Geoffrey P. Dunn, MD, FACS

Dame Cicely Saunders, the founder of the modern hospice movement, gave me this advice early in my palliative medicine career: “Never stop thanking those who help you along.” There are many to thank and much to be thankful for since the palliative care series in ACS Surgery News commenced in September 2012. The series proposal was enthusiastically endorsed by the then Editor, Layton F. Rikkers, and promptly launched owing to the personal interest of the first series editor, Elizabeth Wood. Their strong advocacy continues with the current co-editors, Karen Deveney and Tyler Hughes and the ever-watchful eye and assistance of managing editor, Therese Borden.

The purpose of the series was to keep the concept of surgical palliative care visible to the Fellowship through the reflections of surgeons and surgeons in training, while commenting on timely issues relevant to palliative care. We were fortunate to be coupled with Peter Angelos’s astute, widely read series on ethics. Our respective areas of interest widely overlap and have come into sharper focus for the surgical community over roughly the same period of time.

It was my hope that our contributions on palliative care would emulate the qualities and quality of Dr. Angelos’s articles – commentaries that would be of interest to the entire spectrum of surgical specialties and venues of practice. While the ethics column focused on doing the right thing, we would be focused on how to do the right thing in our response to suffering. Thanks are due to ACS Surgery News for its consistent representation of the new specialty of surgical palliative care on a par with other surgical specialties. It is culturally significant that this advocacy included strong support from laypeople.

I have been gratified and am thankful for the frequent uplifting discussions and debates triggered by palliative care columns in well-thumbed copies of ACS Surgery News in our OR lounge.

I didn’t have to look far to find inspiration and direction for the advocacy of palliative care in surgical practice. My father, David D. Dunn, MD, FACS, who represented everything noble, humane, and sensible in surgery, was a community-based general surgeon practicing in an era when the “general surgeon” performed thoracic, vascular, trauma, pediatric, and plastic surgery in addition to abdominal surgery. He had extensive experience with responding to suffering in a fundamentally affirmative way. He founded the first hospice in our community to meet the needs of a proud, cantankerous, elderly man septic with a gangrenous leg who declined amputation. He also witnessed mass suffering when he commanded a field hospital tasked with the resuscitation of survivors of a liberated Nazi concentration camp. The experience could have easily destroyed him from the resulting cynicism about humanity or PTSD. But instead he claimed he learned the first step in responding to mass calamity is the resuscitation of hope. He recalled a rescued physician who was given a clean lab coat and a stethoscope even before he was given his first real meal in years. He believed the hallmarks of steadfastness and non-abandonment are the core of the surgical persona. Late in his long life that ended just before this series launched, he observed, “It’s all palliative when you get right down to it. You [meaning the next generation] have to figure out the details and do your bit.”

The future is bright to “figure out the details and do your bit” for surgeons interested in palliative care. A number of young surgeons and surgeons in training, some who have done fellowships and become ABS certified in Hospice and Palliative Medicine, have had the opportunity to be heard and their specialty field be recognized by the greater surgical community because of ACS Surgery News.

I once asked a physically and emotionally exhausted family member of an “ICU to nowhere” patient why he thought patients get “stuck” in the ICU. He answered eloquently, “People just don’t think they should die.” The prevailing biophysical and increasingly “corporate” framework for care of the seriously ill is handicapped by its inability to effectively respond to the psychological and spiritual questions raised by this comment. Inability of surgeons to reconcile personal moral imperatives with big data and corporate medicine may be contributing to burnout, one of the most frequently acknowledged problems for surgeons today. Disease management alone, even if completely evidence-based, will not break this type of gridlock nor leave patients, families, and practitioners with a lasting sense of support. We will always need a broader framework that gives us a lens through which we can see and a voice with which we can answer the serious concerns that trouble our seriously ill patients and their families. I thank ACS Surgery News for conscientiously providing us a lens and a voice over the past 7 years.

Dr. Dunn was formerly the medical director of the palliative care consultation service at the University of Pittsburgh Medical Center Hamot in Erie, Pa., and Chair of the ACS Committee on Surgical Palliative Care.

