Care Coach-led Integrated Palliative Surgical Oncology and Rehabilitation Care Model for Advanced Cancer Patients
Effectiveness of A Care Coach-led Integrated Palliative Surgical Oncology and Rehabilitation Care Model in Patients With Advanced Cancer Undergoing Major Surgery: A Randomized Controlled Trial
Singapore General Hospital
770 participants
Aug 20, 2025
INTERVENTIONAL
Conditions
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 Criteria12
- (i) Patients:
- Aged 21 and above,
- Diagnosis of advanced cancer, i.e. stage 3 or 4 solid organ cancer or diagnosed with cancer that requires complex surgery,
- Planned for elective major surgery (Table of Surgical Procedures (TOSP) table code 4 or more or surgery involves more than one surgical discipline,
- Able to speak and read English or Chinese
- (ii) Caregivers:
- Age 21 and above,
- 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,
- Able to speak and read English or Chinese.
- (iii) Healthcare Providers (Qualitative interview only):
- Age 21 and above,
- Currently working as a Healthcare professional at SGH or NCCS and involved in this study.
Exclusion Criteria9
- (i) Patients:
- Patient refusal,
- Have complex PC needs requiring specialty palliative care (SPC) intervention before surgery,
- Active mental illness or severe dementia and certified unfit to make medical decision by a specialist physician,
- Scheduled for Emergency surgery.
- (ii) Caregivers:
- \. Unwilling to participate in the study.
- (iii) Healthcare Providers (Qualitative interview only):
- \. Unwilling to participate in the Qualitative interview.
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Interventions
* Patients will receive the current standard of care based on their surgeon's usual clinical practice. * Additionally, patients will receive the Care Coach-led Palliative Surgical Oncology (PSO) intervention during all phases of their surgical journey. * After pre-surgery consultations, care coaches will conduct Serious Illness Conversations (SIC) and focus on exploration of patients' hopes and worries, critical functions, social setup, and identification of a healthcare proxy. The SIC will also be conducted at 1, 3, 6, 9 and 12 months post-surgery. * The Care coach will also screen for psychological and emotional needs using the Distress Thermometer and Problem List (pre-surgery and at 1, 3, 6, 9 \&12 months post-surgery). This will help to identify areas requiring palliative interventions such as symptom management or psychosocial support and for follow-up actions to be taken. * ACP will also be offered at each timepoint to those who have yet to do so.
• Patients will receive services from a dedicated rehabilitation service comprising of a Rehabilitation Physician, Physiotherapist, and Dietician. * Pre-surgery: Patients will be triaged based on their frailty \[Clinical Frailty Scale (CFS)\], malnutrition risk \[Malnutrition Universal Screening Tool (MUST)\], and physical function \[5-sit-to-stand (5-STS)\] and will receive preventive rehabilitation interventions tailored to their functional needs. * During surgical admission: The rehabilitation physician will review the progress of patients and refer them to a dietitian if needed. Patients may be followed-up by a rehabilitation physician one-month post-discharge and referred to a physiotherapist if required. * Post-surgery: Patients will be screened by care coaches for health needs using the EQ-5D-5L at months 3, 6, 9 \& 12 post-surgery who will make referrals to a rehabilitation physician, nurse and psychologist, as needed.
Locations(2)
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NCT07133269