Palliative Care

The juxtaposition between my first 2 days of neurosurgery could not have been more profound. On my first day as a third-year medical student, the attending and chief resident let me take the lead on the first case: a straightforward brain biopsy. I got to make the incision, drill the burr hole, and perform the needle biopsy. I still remember the thrill of the technical challenge, the controlled violence of drilling into the skull, and the finesse of accessing the tumor core.

The buzz was so strong that I barely registered the diagnosis that was called back from the pathologist: glioblastoma. It was not until I saw the face of the disease the next morning that I understood the reality of a GBM diagnosis. That face belonged to a 47-year-old man who hadn’t slept all night, wide eyed with apprehension at what news I might bring. He beseeched me with questions, and though his aphasia left him stammering to get the words out, I knew exactly what he was asking: Would he live or die? It was a question I was in no position to answer. Instead, I reassured him that we were waiting on the final pathology, all the while trying to forget the fact that the frozen section suggested an aggressive subtype, surely heralding a poor prognosis.

In his poignant memoir, “Do No Harm: Stories of Life, Death and Brain Surgery” (New York: Thomas Dunne Book, 2015), Dr. Henry Marsh writes beautifully about how difficult it can be to find the balance between optimism and realism.  In one memorable passage, Dr. Marsh shows a house officer a scan of a highly malignant brain tumor and asks him what he would say to the patient. The trainee reflexively hides behind jargon, skirting around what he knew to be the truth: This tumor would kill her. Marsh presses him to admit that he’s lying, before lamenting at how hard it is to improve these critical communication skills: “When I have had to break bad news I never know whether I have done it well or not. The patients aren’t going to ring me up afterward and say, ‘Mr. Marsh, I really liked the way you told me that I was going to die,’ or ‘Mr. Marsh, you were crap.’ You can only hope that you haven’t made too much of a mess of it.”

I could certainly relate to Dr. Marsh’s house officer as I walked away from my own patient. I felt almost deceitful withholding diagnostic information from him, even if I did the “right” thing. It made me wonder, why did I want to become a neurosurgeon? Surely to help people through some of the most difficult moments of their lives. But is it possible to be a source of comfort when you are required so often to be a harbinger of death? The answer depends on whether one can envision a role for the neurosurgeon beyond the mandate of “life at all costs.”

While the field has become known for its life-saving procedures, neurosurgeons are called just as often to preside over the end of their patient’s lives – work that requires just as much skill as any technical procedure. Dr. Marsh recognized the tremendous human cost of neglecting that work. For cases that appear “hopeless,” he writes, “We often end up operating because it’s easier than being honest, and it means that we can avoid a painful conversation.”

We are only beginning to understand the many issues that neurosurgical patients face at the end of life, but so far it is clear that neurosurgical trainees require substantive training in prognostication, communication, and palliation (Crit Care Med. 2015 Sep;43[9]:1964-77 1,2; J Neurooncol. 2009 Jan;91[1]:39-43). Is there room in the current training paradigm for more formal education in these domains? As we move further into the 21st century, we must embrace the need for masterful clinicians outside of the operating room if we are to ever challenge the axiom set forth by the renowned French surgeon, René Leriche, some 65 years ago: “Every surgeon carries within himself a small cemetery, where from time to time he goes to pray – a place of bitterness and regret, where he must look for an explanation for his failures.” Let us look forward to the day when this is no longer the case.

Stephen Miranda is a medical student from the University of Rochester, who is now working as a research fellow at Ariadne Labs, a joint center for health systems innovation at Brigham & Women’s Hospital and Harvard T.H. Chan School of Public Health, both in Boston.

The juxtaposition between my first 2 days of neurosurgery could not have been more profound. On my first day as a third-year medical student, the attending and chief resident let me take the lead on the first case: a straightforward brain biopsy. I got to make the incision, drill the burr hole, and perform the needle biopsy. I still remember the thrill of the technical challenge, the controlled violence of drilling into the skull, and the finesse of accessing the tumor core.

The buzz was so strong that I barely registered the diagnosis that was called back from the pathologist: glioblastoma. It was not until I saw the face of the disease the next morning that I understood the reality of a GBM diagnosis. That face belonged to a 47-year-old man who hadn’t slept all night, wide eyed with apprehension at what news I might bring. He beseeched me with questions, and though his aphasia left him stammering to get the words out, I knew exactly what he was asking: Would he live or die? It was a question I was in no position to answer. Instead, I reassured him that we were waiting on the final pathology, all the while trying to forget the fact that the frozen section suggested an aggressive subtype, surely heralding a poor prognosis.

In his poignant memoir, “Do No Harm: Stories of Life, Death and Brain Surgery” (New York: Thomas Dunne Book, 2015), Dr. Henry Marsh writes beautifully about how difficult it can be to find the balance between optimism and realism.  In one memorable passage, Dr. Marsh shows a house officer a scan of a highly malignant brain tumor and asks him what he would say to the patient. The trainee reflexively hides behind jargon, skirting around what he knew to be the truth: This tumor would kill her. Marsh presses him to admit that he’s lying, before lamenting at how hard it is to improve these critical communication skills: “When I have had to break bad news I never know whether I have done it well or not. The patients aren’t going to ring me up afterward and say, ‘Mr. Marsh, I really liked the way you told me that I was going to die,’ or ‘Mr. Marsh, you were crap.’ You can only hope that you haven’t made too much of a mess of it.”

I could certainly relate to Dr. Marsh’s house officer as I walked away from my own patient. I felt almost deceitful withholding diagnostic information from him, even if I did the “right” thing. It made me wonder, why did I want to become a neurosurgeon? Surely to help people through some of the most difficult moments of their lives. But is it possible to be a source of comfort when you are required so often to be a harbinger of death? The answer depends on whether one can envision a role for the neurosurgeon beyond the mandate of “life at all costs.”

While the field has become known for its life-saving procedures, neurosurgeons are called just as often to preside over the end of their patient’s lives – work that requires just as much skill as any technical procedure. Dr. Marsh recognized the tremendous human cost of neglecting that work. For cases that appear “hopeless,” he writes, “We often end up operating because it’s easier than being honest, and it means that we can avoid a painful conversation.”

We are only beginning to understand the many issues that neurosurgical patients face at the end of life, but so far it is clear that neurosurgical trainees require substantive training in prognostication, communication, and palliation (Crit Care Med. 2015 Sep;43[9]:1964-77 1,2; J Neurooncol. 2009 Jan;91[1]:39-43). Is there room in the current training paradigm for more formal education in these domains? As we move further into the 21st century, we must embrace the need for masterful clinicians outside of the operating room if we are to ever challenge the axiom set forth by the renowned French surgeon, René Leriche, some 65 years ago: “Every surgeon carries within himself a small cemetery, where from time to time he goes to pray – a place of bitterness and regret, where he must look for an explanation for his failures.” Let us look forward to the day when this is no longer the case.

Stephen Miranda is a medical student from the University of Rochester, who is now working as a research fellow at Ariadne Labs, a joint center for health systems innovation at Brigham & Women’s Hospital and Harvard T.H. Chan School of Public Health, both in Boston.

The juxtaposition between my first 2 days of neurosurgery could not have been more profound. On my first day as a third-year medical student, the attending and chief resident let me take the lead on the first case: a straightforward brain biopsy. I got to make the incision, drill the burr hole, and perform the needle biopsy. I still remember the thrill of the technical challenge, the controlled violence of drilling into the skull, and the finesse of accessing the tumor core.

The buzz was so strong that I barely registered the diagnosis that was called back from the pathologist: glioblastoma. It was not until I saw the face of the disease the next morning that I understood the reality of a GBM diagnosis. That face belonged to a 47-year-old man who hadn’t slept all night, wide eyed with apprehension at what news I might bring. He beseeched me with questions, and though his aphasia left him stammering to get the words out, I knew exactly what he was asking: Would he live or die? It was a question I was in no position to answer. Instead, I reassured him that we were waiting on the final pathology, all the while trying to forget the fact that the frozen section suggested an aggressive subtype, surely heralding a poor prognosis.

In his poignant memoir, “Do No Harm: Stories of Life, Death and Brain Surgery” (New York: Thomas Dunne Book, 2015), Dr. Henry Marsh writes beautifully about how difficult it can be to find the balance between optimism and realism.  In one memorable passage, Dr. Marsh shows a house officer a scan of a highly malignant brain tumor and asks him what he would say to the patient. The trainee reflexively hides behind jargon, skirting around what he knew to be the truth: This tumor would kill her. Marsh presses him to admit that he’s lying, before lamenting at how hard it is to improve these critical communication skills: “When I have had to break bad news I never know whether I have done it well or not. The patients aren’t going to ring me up afterward and say, ‘Mr. Marsh, I really liked the way you told me that I was going to die,’ or ‘Mr. Marsh, you were crap.’ You can only hope that you haven’t made too much of a mess of it.”

I could certainly relate to Dr. Marsh’s house officer as I walked away from my own patient. I felt almost deceitful withholding diagnostic information from him, even if I did the “right” thing. It made me wonder, why did I want to become a neurosurgeon? Surely to help people through some of the most difficult moments of their lives. But is it possible to be a source of comfort when you are required so often to be a harbinger of death? The answer depends on whether one can envision a role for the neurosurgeon beyond the mandate of “life at all costs.”

While the field has become known for its life-saving procedures, neurosurgeons are called just as often to preside over the end of their patient’s lives – work that requires just as much skill as any technical procedure. Dr. Marsh recognized the tremendous human cost of neglecting that work. For cases that appear “hopeless,” he writes, “We often end up operating because it’s easier than being honest, and it means that we can avoid a painful conversation.”

We are only beginning to understand the many issues that neurosurgical patients face at the end of life, but so far it is clear that neurosurgical trainees require substantive training in prognostication, communication, and palliation (Crit Care Med. 2015 Sep;43[9]:1964-77 1,2; J Neurooncol. 2009 Jan;91[1]:39-43). Is there room in the current training paradigm for more formal education in these domains? As we move further into the 21st century, we must embrace the need for masterful clinicians outside of the operating room if we are to ever challenge the axiom set forth by the renowned French surgeon, René Leriche, some 65 years ago: “Every surgeon carries within himself a small cemetery, where from time to time he goes to pray – a place of bitterness and regret, where he must look for an explanation for his failures.” Let us look forward to the day when this is no longer the case.

Stephen Miranda is a medical student from the University of Rochester, who is now working as a research fellow at Ariadne Labs, a joint center for health systems innovation at Brigham & Women’s Hospital and Harvard T.H. Chan School of Public Health, both in Boston.

Mrs. J, a physically frail but mentally sharp 75-year-old with known metastatic gastric cancer was admitted to the hospital 2 days ago with a small bowel obstruction. Despite appropriate conservative management, her symptoms are worsening. Her prior cancer treatment consisted of gastric resection with reconstruction and chemo and radiation therapy. The probability of identifying a treatable cause for her bowel obstruction during exploratory laparotomy is believed to be small.

Mr. S, a debilitated 58-year-old previously treated with primary chemotherapy and radiation for cancer at the base of his tongue, presents to your office with severe pain due to recurrent disease. The cancer is potentially resectable, but it will require an extensive resection necessitating complex free flap reconstruction in this previously irradiated field.