Dame Cicely Saunders, the founder of the modern hospice movement, gave me this advice early in my palliative medicine career: “Never stop thanking those who help you along.” There are many to thank and much to be thankful for since the palliative care series in ACS Surgery News commenced in September 2012. The series proposal was enthusiastically endorsed by the then Editor, Layton F. Rikkers, and promptly launched owing to the personal interest of the first series editor, Elizabeth Wood. Their strong advocacy continues with the current co-editors, Karen Deveney and Tyler Hughes and the ever-watchful eye and assistance of managing editor, Therese Borden.

The purpose of the series was to keep the concept of surgical palliative care visible to the Fellowship through the reflections of surgeons and surgeons in training, while commenting on timely issues relevant to palliative care. We were fortunate to be coupled with Peter Angelos’s astute, widely read series on ethics. Our respective areas of interest widely overlap and have come into sharper focus for the surgical community over roughly the same period of time.

It was my hope that our contributions on palliative care would emulate the qualities and quality of Dr. Angelos’s articles – commentaries that would be of interest to the entire spectrum of surgical specialties and venues of practice. While the ethics column focused on doing the right thing, we would be focused on how to do the right thing in our response to suffering. Thanks are due to ACS Surgery News for its consistent representation of the new specialty of surgical palliative care on a par with other surgical specialties. It is culturally significant that this advocacy included strong support from laypeople.

I have been gratified and am thankful for the frequent uplifting discussions and debates triggered by palliative care columns in well-thumbed copies of ACS Surgery News in our OR lounge.

I didn’t have to look far to find inspiration and direction for the advocacy of palliative care in surgical practice. My father, David D. Dunn, MD, FACS, who represented everything noble, humane, and sensible in surgery, was a community-based general surgeon practicing in an era when the “general surgeon” performed thoracic, vascular, trauma, pediatric, and plastic surgery in addition to abdominal surgery. He had extensive experience with responding to suffering in a fundamentally affirmative way. He founded the first hospice in our community to meet the needs of a proud, cantankerous, elderly man septic with a gangrenous leg who declined amputation. He also witnessed mass suffering when he commanded a field hospital tasked with the resuscitation of survivors of a liberated Nazi concentration camp. The experience could have easily destroyed him from the resulting cynicism about humanity or PTSD. But instead he claimed he learned the first step in responding to mass calamity is the resuscitation of hope. He recalled a rescued physician who was given a clean lab coat and a stethoscope even before he was given his first real meal in years. He believed the hallmarks of steadfastness and non-abandonment are the core of the surgical persona. Late in his long life that ended just before this series launched, he observed, “It’s all palliative when you get right down to it. You [meaning the next generation] have to figure out the details and do your bit.”

The future is bright to “figure out the details and do your bit” for surgeons interested in palliative care. A number of young surgeons and surgeons in training, some who have done fellowships and become ABS certified in Hospice and Palliative Medicine, have had the opportunity to be heard and their specialty field be recognized by the greater surgical community because of ACS Surgery News.

I once asked a physically and emotionally exhausted family member of an “ICU to nowhere” patient why he thought patients get “stuck” in the ICU. He answered eloquently, “People just don’t think they should die.” The prevailing biophysical and increasingly “corporate” framework for care of the seriously ill is handicapped by its inability to effectively respond to the psychological and spiritual questions raised by this comment. Inability of surgeons to reconcile personal moral imperatives with big data and corporate medicine may be contributing to burnout, one of the most frequently acknowledged problems for surgeons today. Disease management alone, even if completely evidence-based, will not break this type of gridlock nor leave patients, families, and practitioners with a lasting sense of support. We will always need a broader framework that gives us a lens through which we can see and a voice with which we can answer the serious concerns that trouble our seriously ill patients and their families. I thank ACS Surgery News for conscientiously providing us a lens and a voice over the past 7 years.

Dr. Dunn was formerly the medical director of the palliative care consultation service at the University of Pittsburgh Medical Center Hamot in Erie, Pa., and Chair of the ACS Committee on Surgical Palliative Care.

