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

"* 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. The PSO intervention will be delivered during all phases of an advanced cancer patient's surgical journey.~ * Pre-surgery: 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 Care coach will also screen for psychological and emotional needs using the Distress Thermometer pre-surgery upon recruitment, 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."

"• 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 functional needs using the CFS and 5-STS at months 3, 6, 9 \& 12 post-surgery who will make referrals to rehabilitation professionals as needed."