Is an operation indicated in either/both of these patients? The risk of causing harm with these operations may outweigh the potential benefits, so how do you decide?

Surgery residents have a lot to learn during their residency training. Not only must they gain a mastery of the pathophysiology of surgical disease, they must learn a multitude of operations while they hone their manual dexterity skills. And they must learn how to take care of a multitude of patients.

Less understood and explicitly taught is how to determine whether an operation is appropriate for this specific patient. Understanding the pathophysiology of the patient’s illness is not enough; it requires an ability to effectively communicate with the patient, to understand that person’s hopes and goals, and then honestly determine whether an operation is in fact indicated. It may sound like the antithesis of surgical training, but learning when not to operate is as important as learning when to do so.

Sometimes it’s easy. When the underlying condition is easily treatable by an operation and without it the previously healthy patient will likely die, operation is usually warranted and accepted. For the critically ill patient who will not survive transfer to the operating room and induction of anesthesia, an operation would be impossible.

As illustrated by the patients described at the beginning of this piece, the decision making can be a bit more complicated.

These are the type of patients the surgeon intuitively believes will not do well, but they are referred for an operation and what surgeons do, is ... operate. “To cut is to cure,” is the old adage, not “To cut is to care.”

These are some of the toughest decisions a surgeon can make and are the ones surgeons seem to remember. The enormous responsibility that accompanies the decision to take someone to the operating room and through a potentially difficult postoperative period can be burdensome for the surgeon and potentially fraught with suffering for all.

Understanding how to address goals of care with patients and families can make these decisions easier. Yet these communication skills are not necessarily emphasized during surgical training, and in fact, they are not the forte of many physicians in general, which has led to the growth of the specialty of palliative medicine. Palliative medicine specialists are trained experts in these communication techniques.

One of the cardinal goals of palliative medicine is to help patients and families think about and clarify their treatment goals. Asking questions about “code status” is not the same as exploring someone’s overall treatment goals. Goals can range from wanting to stay alive no matter in what condition to wanting to be kept comfortable at home surrounded by loved ones even if it means a potentially shorter lifespan. By having patients clarify their ultimate goals it may become apparent that a high-risk operation is not the best way to proceed. Perhaps aggressive pain management and arranging effective home support better meets the patient’s overall goals.

You don’t have to be a palliative medicine specialist to have these conversations with patients, but it does require specific communication skills, which can be taught.

For example, many clinicians start their patient encounters by giving a brief overview of the current situation or skip straight to discussions concerning the various treatment options. But are you sure you and your patient are really starting from the same place? You can’t assume that the patient/family truly understands the medical condition, no matter what may be implied in the medical record or the referring physician’s notes. And you can’t assume a patient wants an operation just because he or she shows up in your office.

A more effective way to start the conversation is to begin by asking patients what they understand about their conditions. This will ensure your subsequent discussion corrects any misinformation and better clarifies their understanding of the situation. Starting your encounter in this fashion is critical and can avoid misunderstandings that can lead to treatments the patients do not actually want, and mistrust should complications arise.

An elective rotation with palliative medicine providers to learn these skills can be a great addition to surgical residency training. These conversations can be some of the most meaningful patient interactions a physician can experience. Incorporating an elective rotation with a palliative medicine team into surgical residency training can add value to residency training and have long-lasting benefit for future surgeons, and ultimately, for their patients, as they venture on in their surgical careers.

Nadine B. Semer, M.D., MPH, FACS, is board certified in general surgery, plastic surgery, and palliative medicine. As a reconstructive plastic surgeon, she has worked not only in the United States, but has had the privilege of taking her skills to underserved and resource-poor areas throughout the world. She currently is practicing palliative medicine full time, and is an assistant professor at UT Southwestern Medical School, in Dallas, based at Parkland Hospital.

Mrs. J, a physically frail but mentally sharp 75-year-old with known metastatic gastric cancer was admitted to the hospital 2 days ago with a small bowel obstruction. Despite appropriate conservative management, her symptoms are worsening. Her prior cancer treatment consisted of gastric resection with reconstruction and chemo and radiation therapy. The probability of identifying a treatable cause for her bowel obstruction during exploratory laparotomy is believed to be small.

Mr. S, a debilitated 58-year-old previously treated with primary chemotherapy and radiation for cancer at the base of his tongue, presents to your office with severe pain due to recurrent disease. The cancer is potentially resectable, but it will require an extensive resection necessitating complex free flap reconstruction in this previously irradiated field.

Is an operation indicated in either/both of these patients? The risk of causing harm with these operations may outweigh the potential benefits, so how do you decide?

Surgery residents have a lot to learn during their residency training. Not only must they gain a mastery of the pathophysiology of surgical disease, they must learn a multitude of operations while they hone their manual dexterity skills. And they must learn how to take care of a multitude of patients.

Less understood and explicitly taught is how to determine whether an operation is appropriate for this specific patient. Understanding the pathophysiology of the patient’s illness is not enough; it requires an ability to effectively communicate with the patient, to understand that person’s hopes and goals, and then honestly determine whether an operation is in fact indicated. It may sound like the antithesis of surgical training, but learning when not to operate is as important as learning when to do so.

Sometimes it’s easy. When the underlying condition is easily treatable by an operation and without it the previously healthy patient will likely die, operation is usually warranted and accepted. For the critically ill patient who will not survive transfer to the operating room and induction of anesthesia, an operation would be impossible.

As illustrated by the patients described at the beginning of this piece, the decision making can be a bit more complicated.

These are the type of patients the surgeon intuitively believes will not do well, but they are referred for an operation and what surgeons do, is ... operate. “To cut is to cure,” is the old adage, not “To cut is to care.”

These are some of the toughest decisions a surgeon can make and are the ones surgeons seem to remember. The enormous responsibility that accompanies the decision to take someone to the operating room and through a potentially difficult postoperative period can be burdensome for the surgeon and potentially fraught with suffering for all.

Understanding how to address goals of care with patients and families can make these decisions easier. Yet these communication skills are not necessarily emphasized during surgical training, and in fact, they are not the forte of many physicians in general, which has led to the growth of the specialty of palliative medicine. Palliative medicine specialists are trained experts in these communication techniques.

One of the cardinal goals of palliative medicine is to help patients and families think about and clarify their treatment goals. Asking questions about “code status” is not the same as exploring someone’s overall treatment goals. Goals can range from wanting to stay alive no matter in what condition to wanting to be kept comfortable at home surrounded by loved ones even if it means a potentially shorter lifespan. By having patients clarify their ultimate goals it may become apparent that a high-risk operation is not the best way to proceed. Perhaps aggressive pain management and arranging effective home support better meets the patient’s overall goals.

You don’t have to be a palliative medicine specialist to have these conversations with patients, but it does require specific communication skills, which can be taught.

For example, many clinicians start their patient encounters by giving a brief overview of the current situation or skip straight to discussions concerning the various treatment options. But are you sure you and your patient are really starting from the same place? You can’t assume that the patient/family truly understands the medical condition, no matter what may be implied in the medical record or the referring physician’s notes. And you can’t assume a patient wants an operation just because he or she shows up in your office.

A more effective way to start the conversation is to begin by asking patients what they understand about their conditions. This will ensure your subsequent discussion corrects any misinformation and better clarifies their understanding of the situation. Starting your encounter in this fashion is critical and can avoid misunderstandings that can lead to treatments the patients do not actually want, and mistrust should complications arise.

An elective rotation with palliative medicine providers to learn these skills can be a great addition to surgical residency training. These conversations can be some of the most meaningful patient interactions a physician can experience. Incorporating an elective rotation with a palliative medicine team into surgical residency training can add value to residency training and have long-lasting benefit for future surgeons, and ultimately, for their patients, as they venture on in their surgical careers.

Nadine B. Semer, M.D., MPH, FACS, is board certified in general surgery, plastic surgery, and palliative medicine. As a reconstructive plastic surgeon, she has worked not only in the United States, but has had the privilege of taking her skills to underserved and resource-poor areas throughout the world. She currently is practicing palliative medicine full time, and is an assistant professor at UT Southwestern Medical School, in Dallas, based at Parkland Hospital.

Mrs. J, a physically frail but mentally sharp 75-year-old with known metastatic gastric cancer was admitted to the hospital 2 days ago with a small bowel obstruction. Despite appropriate conservative management, her symptoms are worsening. Her prior cancer treatment consisted of gastric resection with reconstruction and chemo and radiation therapy. The probability of identifying a treatable cause for her bowel obstruction during exploratory laparotomy is believed to be small.

Mr. S, a debilitated 58-year-old previously treated with primary chemotherapy and radiation for cancer at the base of his tongue, presents to your office with severe pain due to recurrent disease. The cancer is potentially resectable, but it will require an extensive resection necessitating complex free flap reconstruction in this previously irradiated field.

Is an operation indicated in either/both of these patients? The risk of causing harm with these operations may outweigh the potential benefits, so how do you decide?

Surgery residents have a lot to learn during their residency training. Not only must they gain a mastery of the pathophysiology of surgical disease, they must learn a multitude of operations while they hone their manual dexterity skills. And they must learn how to take care of a multitude of patients.

Less understood and explicitly taught is how to determine whether an operation is appropriate for this specific patient. Understanding the pathophysiology of the patient’s illness is not enough; it requires an ability to effectively communicate with the patient, to understand that person’s hopes and goals, and then honestly determine whether an operation is in fact indicated. It may sound like the antithesis of surgical training, but learning when not to operate is as important as learning when to do so.

Sometimes it’s easy. When the underlying condition is easily treatable by an operation and without it the previously healthy patient will likely die, operation is usually warranted and accepted. For the critically ill patient who will not survive transfer to the operating room and induction of anesthesia, an operation would be impossible.

As illustrated by the patients described at the beginning of this piece, the decision making can be a bit more complicated.

These are the type of patients the surgeon intuitively believes will not do well, but they are referred for an operation and what surgeons do, is ... operate. “To cut is to cure,” is the old adage, not “To cut is to care.”

These are some of the toughest decisions a surgeon can make and are the ones surgeons seem to remember. The enormous responsibility that accompanies the decision to take someone to the operating room and through a potentially difficult postoperative period can be burdensome for the surgeon and potentially fraught with suffering for all.

Understanding how to address goals of care with patients and families can make these decisions easier. Yet these communication skills are not necessarily emphasized during surgical training, and in fact, they are not the forte of many physicians in general, which has led to the growth of the specialty of palliative medicine. Palliative medicine specialists are trained experts in these communication techniques.

One of the cardinal goals of palliative medicine is to help patients and families think about and clarify their treatment goals. Asking questions about “code status” is not the same as exploring someone’s overall treatment goals. Goals can range from wanting to stay alive no matter in what condition to wanting to be kept comfortable at home surrounded by loved ones even if it means a potentially shorter lifespan. By having patients clarify their ultimate goals it may become apparent that a high-risk operation is not the best way to proceed. Perhaps aggressive pain management and arranging effective home support better meets the patient’s overall goals.