Dame Cicely Saunders, the founder of the modern hospice movement, gave me this advice early in my palliative medicine career: “Never stop thanking those who help you along.” There are many to thank and much to be thankful for since the palliative care series in ACS Surgery News commenced in September 2012. The series proposal was enthusiastically endorsed by the then Editor, Layton F. Rikkers, and promptly launched owing to the personal interest of the first series editor, Elizabeth Wood. Their strong advocacy continues with the current co-editors, Karen Deveney and Tyler Hughes and the ever-watchful eye and assistance of managing editor, Therese Borden.

The purpose of the series was to keep the concept of surgical palliative care visible to the Fellowship through the reflections of surgeons and surgeons in training, while commenting on timely issues relevant to palliative care. We were fortunate to be coupled with Peter Angelos’s astute, widely read series on ethics. Our respective areas of interest widely overlap and have come into sharper focus for the surgical community over roughly the same period of time.

It was my hope that our contributions on palliative care would emulate the qualities and quality of Dr. Angelos’s articles – commentaries that would be of interest to the entire spectrum of surgical specialties and venues of practice. While the ethics column focused on doing the right thing, we would be focused on how to do the right thing in our response to suffering. Thanks are due to ACS Surgery News for its consistent representation of the new specialty of surgical palliative care on a par with other surgical specialties. It is culturally significant that this advocacy included strong support from laypeople.

I have been gratified and am thankful for the frequent uplifting discussions and debates triggered by palliative care columns in well-thumbed copies of ACS Surgery News in our OR lounge.

I didn’t have to look far to find inspiration and direction for the advocacy of palliative care in surgical practice. My father, David D. Dunn, MD, FACS, who represented everything noble, humane, and sensible in surgery, was a community-based general surgeon practicing in an era when the “general surgeon” performed thoracic, vascular, trauma, pediatric, and plastic surgery in addition to abdominal surgery. He had extensive experience with responding to suffering in a fundamentally affirmative way. He founded the first hospice in our community to meet the needs of a proud, cantankerous, elderly man septic with a gangrenous leg who declined amputation. He also witnessed mass suffering when he commanded a field hospital tasked with the resuscitation of survivors of a liberated Nazi concentration camp. The experience could have easily destroyed him from the resulting cynicism about humanity or PTSD. But instead he claimed he learned the first step in responding to mass calamity is the resuscitation of hope. He recalled a rescued physician who was given a clean lab coat and a stethoscope even before he was given his first real meal in years. He believed the hallmarks of steadfastness and non-abandonment are the core of the surgical persona. Late in his long life that ended just before this series launched, he observed, “It’s all palliative when you get right down to it. You [meaning the next generation] have to figure out the details and do your bit.”

The future is bright to “figure out the details and do your bit” for surgeons interested in palliative care. A number of young surgeons and surgeons in training, some who have done fellowships and become ABS certified in Hospice and Palliative Medicine, have had the opportunity to be heard and their specialty field be recognized by the greater surgical community because of ACS Surgery News.

I once asked a physically and emotionally exhausted family member of an “ICU to nowhere” patient why he thought patients get “stuck” in the ICU. He answered eloquently, “People just don’t think they should die.” The prevailing biophysical and increasingly “corporate” framework for care of the seriously ill is handicapped by its inability to effectively respond to the psychological and spiritual questions raised by this comment. Inability of surgeons to reconcile personal moral imperatives with big data and corporate medicine may be contributing to burnout, one of the most frequently acknowledged problems for surgeons today. Disease management alone, even if completely evidence-based, will not break this type of gridlock nor leave patients, families, and practitioners with a lasting sense of support. We will always need a broader framework that gives us a lens through which we can see and a voice with which we can answer the serious concerns that trouble our seriously ill patients and their families. I thank ACS Surgery News for conscientiously providing us a lens and a voice over the past 7 years.

Dr. Dunn was formerly the medical director of the palliative care consultation service at the University of Pittsburgh Medical Center Hamot in Erie, Pa., and Chair of the ACS Committee on Surgical Palliative Care.

