ABSTRACT By 2030, adults older than 65 years will exceed 20% of the U.S. population. In parallel to this rapidly changing demographic, rates of surgery in this population are expected to increase by as much as 30%. Such patients account for a disproportionately higher share of postsurgical morbidity and mortality. Although substantial efforts have been made to reduce postsurgical complications and death, far less attention has been aimed at end-of-life care in older adults undergoing surgery or being considered for surgery (i.e., surgical patients). High quality end-of-life care among older adult surgical patients is seldom informed by the patient and family perspective. Further, elements of this care are poorly defined and largely understudied. Through our unique and robust collaborative infrastructure of surgical programs, the Michigan Surgical Quality Collaborative (MSQC), we will evaluate perceived satisfaction with and quality of end-of-life care following surgery using a previously validated Bereaved Family Survey and validated quality measures across hospitals in Michigan (Aim 1), and develop an in-depth understanding of the key elements necessary for improved end- of-life care for older adults at high risk of postsurgical death or poor outcomes (Aim 2). Informed from findings in Aims 1 and 2, we will then develop and pilot test an intervention aimed at improving end-of-life care for surgical patients and their families (Aim 3). The MSQC is the largest population-based surgical quality improvement collaborative in the U.S. comprising 73 hospitals and representing over 50,000 patients per year. This study will have an immediate impact on local and national initiatives by revealing how surgeons and hospitals can better anticipate and manage older adult surgical patients and their families’ end-of- life care needs. Results from this study will provide essential preliminary data for future studies aimed at interventions that improve end-of-life care for older adults at risk of postsurgical death or poor outcomes. Further, this research plan will lead to a unique data infrastructure through the MSQC that can be used for future studies. The project, the multidisciplinary mentorship team, and educational plan are ideally suited to address the career and leadership needs of the candidate, Pasithorn A. Suwanabol, MD, MS. Dr. Suwanabol is board-certified in general and colorectal surgery with a clinical and research interest in palliative and end-of-life care for older adult surgical patients. Her prior research experience understanding variation in surgical and palliative care, as well as the surgeon’s role in the provision of palliative care, has prepared her for this proposal. However, in order to achieve her goal of becoming a leader in improving care for older adults at high risk of postsurgical death or poor outcomes, she requires additional training in engaging patients and families into research through advanced survey and qualitative methods, clinical exposure to palliative care and geriatrics, and leadership development.

PROJECT NARRATIVE This proposal aims to identify the unmet needs of older adult surgical patients and their families and to improve the quality of end-of-life care for at-risk individuals. These results will have an immediate impact on efforts to fully understand the care that is currently provided to such patients and their families and will provide critical insight into how surgeons and hospitals can better anticipate and manage the needs of older adults at high risk of postsurgical death or poor outcomes. The associated career development plan will serve as a vehicle for the candidate’s professional development as she transitions to independent investigator status.