You don’t have to be a palliative medicine specialist to have these conversations with patients, but it does require specific communication skills, which can be taught.

For example, many clinicians start their patient encounters by giving a brief overview of the current situation or skip straight to discussions concerning the various treatment options. But are you sure you and your patient are really starting from the same place? You can’t assume that the patient/family truly understands the medical condition, no matter what may be implied in the medical record or the referring physician’s notes. And you can’t assume a patient wants an operation just because he or she shows up in your office.

A more effective way to start the conversation is to begin by asking patients what they understand about their conditions. This will ensure your subsequent discussion corrects any misinformation and better clarifies their understanding of the situation. Starting your encounter in this fashion is critical and can avoid misunderstandings that can lead to treatments the patients do not actually want, and mistrust should complications arise.

An elective rotation with palliative medicine providers to learn these skills can be a great addition to surgical residency training. These conversations can be some of the most meaningful patient interactions a physician can experience. Incorporating an elective rotation with a palliative medicine team into surgical residency training can add value to residency training and have long-lasting benefit for future surgeons, and ultimately, for their patients, as they venture on in their surgical careers.

Nadine B. Semer, M.D., MPH, FACS, is board certified in general surgery, plastic surgery, and palliative medicine. As a reconstructive plastic surgeon, she has worked not only in the United States, but has had the privilege of taking her skills to underserved and resource-poor areas throughout the world. She currently is practicing palliative medicine full time, and is an assistant professor at UT Southwestern Medical School, in Dallas, based at Parkland Hospital.

Dying patients teach us to think more carefully about whether or not our surgical interventions will be beneficial.

I work in palliative care, and my surgical colleagues, especially the residents, are often surprised when I call them and ask them to consult on my patients who are very ill and have a “Do Not Resuscitate” order in their charts. I’m also an anesthesiologist working in interventional pain management, and I regularly do procedures on patients who have prognoses that are extremely limited. For other patients, I recommend against any interventions at all.

How do we know when to intervene on patients who are dying? Perhaps more importantly, how do we know when NOT to intervene? Two recent
cases of almost identical fractures illustrated for me the need to think beyond the anatomic problem when evaluating options for care.

Last year, I admitted a woman, “Donna,” with widely metastatic breast cancer to our inpatient palliative care service. She had fallen at home and hurt her arm about 2 months prior to admission. She had been confined to her bed for about 6 weeks. She was brought to the hospital because she was becoming delirious. She had many sources of pain that were relatively well controlled when she was lying down, but her worst pain was in her left arm. We found a fracture of her humerus. When her family learned that the fracture would not heal on its own because of the large metastasis there, they demanded surgery to fix it. Shortly thereafter, I re-admitted a patient, “Cindy,” with a very similar story. She also had widely metastatic breast cancer, and her pain had been very difficult to control. We had found a pain regimen that worked well for her on her previous admission, but she had fallen over her walker and broke her humerus after we had discharged her to a rehab facility. When I saw her back in the hospital, I told her that I thought she would need surgery to fix her arm. She was depressed by this setback, she was in pain again, and she told me that she would prefer not to have any intervention because she feared the additional pain that it would cause.

With Donna, we sat down with her and her family to hear what their hopes were for her care. They understood that she did not have further chemotherapy or radiation options for her cancer, but they thought if she got the surgery that at least she would be able to get out of bed and walk again. My colleague carefully explained that yes, he could fix the fracture and that this could mean that the pain in her left arm would improve. He went on to say, however, that he did not think that the surgery would allow her to walk again as she had not been able to walk for a few weeks after the injury. When the family heard that the surgery probably wouldn’t restore her mobility, they decided against the procedure. With Cindy, we had a very different conversation. She was not inclined to have the procedure, but I expressed my concern that she wouldn’t be able to walk again unless she had the procedure because she needed her arms to use her walker. Although she did not have any further chemotherapy or radiation options, her oncologist had told us that her prognosis could be several months. In this case, my surgical colleague explained that he could perform surgery for the fracture and that he thought that it would both help her pain and allow her to use her walker again. We recommended that she have the surgery given her hope to continue to live independently, as she had been, for as long as possible. She ultimately agreed to do so and was able to return home.

These two patients reminded me again of how important it is for us to understand what our patients’ hopes and expectations are for a procedure. It is very distressing for clinicians when desperate families want treatments that likely have little benefit. When patients have limited prognoses, aligning patient goals and procedure goals is especially important as the outcome of the procedure can define the patient’s remaining days.

Donna’s family demanded a surgery expecting a result that was very unlikely, and Cindy initially declined the same surgery that ultimately benefitted her greatly. Our job is to make and execute the medical recommendations that best fit with our patients’ goals and understanding. Sometimes this will mean performing procedures on patients who are extremely ill and have “Do Not Resuscitate” orders, and at other times, it will mean not doing procedures, even if a patient and family want them to be done.

Dr. Rickerson is an anesthesiologist at the Dana-Farber Cancer Institute and Brigham and Women’s Hospital, Boston.


Dying patients teach us to think more carefully about whether or not our surgical interventions will be beneficial.

I work in palliative care, and my surgical colleagues, especially the residents, are often surprised when I call them and ask them to consult on my patients who are very ill and have a “Do Not Resuscitate” order in their charts. I’m also an anesthesiologist working in interventional pain management, and I regularly do procedures on patients who have prognoses that are extremely limited. For other patients, I recommend against any interventions at all.

How do we know when to intervene on patients who are dying? Perhaps more importantly, how do we know when NOT to intervene? Two recent
cases of almost identical fractures illustrated for me the need to think beyond the anatomic problem when evaluating options for care.

Last year, I admitted a woman, “Donna,” with widely metastatic breast cancer to our inpatient palliative care service. She had fallen at home and hurt her arm about 2 months prior to admission. She had been confined to her bed for about 6 weeks. She was brought to the hospital because she was becoming delirious. She had many sources of pain that were relatively well controlled when she was lying down, but her worst pain was in her left arm. We found a fracture of her humerus. When her family learned that the fracture would not heal on its own because of the large metastasis there, they demanded surgery to fix it. Shortly thereafter, I re-admitted a patient, “Cindy,” with a very similar story. She also had widely metastatic breast cancer, and her pain had been very difficult to control. We had found a pain regimen that worked well for her on her previous admission, but she had fallen over her walker and broke her humerus after we had discharged her to a rehab facility. When I saw her back in the hospital, I told her that I thought she would need surgery to fix her arm. She was depressed by this setback, she was in pain again, and she told me that she would prefer not to have any intervention because she feared the additional pain that it would cause.

With Donna, we sat down with her and her family to hear what their hopes were for her care. They understood that she did not have further chemotherapy or radiation options for her cancer, but they thought if she got the surgery that at least she would be able to get out of bed and walk again. My colleague carefully explained that yes, he could fix the fracture and that this could mean that the pain in her left arm would improve. He went on to say, however, that he did not think that the surgery would allow her to walk again as she had not been able to walk for a few weeks after the injury. When the family heard that the surgery probably wouldn’t restore her mobility, they decided against the procedure. With Cindy, we had a very different conversation. She was not inclined to have the procedure, but I expressed my concern that she wouldn’t be able to walk again unless she had the procedure because she needed her arms to use her walker. Although she did not have any further chemotherapy or radiation options, her oncologist had told us that her prognosis could be several months. In this case, my surgical colleague explained that he could perform surgery for the fracture and that he thought that it would both help her pain and allow her to use her walker again. We recommended that she have the surgery given her hope to continue to live independently, as she had been, for as long as possible. She ultimately agreed to do so and was able to return home.

These two patients reminded me again of how important it is for us to understand what our patients’ hopes and expectations are for a procedure. It is very distressing for clinicians when desperate families want treatments that likely have little benefit. When patients have limited prognoses, aligning patient goals and procedure goals is especially important as the outcome of the procedure can define the patient’s remaining days.

Donna’s family demanded a surgery expecting a result that was very unlikely, and Cindy initially declined the same surgery that ultimately benefitted her greatly. Our job is to make and execute the medical recommendations that best fit with our patients’ goals and understanding. Sometimes this will mean performing procedures on patients who are extremely ill and have “Do Not Resuscitate” orders, and at other times, it will mean not doing procedures, even if a patient and family want them to be done.

Dr. Rickerson is an anesthesiologist at the Dana-Farber Cancer Institute and Brigham and Women’s Hospital, Boston.


Dying patients teach us to think more carefully about whether or not our surgical interventions will be beneficial.

I work in palliative care, and my surgical colleagues, especially the residents, are often surprised when I call them and ask them to consult on my patients who are very ill and have a “Do Not Resuscitate” order in their charts. I’m also an anesthesiologist working in interventional pain management, and I regularly do procedures on patients who have prognoses that are extremely limited. For other patients, I recommend against any interventions at all.

How do we know when to intervene on patients who are dying? Perhaps more importantly, how do we know when NOT to intervene? Two recent
cases of almost identical fractures illustrated for me the need to think beyond the anatomic problem when evaluating options for care.

Last year, I admitted a woman, “Donna,” with widely metastatic breast cancer to our inpatient palliative care service. She had fallen at home and hurt her arm about 2 months prior to admission. She had been confined to her bed for about 6 weeks. She was brought to the hospital because she was becoming delirious. She had many sources of pain that were relatively well controlled when she was lying down, but her worst pain was in her left arm. We found a fracture of her humerus. When her family learned that the fracture would not heal on its own because of the large metastasis there, they demanded surgery to fix it. Shortly thereafter, I re-admitted a patient, “Cindy,” with a very similar story. She also had widely metastatic breast cancer, and her pain had been very difficult to control. We had found a pain regimen that worked well for her on her previous admission, but she had fallen over her walker and broke her humerus after we had discharged her to a rehab facility. When I saw her back in the hospital, I told her that I thought she would need surgery to fix her arm. She was depressed by this setback, she was in pain again, and she told me that she would prefer not to have any intervention because she feared the additional pain that it would cause.

With Donna, we sat down with her and her family to hear what their hopes were for her care. They understood that she did not have further chemotherapy or radiation options for her cancer, but they thought if she got the surgery that at least she would be able to get out of bed and walk again. My colleague carefully explained that yes, he could fix the fracture and that this could mean that the pain in her left arm would improve. He went on to say, however, that he did not think that the surgery would allow her to walk again as she had not been able to walk for a few weeks after the injury. When the family heard that the surgery probably wouldn’t restore her mobility, they decided against the procedure. With Cindy, we had a very different conversation. She was not inclined to have the procedure, but I expressed my concern that she wouldn’t be able to walk again unless she had the procedure because she needed her arms to use her walker. Although she did not have any further chemotherapy or radiation options, her oncologist had told us that her prognosis could be several months. In this case, my surgical colleague explained that he could perform surgery for the fracture and that he thought that it would both help her pain and allow her to use her walker again. We recommended that she have the surgery given her hope to continue to live independently, as she had been, for as long as possible. She ultimately agreed to do so and was able to return home.

These two patients reminded me again of how important it is for us to understand what our patients’ hopes and expectations are for a procedure. It is very distressing for clinicians when desperate families want treatments that likely have little benefit. When patients have limited prognoses, aligning patient goals and procedure goals is especially important as the outcome of the procedure can define the patient’s remaining days.