It was a banner year in 1998 for the moral and ethical evolution of the College. That year saw the release of its Statement of Principles of End-of-Life Care, a seminal document for the emerging framework of surgical palliative care and the first light of the work of my colleague, Peter Angelos, MD, FACS, which did much to make made ethics a less arcane element of surgical practice. These developments followed the 1997 Clinical Congress during which the College joined the then-active national debate about physician-assisted suicide.

The national debate eventually culminated with the U.S. Supreme Court’s two 1997 rulings that physician-assisted suicide is not a protected liberty interest under the Constitution. These rulings in Vacco v. Quill and Washington v. Glucksberg deferred to the states the legalization of physician-assisted suicide.

Kill the suffering, not the patient

It was ironic that the College’s attention to surgical palliative care started, literally, with a dead end. The 1997 symposium’s focus on physician-assisted suicide revealed how little there was in the surgeon’s toolbox to assist seriously ill patients and their families. At this well-attended event with a distinguished panel of surgeons and ethicists moderated by the late Thomas Krizek, MD, FACS, I heard fear of death, fear of suffering, and fear of our helplessness as practitioners in the face of our patients’ deaths. The debate was about control, not the effective response to the many species of suffering encountered in surgical practice.

Hospice care and the nascent concept of palliative care were acknowledged by both sides of the debate as beneficial but as distinctly apart from surgery. The need for improved palliative care was the one unifying idea that emerged from that day’s discussion. All sides seemed to agree that striving to mitigate suffering during the course of any serious illness would be preferable to allowing it to continue unabated until silencing it with deliberate death as a last resort. The ensuing challenge for surgeons would be the reconciliation of cure and palliation, each so much a part of surgical history, especially in the past 200 years. This would prove to be a tall order as surgeons had done such a tidy job separating these two priorities without even realizing it since the second World War. Nothing less than the soul of surgery (and medicine) would be at stake from the relentless technocratic “progress” that threatened to swallow health care and so many other aspects of our culture – a culture that perhaps has been too intoxicated by the individual “pursuit of life, liberty, and happiness” while overlooking the suffering of one’s neighbor.

Recent evidence of burnout raises the possibility that we surgeons have internalized this conflict. Because of our sacred fellowship in healing, are we now, as we were 20 years ago, in the midst of a new spiritual crisis? As the operative repertoire and our professional status become increasingly transient we will be compelled to ground our identities in something more fulfilling and enduring.

Hope in fellowship

Now, as in 1998, there is hope. Hope lies in our fellowship. The focus of palliative care as understood by surgeons has broadened considerably, encouraged by the gradual public acceptance of palliative approaches to care extending beyond hospice care and the generally favorable experiences surgeons have had with palliative care teams, some of which have been directed by surgeons. There are now dozens of surgeons currently certified in Hospice and Palliative Medicine by the American Board of Surgery who are much more skilled in palliative care than anyone practicing in 1998. The ABS’s decision (2006) to offer certification in Hospice and Palliative Medicine was, in itself, an indication of how far things had progressed since 1998.

Several challenges to contemporary surgery will benefit from the growing reservoir of palliative care expertise such as enhanced communication skill, opioid management, and burnout. The concept of shared decision making is only one example. The multidimensional understanding of suffering, a cardinal principle of palliative philosophy, could transform the current dilemma of “What do we do about opioids?” to the scientific and social research question, “What should be done with opioid receptors and countless other receptors that shape the pain experience?” And lastly, the current postgraduate educational focus on communication and burnout indicate a readiness for introspection and fellowship by surgeons, a necessary prerequisite in meeting any existential or spiritual challenge to our art.

We have come a long way in 20 years but there are still miles to go before we sleep.

Dr. Dunn was formerly the medical director of the palliative care consultation service at the University of Pittsburgh Medical Center Hamot in Erie, Pa., and Chair of the ACS Committee on Surgical Palliative Care.

It was a banner year in 1998 for the moral and ethical evolution of the College. That year saw the release of its Statement of Principles of End-of-Life Care, a seminal document for the emerging framework of surgical palliative care and the first light of the work of my colleague, Peter Angelos, MD, FACS, which did much to make made ethics a less arcane element of surgical practice. These developments followed the 1997 Clinical Congress during which the College joined the then-active national debate about physician-assisted suicide.

