients, represent key barriers to palliative care practices. Our participants’ values mirror the “rescue” or “heroic” posture described by Joan Casell in 1986: “You could not have a good surgeon who did not believe in the concept of the Hero... and every surgical trainee worth his salt would like to be a hero.”^35,36 This ingrained mentality that surgeons need to “do everything” to fix surgical patients, contradicts the concept of palliative care where comfort and quality of life takes precedence.^37,38 Therefore, our findings highlight the need to devise strategies to enable a mindset shift from an aggressive do everything ethos to a patient-centered palliative surgical care approach through education, awareness, and eventually culture change. This may include the incorporation of structured palliative care education programs during surgical residency training, and regular compliance checks to ensure that palliative care best practices are well integrated into surgical care in patients with serious illness.

The successful delivery of palliative care in surgical patients with serious illness often requires a multi-disciplinary team.^16,39 However differing opinions and discordant perceptions over who knows best and who should decide, creates conflict over treatment decision during end-of-life.^40,41 In a qualitative study aimed at understanding communication between surgeons and intensive care physicians, Haas et al. found that major barriers to effective communication exist, especially near end-of-life, where intensivists tended maintain a rigid approach to the intensivist-led model, often excluding surgeons from end-of-life discussions.³⁸ In our study, we found that other healthcare professionals, including medical oncologists, and intensivists, held stereotypical views that a surgeon’s role does not include the provision of palliative care. This acts as a significant deterrent preventing the routine adoption of surgical palliative care. Furthermore, among surgeons, differing views on the adoption of palliative care in surgery exist, discouraging palliative care “converts” from actively promoting palliative concepts. This was well-expressed by P14: “people in surgery who are more interested in palliative care, they are perceived to be softies, weaklings, inferior or just having like misguided career intentions or being in the wrong place. So that makes it hard for someone to push for palliative care when you are in that type of department or team.” Pearl Katz, in her exploration of surgical culture, concurs that it’s the interplay of the individual surgeons’ heroic tendencies that creates a community of practice where the ideal surgical standard involves the obsessive pursuit of life-prolongation over palliative care.⁴² To address these community-level barriers, the establishment of a supportive multi-disciplinary palliative surgical care team is essential and can create a community of practice and surgical culture that encourages surgical palliative care practices.

At broader organizational and policy levels, participating surgeons expressed a lack of incentives to adopt palliative care among surgical patients since key performance indicators (KPIs) set out by healthcare organizations do not recognize nor remunerate the delivery of palliative care. In the current study, surgeons were based in a government-affiliated tertiary academic center where palliative care in surgery appears to “goes against the KPIs that we are measured upon” – P4.⁴³ The importance of performance indicators and reimbursement, financial or otherwise, cannot be understated. In a systematic review evaluating the impact of reimbursement methods on clinical behavior of primary care physicians, Gosden et al. found that a fee-for-service model resulted in more patient visits, greater continuity of care, and more diagnostic or curative services.⁴⁴ Findings of our study underscore the need to realign organizational incentive structures. This includes revisiting KPIs to consider palliative and quality-of-life outcomes over conventional surgical targets for patients with serious illness. We provide a summary of recommended strategies to overcome current barriers to surgical palliative care at the individual, interpersonal and community, and organization and policy levels in Table 2.

Table 2.

Barriers and recommended strategies for integrating palliative care in surgery.

Level	Barriers to palliative care delivery in surgery	Recommendation
Individual	Inadequate palliative care trainingMisalignment between surgeon’s professional identity and their understanding of palliative care	Structured palliative care education and training for surgical trainees
Interpersonal and community	Poor intra- and inter-teamwork among providers caring for adults with serious illness in surgery	Establishment of a multi-disciplinary palliative surgical care team (including surgeons, specialist palliative care physicians, intensivists, medical oncologists, etc.) to create a community of practice that encourages palliative care delivery among surgical patients
Organization and policy	SubspecializationLack of incentivizing policiesLack of a support system	Realign key performance indicators to include outcomes that are palliative care and patient-centricMulti-disciplinary palliative surgical care discussion platform where surgeons can be well-supported by specialist palliative care experts when challenged with surgical patients with complex end-of-life issues

To ensure methodological rigor, the current study employed purposeful sampling strategies to capture a diverse range of surgical perspectives. All interviews were conducted by a single qualitatively trained researcher to ensure uniformity and mitigate bias. Interviews were recorded and transcribed verbatim by two independent research assistants for accuracy. During data analysis, reflexivity was practiced by the research team through reflective journaling and peer debriefing to account for potential biases. These steps collectively support the trustworthiness and rigor of our findings.

The current study has several limitations. First, we sampled surgeons who practiced at an Asian academic center, as such, our findings may not be generalizable to all other surgeons. Nevertheless, our sample included surgeons from different subspecialties and at varying years of practice and should capture a wide perspective of surgeons who are actively involved in the care of patients with serious illness. The voluntary nature of participants may also lead to selection bias where included surgeons were more inclined or familiar with the practice of palliative care in surgery, hence understating potential barriers.

Conclusion

The current study sheds light on surgeon-reported barriers on palliative care delivery for surgical patients with serious illness. Barriers are multi-layered and occur at personal, interpersonal, community, organizational, and policy levels. A multi-prong approach targeting these challenges is necessary to create a supportive environment where palliative care practices can flourish, with the central mission of improving quality of care for surgical patients.

Supplemental Material

sj-docx-1-pcr-10.1177_26323524251370405 – Supplemental material for Palliative care in surgery: Where are we at?