Donna’s family demanded a surgery expecting a result that was very unlikely, and Cindy initially declined the same surgery that ultimately benefitted her greatly. Our job is to make and execute the medical recommendations that best fit with our patients’ goals and understanding. Sometimes this will mean performing procedures on patients who are extremely ill and have “Do Not Resuscitate” orders, and at other times, it will mean not doing procedures, even if a patient and family want them to be done.

Dr. Rickerson is an anesthesiologist at the Dana-Farber Cancer Institute and Brigham and Women’s Hospital, Boston.


A few months ago, a colleague asked me about treating a patient’s pain that he was managing for months both in and out of the hospital for what was now an incurable condition. This very skilled surgeon believed that the patient should “not require” such high doses of opioids based on the clinical picture of a healed surgical wound but felt at a loss of what else to do. He did not want to abandon his relationship with the patient. He considered referral to the anesthesia pain clinic as escalating pain requirements were exceeding his comfort level.

Alternatively, he considered deferring pain management to the patient’s primary care provider. Instead, we worked together through a rational pain approach and explored external factors that may have been contributing to the patient’s total pain experience. This brief vignette is not atypical and sheds light onto the ongoing need to fill an education gap for surgeons who deal with patients at the end of life.

It has been almost 25 years since the term “pain as the fifth vital sign” was first introduced into the lexicon of clinical practice. The idea was to provide as much zeal to the topic of pain as we do to a patient’s other vital physiological measures. Yet, seriously ill patients with potential life-limiting conditions continue to experience significant pain, especially at the end of life. Among patients with nonmalignant diagnoses, more than 40% experience severe pain within days of their death. For those with malignant conditions, 15%-75% report moderate to severe pain during the final weeks of life. Whether in the ICU, hospital ward, or outpatient setting, our surgical community struggles to provide effective symptomatic pain control in many patients who have transitioned from a curative pathway to one of comfort.

Although we never intend to allow patients to suffer at the end of life, barriers to appropriate pain control persist. In some case cases, patients may feel embarrassed or ashamed to accept escalating opioid doses. In other cases, patients and families may possess misconceptions about addiction to pain medication. It is important to dispel such myths and distinguish tolerance from dependence. Among opioid-naive patients, the risk of dependence (in other words, addiction) is estimated to be 0.1%.  Among patients with a history of opioid abuse, the risk of addiction is still only 1%.

Large proportions of physicians continue to report inadequate training in pain control and are reluctant to prescribe high-enough doses of opioids to relieve pain, even at the end of life. One well-described reason has been physician fear of regulatory action and possible litigation for higher than typical opioid dosing.
This was the case for my colleague who was reluctant to escalate pain control.

This in turn leads to undertreating pain which, in fact, has been a source of successful litigation. Because undertreatment of pain may be akin to patient negligence, we should strive to become more comfortable with optimal pain treatment strategies. But pain control is not merely about intravenous opioids or pain tablets. Surgeons should at least have an appreciation for, if not a better understanding, of the modern palliative care approach to “total pain.” This construct consists of four interrelated pain domains: physical, psychological (emotional), spiritual, and social.

Although we tend to focus on physical pain, other domains are influenced by anxiety, depression, and fear. If such an approach seems a bridge too far, optimal care should involve a multidisciplinary team that touches on such areas. This may be most efficiently achieved through consultation and coordination with palliative care services when available. This patient’s surgeon soon discovered that family financial concerns were contributing to the patient’s sleepless nights and worsening somatic pain.

Somewhat outside the scope of typical postoperative care, pain relief at the end of life requires dosing and medication choices for extended periods of time. When establishing a treatment strategy, the surgeon should consider the feasibility and efficacy (half-life, duration, bioavailability, active metabolites) of each modality. In our patient, standard dosing was inadequate; for some, basal doses may increase by 25%-100% for progressive disease. To support the surgeon in learning more about this important area of care, multiple online tools and websites are available to assist with pain management choices. A short while ago, I learned from my colleague that this patient died comfortably and essentially pain free for the last months of his life.

Dr. Zonies is an associate professor of surgery in the trauma/critical care division at Oregon Health & Science University, Portland.  He is board certified in hospice and palliative medicine.

A few months ago, a colleague asked me about treating a patient’s pain that he was managing for months both in and out of the hospital for what was now an incurable condition. This very skilled surgeon believed that the patient should “not require” such high doses of opioids based on the clinical picture of a healed surgical wound but felt at a loss of what else to do. He did not want to abandon his relationship with the patient. He considered referral to the anesthesia pain clinic as escalating pain requirements were exceeding his comfort level.

Alternatively, he considered deferring pain management to the patient’s primary care provider. Instead, we worked together through a rational pain approach and explored external factors that may have been contributing to the patient’s total pain experience. This brief vignette is not atypical and sheds light onto the ongoing need to fill an education gap for surgeons who deal with patients at the end of life.

It has been almost 25 years since the term “pain as the fifth vital sign” was first introduced into the lexicon of clinical practice. The idea was to provide as much zeal to the topic of pain as we do to a patient’s other vital physiological measures. Yet, seriously ill patients with potential life-limiting conditions continue to experience significant pain, especially at the end of life. Among patients with nonmalignant diagnoses, more than 40% experience severe pain within days of their death. For those with malignant conditions, 15%-75% report moderate to severe pain during the final weeks of life. Whether in the ICU, hospital ward, or outpatient setting, our surgical community struggles to provide effective symptomatic pain control in many patients who have transitioned from a curative pathway to one of comfort.

Although we never intend to allow patients to suffer at the end of life, barriers to appropriate pain control persist. In some case cases, patients may feel embarrassed or ashamed to accept escalating opioid doses. In other cases, patients and families may possess misconceptions about addiction to pain medication. It is important to dispel such myths and distinguish tolerance from dependence. Among opioid-naive patients, the risk of dependence (in other words, addiction) is estimated to be 0.1%.  Among patients with a history of opioid abuse, the risk of addiction is still only 1%.

Large proportions of physicians continue to report inadequate training in pain control and are reluctant to prescribe high-enough doses of opioids to relieve pain, even at the end of life. One well-described reason has been physician fear of regulatory action and possible litigation for higher than typical opioid dosing.
This was the case for my colleague who was reluctant to escalate pain control.

This in turn leads to undertreating pain which, in fact, has been a source of successful litigation. Because undertreatment of pain may be akin to patient negligence, we should strive to become more comfortable with optimal pain treatment strategies. But pain control is not merely about intravenous opioids or pain tablets. Surgeons should at least have an appreciation for, if not a better understanding, of the modern palliative care approach to “total pain.” This construct consists of four interrelated pain domains: physical, psychological (emotional), spiritual, and social.

Although we tend to focus on physical pain, other domains are influenced by anxiety, depression, and fear. If such an approach seems a bridge too far, optimal care should involve a multidisciplinary team that touches on such areas. This may be most efficiently achieved through consultation and coordination with palliative care services when available. This patient’s surgeon soon discovered that family financial concerns were contributing to the patient’s sleepless nights and worsening somatic pain.

Somewhat outside the scope of typical postoperative care, pain relief at the end of life requires dosing and medication choices for extended periods of time. When establishing a treatment strategy, the surgeon should consider the feasibility and efficacy (half-life, duration, bioavailability, active metabolites) of each modality. In our patient, standard dosing was inadequate; for some, basal doses may increase by 25%-100% for progressive disease. To support the surgeon in learning more about this important area of care, multiple online tools and websites are available to assist with pain management choices. A short while ago, I learned from my colleague that this patient died comfortably and essentially pain free for the last months of his life.

Dr. Zonies is an associate professor of surgery in the trauma/critical care division at Oregon Health & Science University, Portland.  He is board certified in hospice and palliative medicine.

A few months ago, a colleague asked me about treating a patient’s pain that he was managing for months both in and out of the hospital for what was now an incurable condition. This very skilled surgeon believed that the patient should “not require” such high doses of opioids based on the clinical picture of a healed surgical wound but felt at a loss of what else to do. He did not want to abandon his relationship with the patient. He considered referral to the anesthesia pain clinic as escalating pain requirements were exceeding his comfort level.

Alternatively, he considered deferring pain management to the patient’s primary care provider. Instead, we worked together through a rational pain approach and explored external factors that may have been contributing to the patient’s total pain experience. This brief vignette is not atypical and sheds light onto the ongoing need to fill an education gap for surgeons who deal with patients at the end of life.

It has been almost 25 years since the term “pain as the fifth vital sign” was first introduced into the lexicon of clinical practice. The idea was to provide as much zeal to the topic of pain as we do to a patient’s other vital physiological measures. Yet, seriously ill patients with potential life-limiting conditions continue to experience significant pain, especially at the end of life. Among patients with nonmalignant diagnoses, more than 40% experience severe pain within days of their death. For those with malignant conditions, 15%-75% report moderate to severe pain during the final weeks of life. Whether in the ICU, hospital ward, or outpatient setting, our surgical community struggles to provide effective symptomatic pain control in many patients who have transitioned from a curative pathway to one of comfort.

Although we never intend to allow patients to suffer at the end of life, barriers to appropriate pain control persist. In some case cases, patients may feel embarrassed or ashamed to accept escalating opioid doses. In other cases, patients and families may possess misconceptions about addiction to pain medication. It is important to dispel such myths and distinguish tolerance from dependence. Among opioid-naive patients, the risk of dependence (in other words, addiction) is estimated to be 0.1%.  Among patients with a history of opioid abuse, the risk of addiction is still only 1%.

Large proportions of physicians continue to report inadequate training in pain control and are reluctant to prescribe high-enough doses of opioids to relieve pain, even at the end of life. One well-described reason has been physician fear of regulatory action and possible litigation for higher than typical opioid dosing.
This was the case for my colleague who was reluctant to escalate pain control.

This in turn leads to undertreating pain which, in fact, has been a source of successful litigation. Because undertreatment of pain may be akin to patient negligence, we should strive to become more comfortable with optimal pain treatment strategies. But pain control is not merely about intravenous opioids or pain tablets. Surgeons should at least have an appreciation for, if not a better understanding, of the modern palliative care approach to “total pain.” This construct consists of four interrelated pain domains: physical, psychological (emotional), spiritual, and social.

Although we tend to focus on physical pain, other domains are influenced by anxiety, depression, and fear. If such an approach seems a bridge too far, optimal care should involve a multidisciplinary team that touches on such areas. This may be most efficiently achieved through consultation and coordination with palliative care services when available. This patient’s surgeon soon discovered that family financial concerns were contributing to the patient’s sleepless nights and worsening somatic pain.

Somewhat outside the scope of typical postoperative care, pain relief at the end of life requires dosing and medication choices for extended periods of time. When establishing a treatment strategy, the surgeon should consider the feasibility and efficacy (half-life, duration, bioavailability, active metabolites) of each modality. In our patient, standard dosing was inadequate; for some, basal doses may increase by 25%-100% for progressive disease. To support the surgeon in learning more about this important area of care, multiple online tools and websites are available to assist with pain management choices. A short while ago, I learned from my colleague that this patient died comfortably and essentially pain free for the last months of his life.