The national debate eventually culminated with the U.S. Supreme Court’s two 1997 rulings that physician-assisted suicide is not a protected liberty interest under the Constitution. These rulings in Vacco v. Quill and Washington v. Glucksberg deferred to the states the legalization of physician-assisted suicide.

Kill the suffering, not the patient

It was ironic that the College’s attention to surgical palliative care started, literally, with a dead end. The 1997 symposium’s focus on physician-assisted suicide revealed how little there was in the surgeon’s toolbox to assist seriously ill patients and their families. At this well-attended event with a distinguished panel of surgeons and ethicists moderated by the late Thomas Krizek, MD, FACS, I heard fear of death, fear of suffering, and fear of our helplessness as practitioners in the face of our patients’ deaths. The debate was about control, not the effective response to the many species of suffering encountered in surgical practice.

Hospice care and the nascent concept of palliative care were acknowledged by both sides of the debate as beneficial but as distinctly apart from surgery. The need for improved palliative care was the one unifying idea that emerged from that day’s discussion. All sides seemed to agree that striving to mitigate suffering during the course of any serious illness would be preferable to allowing it to continue unabated until silencing it with deliberate death as a last resort. The ensuing challenge for surgeons would be the reconciliation of cure and palliation, each so much a part of surgical history, especially in the past 200 years. This would prove to be a tall order as surgeons had done such a tidy job separating these two priorities without even realizing it since the second World War. Nothing less than the soul of surgery (and medicine) would be at stake from the relentless technocratic “progress” that threatened to swallow health care and so many other aspects of our culture – a culture that perhaps has been too intoxicated by the individual “pursuit of life, liberty, and happiness” while overlooking the suffering of one’s neighbor.

Recent evidence of burnout raises the possibility that we surgeons have internalized this conflict. Because of our sacred fellowship in healing, are we now, as we were 20 years ago, in the midst of a new spiritual crisis? As the operative repertoire and our professional status become increasingly transient we will be compelled to ground our identities in something more fulfilling and enduring.

Hope in fellowship

Now, as in 1998, there is hope. Hope lies in our fellowship. The focus of palliative care as understood by surgeons has broadened considerably, encouraged by the gradual public acceptance of palliative approaches to care extending beyond hospice care and the generally favorable experiences surgeons have had with palliative care teams, some of which have been directed by surgeons. There are now dozens of surgeons currently certified in Hospice and Palliative Medicine by the American Board of Surgery who are much more skilled in palliative care than anyone practicing in 1998. The ABS’s decision (2006) to offer certification in Hospice and Palliative Medicine was, in itself, an indication of how far things had progressed since 1998.

Several challenges to contemporary surgery will benefit from the growing reservoir of palliative care expertise such as enhanced communication skill, opioid management, and burnout. The concept of shared decision making is only one example. The multidimensional understanding of suffering, a cardinal principle of palliative philosophy, could transform the current dilemma of “What do we do about opioids?” to the scientific and social research question, “What should be done with opioid receptors and countless other receptors that shape the pain experience?” And lastly, the current postgraduate educational focus on communication and burnout indicate a readiness for introspection and fellowship by surgeons, a necessary prerequisite in meeting any existential or spiritual challenge to our art.

We have come a long way in 20 years but there are still miles to go before we sleep.

Dr. Dunn was formerly the medical director of the palliative care consultation service at the University of Pittsburgh Medical Center Hamot in Erie, Pa., and Chair of the ACS Committee on Surgical Palliative Care.

It was a banner year in 1998 for the moral and ethical evolution of the College. That year saw the release of its Statement of Principles of End-of-Life Care, a seminal document for the emerging framework of surgical palliative care and the first light of the work of my colleague, Peter Angelos, MD, FACS, which did much to make made ethics a less arcane element of surgical practice. These developments followed the 1997 Clinical Congress during which the College joined the then-active national debate about physician-assisted suicide.

The national debate eventually culminated with the U.S. Supreme Court’s two 1997 rulings that physician-assisted suicide is not a protected liberty interest under the Constitution. These rulings in Vacco v. Quill and Washington v. Glucksberg deferred to the states the legalization of physician-assisted suicide.

