PATH Program for for Severely Frail or Cognitively Impaired Patients Scheduled for Cancer Surgery.

Application of the Palliative and Therapeutic Harmonization (PATH) Program for Shared-decision Making for Severely Frail or Cognitively Impaired Patients Scheduled for Cancer Surgery: a Randomized Control Trial.

This is a single center, non-blinded randomized control trial taking place at the Queen Elizabeth II hospital (QEII) in Nova Scotia. Patients are eligible if aged 75 and older scheduled for elective cancer surgery and screened as severely frail or cognitively impaired. Participants will then be randomized to preoperative standard of care or geriatric assessment through the PATH clinic. Primary outcome will assess time spend at home at 6 months after the surgery.

At Nova Scotia Health Authority (NSHA), geriatric medicine colleagues developed a preoperative palliative and therapeutic harmonization (PATH) clinic with the following objectives: Assess medical conditions, health trajectory, and baseline frailty. Conduct an in-depth discussion with the patient (or their substitute decision maker) to review medical conditions and how frailty stage impacts decision-making about surgery. 3. Co-develop a care plan, including ways to optimize health. The investigators have elaborated a single center randomized cohort trial for patients aged 75 and older, screened as severely frail or cognitively impaired scheduled for curative or palliative-intent surgery for bronchopulmonary, oropharyngeal, orthopaedic, gynaecological, breast or gastrointestinal cancers. Patients enrolled in the trial will be randomized to standard of care preoperative assessment versus PATH geriatric care arm.

Patients will undergo the usual preoperative assessment from preoperative clinic which includes standard general internal medicine and anesthesia assessment.

Geriatric assessment through PATH clinic which includes an evaluation of comorbidities, health trajectory and baseline frailty as well as conducting an in-depth discussion with the patient on how frailty stage impacts decision-making about surgery in order to co-develop a care plan.

Number of days spent at home vs in a hospital or care-facility unit dichotomized as low vs high time at home. High time at home defined as 14 or fewer institution days, and low time defined as more than 14 institution days at 6 months.

Receipt of any homeware service (nursing, wound care, social workers, physiotherapy) from the day of postoperative discharge from the hospital.

Participant passing away or developing a new disability, from the day of index surgery. Assessed using the WHODAS 2.0 disability scale.

Preoperative factors associated with increased home care utilization, death, or new onset disability.

Assessed from date of randomization until documented confirmation that patient has opted for non surgical approach, assessed up to 6 months.

Decisional Regret Scale ranging from 0-100 scores measure the distress or remorse regarding the patient's decision made about undergoing surgery.

Inclusion Criteria: Patients must have a pathologically confirmed diagnosis of bronchopulmonary, oropharyngeal, orthopaedic, gynaecological, breast or gastrointestinal cancer surgery. Patients must be scheduled and consented for curative or palliative intent surgery. Patients must be aged 75 or older. Patients must be screened by the CFS to have: 4a. Mild or greater frailty (CFS equal or greater than 5) due to cognitive impairment. 4b. Moderate or greater frailty (CFS equal or greater than 6) due to medical/physical conditions. 5. Informed consent for participation must be received. Exclusion Criteria: Patients cannot be a resident in a long-term care facility prior to the cancer diagnosis. Urgent/ emergent cases are excluded.

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