Dr. Zonies is an associate professor of surgery in the trauma/critical care division at Oregon Health & Science University, Portland.  He is board certified in hospice and palliative medicine.

The surgery chief resident texted me: “Patient in ED with peritonitis. Incarcerated hernia.”

I came to the ED; should be easy I thought. See the patient, have a short conversation since the chief resident would have done all the preop. Of course, things are rarely that simple.

First, she was a Jehovah’s Witness on warfarin with an INR of 4. More significantly, she had end-stage COPD. I reviewed her CT scan and labs and went to see her and could tell without any conversation she needed an operation. I needed more information, but not about her belly pain or when it started or whether she had peritonitis on exam. I needed to know how far she could walk, how much oxygen was she on at home, how much was she sleeping, how much weight had she lost, and could she leave the house.

It took 30 minutes to determine her functional status, whether she would survive the postoperative ICU care, whether she would come off the ventilator, and would she want a tracheostomy. It took another 15 minutes to discuss blood product use. Her husband was present, and I left them to decide what they wanted within the context of her goals for her life. She accepted some blood products, underwent surgery, and did well. She came off the ventilator quickly postop and returned home from the hospital. Although she did well, we had a plan for the ventilator and her goals of care defined should she have done poorly.

He was 72, had stage IV lung cancer, and was too weak for chemotherapy. Now he had free air and peritonitis. The referring institution called me and said he was too much for their surgeons. I suggested perhaps they needed to have “the talk” prior to transport. They were unwilling to do so and sent him by helicopter because he was hypotensive. He clearly needed an operation by all surgical standards. But I wanted to wait for his family and talk with them before taking him to the OR; he was in no condition for any component of informed consent.

The family arrived 30 minutes later. His wife, the daughters who had been helping to take care of him, and two more relatives that had just arrived in town. His wife was clear: The man was sleeping all the time, losing weight, barely eating a couple of bites, unsteady on his feet, and confused when he was awake. I discussed options: The surgeon part of me wanted to “fix the hole,” the ICU doc in me knew he would die in the ICU on a ventilator, and the palliative medicine part of me knew hospice was his best option. I told the family he needed surgery but would likely not leave the hospital alive. I recommended hospice.

The wife was thoughtful and looked at her daughters and said, “We need to send him to hospice.” The wife and daughters were the easiest family I have spoken with in a long time. She was clear about whet he wanted and how much he had declined in the past few months. We were able to get him to inpatient hospice from the ED.

Surgery has changed, at least in my practice. Oh, what would I give for a healthy 17-year-old with appendicitis who gets better within hours of the operating room and my conversation with the family that takes 10 seconds. Instead, I take care of the very old and the very sick and the very chronically ill. My conversations are not “you need surgery;” that is done by the chief resident. My conversations are “tell me your functional status and what do you want if/when things go poorly.” Much more complicated and much less fun. The surgeon wants to fix the hole. I can fix the hole. But have I really helped the patient and his or her family? Although it takes me longer and involves more of my emotions and skills, it really is better for the patients and their families to have “the talk.”

Next time you see a patient who is chronically ill, please have the conversation about functional status and goals of care, before you operate. Or transfer. Perhaps then we can save the patient a helicopter ride to hospice.

Dr. Toevs is a trauma critical care surgeon at Allegheny General Hospital in Pittsburgh. She has a master’s degree in bioethics and board certification in hospice and palliative medicine.

The surgery chief resident texted me: “Patient in ED with peritonitis. Incarcerated hernia.”

I came to the ED; should be easy I thought. See the patient, have a short conversation since the chief resident would have done all the preop. Of course, things are rarely that simple.

First, she was a Jehovah’s Witness on warfarin with an INR of 4. More significantly, she had end-stage COPD. I reviewed her CT scan and labs and went to see her and could tell without any conversation she needed an operation. I needed more information, but not about her belly pain or when it started or whether she had peritonitis on exam. I needed to know how far she could walk, how much oxygen was she on at home, how much was she sleeping, how much weight had she lost, and could she leave the house.

It took 30 minutes to determine her functional status, whether she would survive the postoperative ICU care, whether she would come off the ventilator, and would she want a tracheostomy. It took another 15 minutes to discuss blood product use. Her husband was present, and I left them to decide what they wanted within the context of her goals for her life. She accepted some blood products, underwent surgery, and did well. She came off the ventilator quickly postop and returned home from the hospital. Although she did well, we had a plan for the ventilator and her goals of care defined should she have done poorly.

He was 72, had stage IV lung cancer, and was too weak for chemotherapy. Now he had free air and peritonitis. The referring institution called me and said he was too much for their surgeons. I suggested perhaps they needed to have “the talk” prior to transport. They were unwilling to do so and sent him by helicopter because he was hypotensive. He clearly needed an operation by all surgical standards. But I wanted to wait for his family and talk with them before taking him to the OR; he was in no condition for any component of informed consent.

The family arrived 30 minutes later. His wife, the daughters who had been helping to take care of him, and two more relatives that had just arrived in town. His wife was clear: The man was sleeping all the time, losing weight, barely eating a couple of bites, unsteady on his feet, and confused when he was awake. I discussed options: The surgeon part of me wanted to “fix the hole,” the ICU doc in me knew he would die in the ICU on a ventilator, and the palliative medicine part of me knew hospice was his best option. I told the family he needed surgery but would likely not leave the hospital alive. I recommended hospice.

The wife was thoughtful and looked at her daughters and said, “We need to send him to hospice.” The wife and daughters were the easiest family I have spoken with in a long time. She was clear about whet he wanted and how much he had declined in the past few months. We were able to get him to inpatient hospice from the ED.

Surgery has changed, at least in my practice. Oh, what would I give for a healthy 17-year-old with appendicitis who gets better within hours of the operating room and my conversation with the family that takes 10 seconds. Instead, I take care of the very old and the very sick and the very chronically ill. My conversations are not “you need surgery;” that is done by the chief resident. My conversations are “tell me your functional status and what do you want if/when things go poorly.” Much more complicated and much less fun. The surgeon wants to fix the hole. I can fix the hole. But have I really helped the patient and his or her family? Although it takes me longer and involves more of my emotions and skills, it really is better for the patients and their families to have “the talk.”

Next time you see a patient who is chronically ill, please have the conversation about functional status and goals of care, before you operate. Or transfer. Perhaps then we can save the patient a helicopter ride to hospice.

Dr. Toevs is a trauma critical care surgeon at Allegheny General Hospital in Pittsburgh. She has a master’s degree in bioethics and board certification in hospice and palliative medicine.

The surgery chief resident texted me: “Patient in ED with peritonitis. Incarcerated hernia.”

I came to the ED; should be easy I thought. See the patient, have a short conversation since the chief resident would have done all the preop. Of course, things are rarely that simple.

First, she was a Jehovah’s Witness on warfarin with an INR of 4. More significantly, she had end-stage COPD. I reviewed her CT scan and labs and went to see her and could tell without any conversation she needed an operation. I needed more information, but not about her belly pain or when it started or whether she had peritonitis on exam. I needed to know how far she could walk, how much oxygen was she on at home, how much was she sleeping, how much weight had she lost, and could she leave the house.

It took 30 minutes to determine her functional status, whether she would survive the postoperative ICU care, whether she would come off the ventilator, and would she want a tracheostomy. It took another 15 minutes to discuss blood product use. Her husband was present, and I left them to decide what they wanted within the context of her goals for her life. She accepted some blood products, underwent surgery, and did well. She came off the ventilator quickly postop and returned home from the hospital. Although she did well, we had a plan for the ventilator and her goals of care defined should she have done poorly.

He was 72, had stage IV lung cancer, and was too weak for chemotherapy. Now he had free air and peritonitis. The referring institution called me and said he was too much for their surgeons. I suggested perhaps they needed to have “the talk” prior to transport. They were unwilling to do so and sent him by helicopter because he was hypotensive. He clearly needed an operation by all surgical standards. But I wanted to wait for his family and talk with them before taking him to the OR; he was in no condition for any component of informed consent.

The family arrived 30 minutes later. His wife, the daughters who had been helping to take care of him, and two more relatives that had just arrived in town. His wife was clear: The man was sleeping all the time, losing weight, barely eating a couple of bites, unsteady on his feet, and confused when he was awake. I discussed options: The surgeon part of me wanted to “fix the hole,” the ICU doc in me knew he would die in the ICU on a ventilator, and the palliative medicine part of me knew hospice was his best option. I told the family he needed surgery but would likely not leave the hospital alive. I recommended hospice.

The wife was thoughtful and looked at her daughters and said, “We need to send him to hospice.” The wife and daughters were the easiest family I have spoken with in a long time. She was clear about whet he wanted and how much he had declined in the past few months. We were able to get him to inpatient hospice from the ED.

Surgery has changed, at least in my practice. Oh, what would I give for a healthy 17-year-old with appendicitis who gets better within hours of the operating room and my conversation with the family that takes 10 seconds. Instead, I take care of the very old and the very sick and the very chronically ill. My conversations are not “you need surgery;” that is done by the chief resident. My conversations are “tell me your functional status and what do you want if/when things go poorly.” Much more complicated and much less fun. The surgeon wants to fix the hole. I can fix the hole. But have I really helped the patient and his or her family? Although it takes me longer and involves more of my emotions and skills, it really is better for the patients and their families to have “the talk.”

Next time you see a patient who is chronically ill, please have the conversation about functional status and goals of care, before you operate. Or transfer. Perhaps then we can save the patient a helicopter ride to hospice.

Dr. Toevs is a trauma critical care surgeon at Allegheny General Hospital in Pittsburgh. She has a master’s degree in bioethics and board certification in hospice and palliative medicine.

At my semiannual palliative medicine fellowship evaluation, I was asked, "What is your best strength?" and after a few seconds I said, "Adaptability."

Often, the most profound thoughts come spontaneously before habit interferes. As a practicing cardiothoracic surgeon for more than 16 years, my transition to palliative medicine and a hospice fellowship required the ability to reinvent myself, to embrace new ideas, to let go of old routines, and to accept new possibilities. In other words, to adapt to change.

During my surgical training I was most impressed with surgeons who could think calmly and rationally on the fly. As surgeons, we all understand the benefit of preparation and how contingency planning optimizes safety. But we also know from experience that no matter how well prepared you think you are, something can and almost invariably does happen that is unintentional, unanticipated, and unplanned that sabotages your preparation. So, too, is it with life.

I would never have predicted at the start of my career as a cardiothoracic and vascular surgeon that I would change, at midcareer, to palliative medicine. I am not going to explain all the events that pushed me to make a change, but suffice it to say I came to the proverbial fork in the road. I could have continued down the same path, frustrated and unhappy, but comfortable with my routines, or I could stop feeling sorry for myself, stop complaining, adapt to the changes, and go in a different direction. I chose the latter. I do miss the exhilaration and teamwork of surgery, but I have replaced it with the more profound collaboration of the palliative inter-disciplinary team that includes nurses, chaplains, social workers, therapists, and patients.