Kill the suffering, not the patient

It was ironic that the College’s attention to surgical palliative care started, literally, with a dead end. The 1997 symposium’s focus on physician-assisted suicide revealed how little there was in the surgeon’s toolbox to assist seriously ill patients and their families. At this well-attended event with a distinguished panel of surgeons and ethicists moderated by the late Thomas Krizek, MD, FACS, I heard fear of death, fear of suffering, and fear of our helplessness as practitioners in the face of our patients’ deaths. The debate was about control, not the effective response to the many species of suffering encountered in surgical practice.

Hospice care and the nascent concept of palliative care were acknowledged by both sides of the debate as beneficial but as distinctly apart from surgery. The need for improved palliative care was the one unifying idea that emerged from that day’s discussion. All sides seemed to agree that striving to mitigate suffering during the course of any serious illness would be preferable to allowing it to continue unabated until silencing it with deliberate death as a last resort. The ensuing challenge for surgeons would be the reconciliation of cure and palliation, each so much a part of surgical history, especially in the past 200 years. This would prove to be a tall order as surgeons had done such a tidy job separating these two priorities without even realizing it since the second World War. Nothing less than the soul of surgery (and medicine) would be at stake from the relentless technocratic “progress” that threatened to swallow health care and so many other aspects of our culture – a culture that perhaps has been too intoxicated by the individual “pursuit of life, liberty, and happiness” while overlooking the suffering of one’s neighbor.

Recent evidence of burnout raises the possibility that we surgeons have internalized this conflict. Because of our sacred fellowship in healing, are we now, as we were 20 years ago, in the midst of a new spiritual crisis? As the operative repertoire and our professional status become increasingly transient we will be compelled to ground our identities in something more fulfilling and enduring.

Hope in fellowship

Now, as in 1998, there is hope. Hope lies in our fellowship. The focus of palliative care as understood by surgeons has broadened considerably, encouraged by the gradual public acceptance of palliative approaches to care extending beyond hospice care and the generally favorable experiences surgeons have had with palliative care teams, some of which have been directed by surgeons. There are now dozens of surgeons currently certified in Hospice and Palliative Medicine by the American Board of Surgery who are much more skilled in palliative care than anyone practicing in 1998. The ABS’s decision (2006) to offer certification in Hospice and Palliative Medicine was, in itself, an indication of how far things had progressed since 1998.

Several challenges to contemporary surgery will benefit from the growing reservoir of palliative care expertise such as enhanced communication skill, opioid management, and burnout. The concept of shared decision making is only one example. The multidimensional understanding of suffering, a cardinal principle of palliative philosophy, could transform the current dilemma of “What do we do about opioids?” to the scientific and social research question, “What should be done with opioid receptors and countless other receptors that shape the pain experience?” And lastly, the current postgraduate educational focus on communication and burnout indicate a readiness for introspection and fellowship by surgeons, a necessary prerequisite in meeting any existential or spiritual challenge to our art.

We have come a long way in 20 years but there are still miles to go before we sleep.

Dr. Dunn was formerly the medical director of the palliative care consultation service at the University of Pittsburgh Medical Center Hamot in Erie, Pa., and Chair of the ACS Committee on Surgical Palliative Care.

Recent public and professional attention to what is now called the opioid epidemic has obvious implications for surgery and palliative care. Because of the status of “epidemic,” there is a sense of urgency within the surgical and palliative care community to reevaluate the assessment and treatment of patients for whom opioid therapy is being considered.

• Expand your patient’s pain history to include nonphysical dimensions of pain and refer appropriately.
• Know your opioids; carry an opioid conversion table. Errors in opioid conversion can result in significant undertreatment of pain but can result in overdosage just as easily.
• Know your pharmacist. Pharmacists are valuable allies in safe opioid prescribing and monitoring practices.
• Be wary of “standardized” order sets that include opioids. There is no standard dose or standard patient as we are rapidly learning from genomics.
• Utilize your state’s patient drug-monitoring program – a new pain for clinicians, but some headaches are worth it. It clearly has already put the brakes on opioid prescribing.