Supplemental material, sj-docx-1-pcr-10.1177_26323524251370405 for Palliative care in surgery: Where are we at? by Darryl W. K. Juan, Yang Yann Foo, Natalie H. Soh, Xiaofan Zhong, Sabrina H. X. Cheok, Alethea C. P. Yee, Gerald C. A. Tay, Jin Yao Teo, Sui An Lie, Yu Guang Tan, Mingzhe Cai, Jane C. J. Seo, Johnny C. A. Ong, Claramae S. Chia and Jolene S. M. Wong in Palliative Care and Social Practice

Supplemental Material

sj-docx-2-pcr-10.1177_26323524251370405 – Supplemental material for Palliative care in surgery: Where are we at?

Supplemental material, sj-docx-2-pcr-10.1177_26323524251370405 for Palliative care in surgery: Where are we at? by Darryl W. K. Juan, Yang Yann Foo, Natalie H. Soh, Xiaofan Zhong, Sabrina H. X. Cheok, Alethea C. P. Yee, Gerald C. A. Tay, Jin Yao Teo, Sui An Lie, Yu Guang Tan, Mingzhe Cai, Jane C. J. Seo, Johnny C. A. Ong, Claramae S. Chia and Jolene S. M. Wong in Palliative Care and Social Practice

Supplemental Material

sj-docx-3-pcr-10.1177_26323524251370405 – Supplemental material for Palliative care in surgery: Where are we at?

Supplemental material, sj-docx-3-pcr-10.1177_26323524251370405 for Palliative care in surgery: Where are we at? by Darryl W. K. Juan, Yang Yann Foo, Natalie H. Soh, Xiaofan Zhong, Sabrina H. X. Cheok, Alethea C. P. Yee, Gerald C. A. Tay, Jin Yao Teo, Sui An Lie, Yu Guang Tan, Mingzhe Cai, Jane C. J. Seo, Johnny C. A. Ong, Claramae S. Chia and Jolene S. M. Wong in Palliative Care and Social Practice

Footnotes

ORCID iD

Jolene S. M. Wong

Ethical considerations

This study was approved by the SingHealth Centralized Institutional Review Board (2022/2265). Participants were assigned pseudonyms in the transcripts to protect their identities. Any identifiable information was removed during data analysis and reporting to maintain participant confidentiality.

Consent to participate

Informed consent was obtained from all participants before conducting the interviews, ensuring confidentiality, and anonymity throughout the research process.

Author contributions

Darryl W. K. Juan: Conceptualization; Data curation; Formal analysis; Funding acquisition; Investigation; Methodology; Project administration; Resources; Software; Supervision; Validation; Visualization; Writing – original draft; Writing – review & editing.

Yang Yann Foo: Conceptualization; Data curation; Formal analysis; Funding acquisition; Investigation; Methodology; Project administration; Resources; Software; Supervision; Validation; Visualization; Writing – original draft; Writing – review & editing.

Natalie H. Soh: Conceptualization; Data curation; Formal analysis; Investigation; Methodology; Project administration; Resources; Software; Supervision; Validation; Visualization; Writing – original draft; Writing – review & editing.

Xiaofan Zhong: Conceptualization; Data curation; Formal analysis; Methodology; Project administration; Resources; Software; Supervision; Validation; Visualization; Writing – original draft; Writing – review & editing.

Sabrina H. X. Cheok: Conceptualization; Data curation; Formal analysis; Methodology; Resources; Software; Supervision; Validation; Visualization; Writing – review & editing.

Alethea C. P. Yee: Conceptualization; Data curation; Formal analysis; Methodology; Resources; Software; Supervision; Validation; Visualization; Writing – review & editing.

Gerald C. A. Tay: Conceptualization; Data curation; Formal analysis; Methodology; Resources; Software; Supervision; Validation; Visualization; Writing – review & editing.

Jin Yao Teo: Conceptualization; Data curation; Formal analysis; Methodology; Resources; Software; Supervision; Validation; Visualization; Writing – review & editing.

Sui An Lie: Conceptualization; Data curation; Formal analysis; Methodology; Resources; Software; Supervision; Validation; Visualization; Writing – review & editing.

Yu Guang Tan: Conceptualization; Data curation; Formal analysis; Methodology; Resources; Software; Supervision; Validation; Visualization; Writing – review & editing.

Mingzhe Cai: Conceptualization; Data curation; Formal analysis; Methodology; Resources; Software; Supervision; Validation; Visualization; Writing – review & editing.

Jane C. J. Seo: Conceptualization; Data curation; Formal analysis; Methodology; Resources; Software; Supervision; Validation; Visualization; Writing – review & editing.

Johnny C. A. Ong: Conceptualization; Data curation; Formal analysis; Methodology; Resources; Software; Supervision; Validation; Visualization; Writing – review & editing.

Claramae S. Chia: Conceptualization; Data curation; Funding acquisition; Investigation; Methodology; Resources; Software; Supervision; Validation; Visualization; Writing – review & editing.

Jolene S. M. Wong: Conceptualization; Data curation; Formal analysis; Funding acquisition; Investigation; Methodology; Project administration; Resources; Software; Supervision; Validation; Visualization; Writing – original draft; Writing – review & editing.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study is supported by SingHealth Duke-NUS Academic Medicine Centre and the National Medical Research Council Singapore. All the funding sources had no role in the study design, data interpretation, or writing of the manuscript.

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data availability statement

The data are not publicly available due to the anonymity of participating facilities and healthcare providers. To ensure there is no privacy breach, de-identified data can be provided upon request.

Supplemental material

Supplemental material for this article is available online.

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