The most frequent question I am asked when people find out that I used to be a heart surgeon is why I changed careers. It’s really not as crazy as it seems. Fundamental to both surgery and palliative medicine are evidence-based options and patient-centered, informed decision making.

Historically, palliative care has had limited acceptance by the surgical community except at the end of life in an actively dying patient, but through the efforts of a few visionaries, palliative surgical care is now valued and deemed worthy of incorporation into general surgical residency training. During the past year I have been introduced to this interdisciplinary approach that improves the quality of life of patients and their families. Because this approach assesses and supports physical, psychological, social, and spiritual needs, it needs to occur with, not after, other appropriate medical treatments.

There is good empiric evidence that the earlier palliative medicine is involved in medical treatment, whether potentially curative or not, the quality of care improves: Caregiver, patient, and family satisfaction increases and resource utilization improves no matter what the delivery setting. These are very compelling data, and they validate the role of palliative medicine in a changing paradigm of health care delivery.

My vision for palliative medicine includes complete integration throughout the trajectory of all chronic illness, especially heart failure, cancer, and dementia, where coordination of care is critical and has been historically fragmented. Palliative medicine is increasing its role in acute care with improved symptom management and early consultation in the emergency department and ICU where better communication with the care team and advance care planning can help define goals of care and limit inappropriate and unwanted treatment.

The adaptability that is so crucial for patients and their families to adjust to progressive and critical illness is the same quality we need as practitioners to accommodate them. I challenge all my surgical colleagues to have the courage and wisdom to change, and to allow the integration of palliative medicine into your practice where and whenever possible.

Dr. Strzalka is a Fellow in Hospice and Palliative Medicine, Section of Palliative Medicine and Supportive Oncology, Taussig Cancer Institute, Cleveland Clinic.

At my semiannual palliative medicine fellowship evaluation, I was asked, "What is your best strength?" and after a few seconds I said, "Adaptability."

Often, the most profound thoughts come spontaneously before habit interferes. As a practicing cardiothoracic surgeon for more than 16 years, my transition to palliative medicine and a hospice fellowship required the ability to reinvent myself, to embrace new ideas, to let go of old routines, and to accept new possibilities. In other words, to adapt to change.

During my surgical training I was most impressed with surgeons who could think calmly and rationally on the fly. As surgeons, we all understand the benefit of preparation and how contingency planning optimizes safety. But we also know from experience that no matter how well prepared you think you are, something can and almost invariably does happen that is unintentional, unanticipated, and unplanned that sabotages your preparation. So, too, is it with life.

I would never have predicted at the start of my career as a cardiothoracic and vascular surgeon that I would change, at midcareer, to palliative medicine. I am not going to explain all the events that pushed me to make a change, but suffice it to say I came to the proverbial fork in the road. I could have continued down the same path, frustrated and unhappy, but comfortable with my routines, or I could stop feeling sorry for myself, stop complaining, adapt to the changes, and go in a different direction. I chose the latter. I do miss the exhilaration and teamwork of surgery, but I have replaced it with the more profound collaboration of the palliative inter-disciplinary team that includes nurses, chaplains, social workers, therapists, and patients.

The most frequent question I am asked when people find out that I used to be a heart surgeon is why I changed careers. It’s really not as crazy as it seems. Fundamental to both surgery and palliative medicine are evidence-based options and patient-centered, informed decision making.

Historically, palliative care has had limited acceptance by the surgical community except at the end of life in an actively dying patient, but through the efforts of a few visionaries, palliative surgical care is now valued and deemed worthy of incorporation into general surgical residency training. During the past year I have been introduced to this interdisciplinary approach that improves the quality of life of patients and their families. Because this approach assesses and supports physical, psychological, social, and spiritual needs, it needs to occur with, not after, other appropriate medical treatments.

There is good empiric evidence that the earlier palliative medicine is involved in medical treatment, whether potentially curative or not, the quality of care improves: Caregiver, patient, and family satisfaction increases and resource utilization improves no matter what the delivery setting. These are very compelling data, and they validate the role of palliative medicine in a changing paradigm of health care delivery.

My vision for palliative medicine includes complete integration throughout the trajectory of all chronic illness, especially heart failure, cancer, and dementia, where coordination of care is critical and has been historically fragmented. Palliative medicine is increasing its role in acute care with improved symptom management and early consultation in the emergency department and ICU where better communication with the care team and advance care planning can help define goals of care and limit inappropriate and unwanted treatment.

The adaptability that is so crucial for patients and their families to adjust to progressive and critical illness is the same quality we need as practitioners to accommodate them. I challenge all my surgical colleagues to have the courage and wisdom to change, and to allow the integration of palliative medicine into your practice where and whenever possible.

Dr. Strzalka is a Fellow in Hospice and Palliative Medicine, Section of Palliative Medicine and Supportive Oncology, Taussig Cancer Institute, Cleveland Clinic.

At my semiannual palliative medicine fellowship evaluation, I was asked, "What is your best strength?" and after a few seconds I said, "Adaptability."

Often, the most profound thoughts come spontaneously before habit interferes. As a practicing cardiothoracic surgeon for more than 16 years, my transition to palliative medicine and a hospice fellowship required the ability to reinvent myself, to embrace new ideas, to let go of old routines, and to accept new possibilities. In other words, to adapt to change.

During my surgical training I was most impressed with surgeons who could think calmly and rationally on the fly. As surgeons, we all understand the benefit of preparation and how contingency planning optimizes safety. But we also know from experience that no matter how well prepared you think you are, something can and almost invariably does happen that is unintentional, unanticipated, and unplanned that sabotages your preparation. So, too, is it with life.

I would never have predicted at the start of my career as a cardiothoracic and vascular surgeon that I would change, at midcareer, to palliative medicine. I am not going to explain all the events that pushed me to make a change, but suffice it to say I came to the proverbial fork in the road. I could have continued down the same path, frustrated and unhappy, but comfortable with my routines, or I could stop feeling sorry for myself, stop complaining, adapt to the changes, and go in a different direction. I chose the latter. I do miss the exhilaration and teamwork of surgery, but I have replaced it with the more profound collaboration of the palliative inter-disciplinary team that includes nurses, chaplains, social workers, therapists, and patients.

The most frequent question I am asked when people find out that I used to be a heart surgeon is why I changed careers. It’s really not as crazy as it seems. Fundamental to both surgery and palliative medicine are evidence-based options and patient-centered, informed decision making.

Historically, palliative care has had limited acceptance by the surgical community except at the end of life in an actively dying patient, but through the efforts of a few visionaries, palliative surgical care is now valued and deemed worthy of incorporation into general surgical residency training. During the past year I have been introduced to this interdisciplinary approach that improves the quality of life of patients and their families. Because this approach assesses and supports physical, psychological, social, and spiritual needs, it needs to occur with, not after, other appropriate medical treatments.

There is good empiric evidence that the earlier palliative medicine is involved in medical treatment, whether potentially curative or not, the quality of care improves: Caregiver, patient, and family satisfaction increases and resource utilization improves no matter what the delivery setting. These are very compelling data, and they validate the role of palliative medicine in a changing paradigm of health care delivery.

My vision for palliative medicine includes complete integration throughout the trajectory of all chronic illness, especially heart failure, cancer, and dementia, where coordination of care is critical and has been historically fragmented. Palliative medicine is increasing its role in acute care with improved symptom management and early consultation in the emergency department and ICU where better communication with the care team and advance care planning can help define goals of care and limit inappropriate and unwanted treatment.

The adaptability that is so crucial for patients and their families to adjust to progressive and critical illness is the same quality we need as practitioners to accommodate them. I challenge all my surgical colleagues to have the courage and wisdom to change, and to allow the integration of palliative medicine into your practice where and whenever possible.

Dr. Strzalka is a Fellow in Hospice and Palliative Medicine, Section of Palliative Medicine and Supportive Oncology, Taussig Cancer Institute, Cleveland Clinic.

For decades, surgeons have been at the forefront of the palliative care movement. From the historic utilization of palliative operations to relieve suffering to creation of the American College of Surgeons Palliative Care Task Force, surgeons are often first-line palliative care providers in the management of patients with advanced malignancy.

Palliative care involves paying attention to symptom distress, communicating with patients and families about goals of care in relation to prognosis and patient preferences, planning transitions, and engaging family support. Yet, despite a clear and established role, many surgeons are not prepared to effectively provide palliative care, and they are often resistant to the use of specialty palliative care services.

In my own training, I have witnessed apprehension and failure to use palliative care services. In one instance, I was managing an older patient after a complicated sarcoma resection. The patient suffered complications, which kept him hospitalized and returning to the hospital after short periods at a long-term acute care facility. I suggested that we call palliative care for assistance in management of the patient. He had pain, nausea, and poor oral intake, and he was depressed and anxious about his future. I was told "we don’t want the patient believing we were giving up on him."

After 3 weeks of minimal change, my attending relented. In a short time, the patient’s pain and nausea were better controlled, and we were able to have discussions with the patient and his family to clarify goals of care. Some of the symptom management techniques used methods that I had not yet encountered in my training and that seemed foreign and curious. But seeing the response left no question as to their utility. The patient was able to leave the hospital 2 weeks later with the palliative care service coordinating his management with the primary care provider and surgical team. This was a positive resolution to a significant problem. But what really hindered palliative care use?

Roadblocks include the term palliative having a negative connotation, being equated with "failure." Increased use of quality metrics may deincentivize palliative operations. Also, there is poor training and support for surgeons to provide primary palliative care services themselves. Yet, despite these barriers, there are opportunities for surgeons to improve care of patients with advanced malignancy by improving surgeon-patient communication and giving greater emphasis to advanced care planning prior to operative interventions.

As front-line providers for these patients, surgeons are an ideal conduit for delivery and improved use of early palliative care. My practice includes a discussion of advanced care planning with all of my cancer patients. I introduce this as a normal part of every discussion and refer the patient to the primary care provider or our Quality of Life service to facilitate further conversations and documentation. By destigmatizing the discussion for patients and families, a door is opened to an important part of comprehensive quality care. We must understand that diseases progress and complications occur. Failing to provide preemptive support to patients and families is true failure. With a preemptive approach, patients, families, and caregivers have a better understanding of the medical situation, and the latter can more effectively support the patient.

To standardize the role that surgeons routinely play in management of patients with advanced malignancy, efforts must focus on education and research. The role of education is twofold. First, surgical trainees need adequate tools to perform routine palliative care and an understanding of the appropriate timing to refer for specialized services. There have been multiple national efforts focused on teaching palliative care to varied practitioners. But given the aging population and the paucity of specialist palliative care providers, a renewed effort is needed. Second, surgeons must understand the role that palliative care plays and the benefits their patients can derive from it. Surgeons are routinely involved throughout the course of care of patients with malignancy from diagnosis to the end of life. Recognition of palliative care as a skill along the continuum of care already provided will improve outcomes.

Finally, research must focus on both models of use of palliative care and the quality of current practice. Palliative care as it pertains to surgeons is understudied: What teaching formats are most likely to affect clinical practice? What components of palliative care have an impact in surgical practice? What is the optimal timing and venue for providing palliative care in surgical practice? What health care system changes are needed to support surgeons to provide primary palliative care services?