Given the recent public and professional attention to the problems of opioid misuse, there is a long-overdue opportunity to reassess not only the indications and management of opioid therapy but also our more general approach to the management of pain. There is now an opportunity for surgeons to play a major role in improving opioid-prescribing practice. One potentially successful approach could be better assessment and management of pain through an awareness and application of palliative care principles. Like all encounters with uncertainty, the best way out of the current opioid dilemma is the way through: Surgeons should not abandon opioids but – in conjunction with nurses, palliative care practitioners, pharmacists, and pain and anesthesia specialists – reinvent their role in the war on suffering.


 

Dr. Dunn is the medical director of the palliative care consultation service at the University of Pittsburgh Medical Center Hamot in Erie, Pa., and vice chair of the ACS Committee on Surgical Palliative Care.

Recent public and professional attention to what is now called the opioid epidemic has obvious implications for surgery and palliative care. Because of the status of “epidemic,” there is a sense of urgency within the surgical and palliative care community to reevaluate the assessment and treatment of patients for whom opioid therapy is being considered.

• Expand your patient’s pain history to include nonphysical dimensions of pain and refer appropriately.
• Know your opioids; carry an opioid conversion table. Errors in opioid conversion can result in significant undertreatment of pain but can result in overdosage just as easily.
• Know your pharmacist. Pharmacists are valuable allies in safe opioid prescribing and monitoring practices.
• Be wary of “standardized” order sets that include opioids. There is no standard dose or standard patient as we are rapidly learning from genomics.
• Utilize your state’s patient drug-monitoring program – a new pain for clinicians, but some headaches are worth it. It clearly has already put the brakes on opioid prescribing.

Given the recent public and professional attention to the problems of opioid misuse, there is a long-overdue opportunity to reassess not only the indications and management of opioid therapy but also our more general approach to the management of pain. There is now an opportunity for surgeons to play a major role in improving opioid-prescribing practice. One potentially successful approach could be better assessment and management of pain through an awareness and application of palliative care principles. Like all encounters with uncertainty, the best way out of the current opioid dilemma is the way through: Surgeons should not abandon opioids but – in conjunction with nurses, palliative care practitioners, pharmacists, and pain and anesthesia specialists – reinvent their role in the war on suffering.


 

Dr. Dunn is the medical director of the palliative care consultation service at the University of Pittsburgh Medical Center Hamot in Erie, Pa., and vice chair of the ACS Committee on Surgical Palliative Care.

Recent public and professional attention to what is now called the opioid epidemic has obvious implications for surgery and palliative care. Because of the status of “epidemic,” there is a sense of urgency within the surgical and palliative care community to reevaluate the assessment and treatment of patients for whom opioid therapy is being considered.

• Expand your patient’s pain history to include nonphysical dimensions of pain and refer appropriately.
• Know your opioids; carry an opioid conversion table. Errors in opioid conversion can result in significant undertreatment of pain but can result in overdosage just as easily.
• Know your pharmacist. Pharmacists are valuable allies in safe opioid prescribing and monitoring practices.
• Be wary of “standardized” order sets that include opioids. There is no standard dose or standard patient as we are rapidly learning from genomics.
• Utilize your state’s patient drug-monitoring program – a new pain for clinicians, but some headaches are worth it. It clearly has already put the brakes on opioid prescribing.

Given the recent public and professional attention to the problems of opioid misuse, there is a long-overdue opportunity to reassess not only the indications and management of opioid therapy but also our more general approach to the management of pain. There is now an opportunity for surgeons to play a major role in improving opioid-prescribing practice. One potentially successful approach could be better assessment and management of pain through an awareness and application of palliative care principles. Like all encounters with uncertainty, the best way out of the current opioid dilemma is the way through: Surgeons should not abandon opioids but – in conjunction with nurses, palliative care practitioners, pharmacists, and pain and anesthesia specialists – reinvent their role in the war on suffering.


 

Dr. Dunn is the medical director of the palliative care consultation service at the University of Pittsburgh Medical Center Hamot in Erie, Pa., and vice chair of the ACS Committee on Surgical Palliative Care.