We are uniquely aware of the complexities of care needed for management of patients with advanced malignancies. We are routinely called on to aid in the management of these patients. Surgical educators and researchers should focus their efforts on what is needed to fully integrate palliative care into patient-centered care already provided by trainees and surgeons.

Dr. Johnston is an assistant professor of surgery in the division of surgical oncology at the Medical College of Wisconsin, Milwaukee. He disclosed no conflicts.

For decades, surgeons have been at the forefront of the palliative care movement. From the historic utilization of palliative operations to relieve suffering to creation of the American College of Surgeons Palliative Care Task Force, surgeons are often first-line palliative care providers in the management of patients with advanced malignancy.

Palliative care involves paying attention to symptom distress, communicating with patients and families about goals of care in relation to prognosis and patient preferences, planning transitions, and engaging family support. Yet, despite a clear and established role, many surgeons are not prepared to effectively provide palliative care, and they are often resistant to the use of specialty palliative care services.

In my own training, I have witnessed apprehension and failure to use palliative care services. In one instance, I was managing an older patient after a complicated sarcoma resection. The patient suffered complications, which kept him hospitalized and returning to the hospital after short periods at a long-term acute care facility. I suggested that we call palliative care for assistance in management of the patient. He had pain, nausea, and poor oral intake, and he was depressed and anxious about his future. I was told "we don’t want the patient believing we were giving up on him."

After 3 weeks of minimal change, my attending relented. In a short time, the patient’s pain and nausea were better controlled, and we were able to have discussions with the patient and his family to clarify goals of care. Some of the symptom management techniques used methods that I had not yet encountered in my training and that seemed foreign and curious. But seeing the response left no question as to their utility. The patient was able to leave the hospital 2 weeks later with the palliative care service coordinating his management with the primary care provider and surgical team. This was a positive resolution to a significant problem. But what really hindered palliative care use?

Roadblocks include the term palliative having a negative connotation, being equated with "failure." Increased use of quality metrics may deincentivize palliative operations. Also, there is poor training and support for surgeons to provide primary palliative care services themselves. Yet, despite these barriers, there are opportunities for surgeons to improve care of patients with advanced malignancy by improving surgeon-patient communication and giving greater emphasis to advanced care planning prior to operative interventions.

As front-line providers for these patients, surgeons are an ideal conduit for delivery and improved use of early palliative care. My practice includes a discussion of advanced care planning with all of my cancer patients. I introduce this as a normal part of every discussion and refer the patient to the primary care provider or our Quality of Life service to facilitate further conversations and documentation. By destigmatizing the discussion for patients and families, a door is opened to an important part of comprehensive quality care. We must understand that diseases progress and complications occur. Failing to provide preemptive support to patients and families is true failure. With a preemptive approach, patients, families, and caregivers have a better understanding of the medical situation, and the latter can more effectively support the patient.

To standardize the role that surgeons routinely play in management of patients with advanced malignancy, efforts must focus on education and research. The role of education is twofold. First, surgical trainees need adequate tools to perform routine palliative care and an understanding of the appropriate timing to refer for specialized services. There have been multiple national efforts focused on teaching palliative care to varied practitioners. But given the aging population and the paucity of specialist palliative care providers, a renewed effort is needed. Second, surgeons must understand the role that palliative care plays and the benefits their patients can derive from it. Surgeons are routinely involved throughout the course of care of patients with malignancy from diagnosis to the end of life. Recognition of palliative care as a skill along the continuum of care already provided will improve outcomes.

Finally, research must focus on both models of use of palliative care and the quality of current practice. Palliative care as it pertains to surgeons is understudied: What teaching formats are most likely to affect clinical practice? What components of palliative care have an impact in surgical practice? What is the optimal timing and venue for providing palliative care in surgical practice? What health care system changes are needed to support surgeons to provide primary palliative care services?

We are uniquely aware of the complexities of care needed for management of patients with advanced malignancies. We are routinely called on to aid in the management of these patients. Surgical educators and researchers should focus their efforts on what is needed to fully integrate palliative care into patient-centered care already provided by trainees and surgeons.

Dr. Johnston is an assistant professor of surgery in the division of surgical oncology at the Medical College of Wisconsin, Milwaukee. He disclosed no conflicts.

For decades, surgeons have been at the forefront of the palliative care movement. From the historic utilization of palliative operations to relieve suffering to creation of the American College of Surgeons Palliative Care Task Force, surgeons are often first-line palliative care providers in the management of patients with advanced malignancy.

Palliative care involves paying attention to symptom distress, communicating with patients and families about goals of care in relation to prognosis and patient preferences, planning transitions, and engaging family support. Yet, despite a clear and established role, many surgeons are not prepared to effectively provide palliative care, and they are often resistant to the use of specialty palliative care services.

In my own training, I have witnessed apprehension and failure to use palliative care services. In one instance, I was managing an older patient after a complicated sarcoma resection. The patient suffered complications, which kept him hospitalized and returning to the hospital after short periods at a long-term acute care facility. I suggested that we call palliative care for assistance in management of the patient. He had pain, nausea, and poor oral intake, and he was depressed and anxious about his future. I was told "we don’t want the patient believing we were giving up on him."

After 3 weeks of minimal change, my attending relented. In a short time, the patient’s pain and nausea were better controlled, and we were able to have discussions with the patient and his family to clarify goals of care. Some of the symptom management techniques used methods that I had not yet encountered in my training and that seemed foreign and curious. But seeing the response left no question as to their utility. The patient was able to leave the hospital 2 weeks later with the palliative care service coordinating his management with the primary care provider and surgical team. This was a positive resolution to a significant problem. But what really hindered palliative care use?

Roadblocks include the term palliative having a negative connotation, being equated with "failure." Increased use of quality metrics may deincentivize palliative operations. Also, there is poor training and support for surgeons to provide primary palliative care services themselves. Yet, despite these barriers, there are opportunities for surgeons to improve care of patients with advanced malignancy by improving surgeon-patient communication and giving greater emphasis to advanced care planning prior to operative interventions.

As front-line providers for these patients, surgeons are an ideal conduit for delivery and improved use of early palliative care. My practice includes a discussion of advanced care planning with all of my cancer patients. I introduce this as a normal part of every discussion and refer the patient to the primary care provider or our Quality of Life service to facilitate further conversations and documentation. By destigmatizing the discussion for patients and families, a door is opened to an important part of comprehensive quality care. We must understand that diseases progress and complications occur. Failing to provide preemptive support to patients and families is true failure. With a preemptive approach, patients, families, and caregivers have a better understanding of the medical situation, and the latter can more effectively support the patient.

To standardize the role that surgeons routinely play in management of patients with advanced malignancy, efforts must focus on education and research. The role of education is twofold. First, surgical trainees need adequate tools to perform routine palliative care and an understanding of the appropriate timing to refer for specialized services. There have been multiple national efforts focused on teaching palliative care to varied practitioners. But given the aging population and the paucity of specialist palliative care providers, a renewed effort is needed. Second, surgeons must understand the role that palliative care plays and the benefits their patients can derive from it. Surgeons are routinely involved throughout the course of care of patients with malignancy from diagnosis to the end of life. Recognition of palliative care as a skill along the continuum of care already provided will improve outcomes.

Finally, research must focus on both models of use of palliative care and the quality of current practice. Palliative care as it pertains to surgeons is understudied: What teaching formats are most likely to affect clinical practice? What components of palliative care have an impact in surgical practice? What is the optimal timing and venue for providing palliative care in surgical practice? What health care system changes are needed to support surgeons to provide primary palliative care services?

We are uniquely aware of the complexities of care needed for management of patients with advanced malignancies. We are routinely called on to aid in the management of these patients. Surgical educators and researchers should focus their efforts on what is needed to fully integrate palliative care into patient-centered care already provided by trainees and surgeons.

Dr. Johnston is an assistant professor of surgery in the division of surgical oncology at the Medical College of Wisconsin, Milwaukee. He disclosed no conflicts.

Recently, members of our palliative care team participated in the care of a man approaching the end of his life. The patient had suffered an in-hospital cardiac arrest 4 weeks earlier, and though he had survived the immediate event, it resulted in anoxic encephalopathy, which rendered him incapable of making decisions.

When it became clear that the patient was declining despite full support, the hospital’s ethics committee was convened to determine goals of care and next steps, as the patient had no family or surrogate decision maker. After determination that the hospital staff had exercised due diligence in attempting to locate a surrogate, the physicians involved reviewed the patient’s case and recommended a change in goals to comfort care. More than one member of the committee expressed confusion as to what interventions are and are not included in comfort care, including medically administered nutrition and hydration (MANH).

Comfort care has traditionally included medications for distressing symptoms (pain, dyspnea, nausea), personal care for hygiene, and choice of place of death (home, hospital, nursing facility), usually with the assistance of a hospice agency.

As the number and complexity of interventions used near the end of life expand, clinicians and hospital staff report confusion about whether these interventions, generally considered to be life-sustaining treatments, can also be considered comfort care. We generally find that when interventions are considered in the context of the patient’s goals of care, the dilemma is clarified. Often the situation is made more complicated by considering the interventions before settling on goals. Broadly speaking, goals of care are derived from a careful consideration (by patient, physician, and family) of the natural history of the illness, expected course and prognosis, and patient preferences.

In the case of the above-referenced patient, we were unable to ascertain his goals because of neurological impairment. We did know, however, that the patient had steadfastly avoided hospitals and medical care of any kind. The attending hospitalist, pulmonologist, and palliative care physician agreed that the patient’s clinical status was declining despite all available interventions, and that his constellation of medical problems constituted a terminal condition. The physicians agreed that future ICU admission, resuscitation, and other new interventions would only prolong his dying process, but not permit him to live outside the hospital. At that time, the patient was receiving nutrition and hydration via a Dobhoff tube, and was tolerating enteral nutrition without excessive residuals or pulmonary secretions.

As with other interventions, whether or not to consider MANH a part of comfort care is individualized. In this patient’s case, in the absence of evidence that he would not want MANH, it was continued. Other patients have expressed the wish that they would under no circumstances accept MANH while receiving comfort care. Both are correct as long as they reflect that patient’s wishes.

With respect to other interventions – including but not limited to BiPAP, inotrope infusion, chemotherapy, radiation therapy, and transfusions – whether or not they provide comfort is a decision to be made jointly by the patient and physician(s). As advances in medicine allow patients to live longer with serious illness, the definition of comfort care must also expand.

Dr. Fredholm and Dr. Bekanich are codirectors of Seton Palliative Care, part of the University of Texas Southwestern Residency Programs in Austin.

Recently, members of our palliative care team participated in the care of a man approaching the end of his life. The patient had suffered an in-hospital cardiac arrest 4 weeks earlier, and though he had survived the immediate event, it resulted in anoxic encephalopathy, which rendered him incapable of making decisions.

When it became clear that the patient was declining despite full support, the hospital’s ethics committee was convened to determine goals of care and next steps, as the patient had no family or surrogate decision maker. After determination that the hospital staff had exercised due diligence in attempting to locate a surrogate, the physicians involved reviewed the patient’s case and recommended a change in goals to comfort care. More than one member of the committee expressed confusion as to what interventions are and are not included in comfort care, including medically administered nutrition and hydration (MANH).

Comfort care has traditionally included medications for distressing symptoms (pain, dyspnea, nausea), personal care for hygiene, and choice of place of death (home, hospital, nursing facility), usually with the assistance of a hospice agency.

As the number and complexity of interventions used near the end of life expand, clinicians and hospital staff report confusion about whether these interventions, generally considered to be life-sustaining treatments, can also be considered comfort care. We generally find that when interventions are considered in the context of the patient’s goals of care, the dilemma is clarified. Often the situation is made more complicated by considering the interventions before settling on goals. Broadly speaking, goals of care are derived from a careful consideration (by patient, physician, and family) of the natural history of the illness, expected course and prognosis, and patient preferences.

In the case of the above-referenced patient, we were unable to ascertain his goals because of neurological impairment. We did know, however, that the patient had steadfastly avoided hospitals and medical care of any kind. The attending hospitalist, pulmonologist, and palliative care physician agreed that the patient’s clinical status was declining despite all available interventions, and that his constellation of medical problems constituted a terminal condition. The physicians agreed that future ICU admission, resuscitation, and other new interventions would only prolong his dying process, but not permit him to live outside the hospital. At that time, the patient was receiving nutrition and hydration via a Dobhoff tube, and was tolerating enteral nutrition without excessive residuals or pulmonary secretions.

As with other interventions, whether or not to consider MANH a part of comfort care is individualized. In this patient’s case, in the absence of evidence that he would not want MANH, it was continued. Other patients have expressed the wish that they would under no circumstances accept MANH while receiving comfort care. Both are correct as long as they reflect that patient’s wishes.

With respect to other interventions – including but not limited to BiPAP, inotrope infusion, chemotherapy, radiation therapy, and transfusions – whether or not they provide comfort is a decision to be made jointly by the patient and physician(s). As advances in medicine allow patients to live longer with serious illness, the definition of comfort care must also expand.

Dr. Fredholm and Dr. Bekanich are codirectors of Seton Palliative Care, part of the University of Texas Southwestern Residency Programs in Austin.

Recently, members of our palliative care team participated in the care of a man approaching the end of his life. The patient had suffered an in-hospital cardiac arrest 4 weeks earlier, and though he had survived the immediate event, it resulted in anoxic encephalopathy, which rendered him incapable of making decisions.

When it became clear that the patient was declining despite full support, the hospital’s ethics committee was convened to determine goals of care and next steps, as the patient had no family or surrogate decision maker. After determination that the hospital staff had exercised due diligence in attempting to locate a surrogate, the physicians involved reviewed the patient’s case and recommended a change in goals to comfort care. More than one member of the committee expressed confusion as to what interventions are and are not included in comfort care, including medically administered nutrition and hydration (MANH).

Comfort care has traditionally included medications for distressing symptoms (pain, dyspnea, nausea), personal care for hygiene, and choice of place of death (home, hospital, nursing facility), usually with the assistance of a hospice agency.

As the number and complexity of interventions used near the end of life expand, clinicians and hospital staff report confusion about whether these interventions, generally considered to be life-sustaining treatments, can also be considered comfort care. We generally find that when interventions are considered in the context of the patient’s goals of care, the dilemma is clarified. Often the situation is made more complicated by considering the interventions before settling on goals. Broadly speaking, goals of care are derived from a careful consideration (by patient, physician, and family) of the natural history of the illness, expected course and prognosis, and patient preferences.

In the case of the above-referenced patient, we were unable to ascertain his goals because of neurological impairment. We did know, however, that the patient had steadfastly avoided hospitals and medical care of any kind. The attending hospitalist, pulmonologist, and palliative care physician agreed that the patient’s clinical status was declining despite all available interventions, and that his constellation of medical problems constituted a terminal condition. The physicians agreed that future ICU admission, resuscitation, and other new interventions would only prolong his dying process, but not permit him to live outside the hospital. At that time, the patient was receiving nutrition and hydration via a Dobhoff tube, and was tolerating enteral nutrition without excessive residuals or pulmonary secretions.

As with other interventions, whether or not to consider MANH a part of comfort care is individualized. In this patient’s case, in the absence of evidence that he would not want MANH, it was continued. Other patients have expressed the wish that they would under no circumstances accept MANH while receiving comfort care. Both are correct as long as they reflect that patient’s wishes.

With respect to other interventions – including but not limited to BiPAP, inotrope infusion, chemotherapy, radiation therapy, and transfusions – whether or not they provide comfort is a decision to be made jointly by the patient and physician(s). As advances in medicine allow patients to live longer with serious illness, the definition of comfort care must also expand.

Dr. Fredholm and Dr. Bekanich are codirectors of Seton Palliative Care, part of the University of Texas Southwestern Residency Programs in Austin.

The Town Hall Meeting held at the Annual Meeting of the American College of Surgeons in Washington, DC, on Oct. 8, entitled, "Introspection – the Next Surgical Time-Out," was cochaired by Geoffrey Dunn, M.D., FACS, and Ann Mosenthal, M.D., FACS, with panelists Dan Hinshaw, M.D., FACS, and David Page, M.D., FACS.

Well-attended, the discussion raised specific issues that addressed the growing need for surgeons to care for themselves in a sometimes chaotic and hostile practice environment. Given a reported 30%-40% burnout rate among surgeons, it was felt prudent to explore a side of the surgical personality too often resistant to self-examination. And like scheduled time-outs before starting a case in the OR, it was felt that a personal time-out before diving into the next procedure or busy office session might blunt the frustration born of time constraints and excessive documentation demands piling up on surgical practitioners of all stripes.

For example, an attendee raised the issue of humanizing the otherwise sterile EHR with personal patient information, perhaps insights about the interior life of the patient unrelated to the diagnosis. Another attendee addressed the need for surgeons to model compassion as well as their reactions to grief for learners at all levels. The notion of using videos to teach introspection was raised and discussed, as was the technique of "reflective" or free (uninhibited) writing and journaling as methods for probing one’s inner landscape and deeper feelings and emotions.

The panel addressed the paradox all surgeons face: the need to confront with objectivity organic surgical disease in all of its anatomic-pathologic complexity, employ technical skills in a time-compressed stressful operating room, interact with other caregivers involved in employing complex technology, and then step away from the operative field and become transformed into a compassionate physician. It is fitting that surgeons understand that draping a patient is both a requirement of sterile technique as well as a metaphorical "hiding of the humanity on the table" in order to shift gears and become engrossed "in the moment," to become focused on the mechanical tasks of cure and not distracted by emotional issues.

What challenges the surgeon in ways he or she may not have anticipated is the act of undraping a wounded human who now needs the surgeon’s empathetic attention as the blood stops flowing. Only self-reflection and a consideration of the profound challenges of these diametrically opposed sides of the surgical personality will sustain surgeons through endless daily lists of complex operations and their associated political, cultural, and psychological burdens. And when cure is no longer possible, confrontation with the patient’s imminent demise too often echoes the confrontation between the surgeon and his or her self-image of invincibility.

Also discussed were two recent changes in the matrix of modern surgical practice that were thought to positively shift the traditional image of surgeons as action hero with relative insensitivity to their patients’ suffering. These features include the minimally invasive surgery revolution which transformed the surgeon from blood-splattered aggressor to a delicate-handed laparoscopic wizard capable of heretofore unseen indirect motor skills maneuvers, a quiet ectomorphic individual rather than the traditional mesomorphic "linebacker" persona. The second change is the rise of women in surgery. Once derided, discouraged, and humiliated at every turn, women are now a valued cohort of colleagues whose innate caregiving skills are matched by an admirable and unflinching work ethic. Introspection seems more natural for women, something the macho surgical male ought to learn from.

Finally, introspection was seen to be somewhat like the "second effect" in opioid administration (hastening death is justifiable if the intent is to reduce suffering, not to cause death). Because although the intent of introspection is ultimately to improve the care of our patients, an unforeseen consequence of introspection may center on the arrival of profound insight into the meaning of the surgeon’s own life.

The potential role of artistic expression by surgeons such as painting or creative writing was entertained and will be further explored in a similar format at next year’s ACS meeting in San Francisco.

Dr. Page is professor of surgery at Tufts University School of Medicine, Boston, and director of Undergraduate Programs in the department of surgery, Baystate Medical Center, Springfield, Mass.

The Town Hall Meeting held at the Annual Meeting of the American College of Surgeons in Washington, DC, on Oct. 8, entitled, "Introspection – the Next Surgical Time-Out," was cochaired by Geoffrey Dunn, M.D., FACS, and Ann Mosenthal, M.D., FACS, with panelists Dan Hinshaw, M.D., FACS, and David Page, M.D., FACS.

Well-attended, the discussion raised specific issues that addressed the growing need for surgeons to care for themselves in a sometimes chaotic and hostile practice environment. Given a reported 30%-40% burnout rate among surgeons, it was felt prudent to explore a side of the surgical personality too often resistant to self-examination. And like scheduled time-outs before starting a case in the OR, it was felt that a personal time-out before diving into the next procedure or busy office session might blunt the frustration born of time constraints and excessive documentation demands piling up on surgical practitioners of all stripes.

For example, an attendee raised the issue of humanizing the otherwise sterile EHR with personal patient information, perhaps insights about the interior life of the patient unrelated to the diagnosis. Another attendee addressed the need for surgeons to model compassion as well as their reactions to grief for learners at all levels. The notion of using videos to teach introspection was raised and discussed, as was the technique of "reflective" or free (uninhibited) writing and journaling as methods for probing one’s inner landscape and deeper feelings and emotions.

The panel addressed the paradox all surgeons face: the need to confront with objectivity organic surgical disease in all of its anatomic-pathologic complexity, employ technical skills in a time-compressed stressful operating room, interact with other caregivers involved in employing complex technology, and then step away from the operative field and become transformed into a compassionate physician. It is fitting that surgeons understand that draping a patient is both a requirement of sterile technique as well as a metaphorical "hiding of the humanity on the table" in order to shift gears and become engrossed "in the moment," to become focused on the mechanical tasks of cure and not distracted by emotional issues.

What challenges the surgeon in ways he or she may not have anticipated is the act of undraping a wounded human who now needs the surgeon’s empathetic attention as the blood stops flowing. Only self-reflection and a consideration of the profound challenges of these diametrically opposed sides of the surgical personality will sustain surgeons through endless daily lists of complex operations and their associated political, cultural, and psychological burdens. And when cure is no longer possible, confrontation with the patient’s imminent demise too often echoes the confrontation between the surgeon and his or her self-image of invincibility.

Also discussed were two recent changes in the matrix of modern surgical practice that were thought to positively shift the traditional image of surgeons as action hero with relative insensitivity to their patients’ suffering. These features include the minimally invasive surgery revolution which transformed the surgeon from blood-splattered aggressor to a delicate-handed laparoscopic wizard capable of heretofore unseen indirect motor skills maneuvers, a quiet ectomorphic individual rather than the traditional mesomorphic "linebacker" persona. The second change is the rise of women in surgery. Once derided, discouraged, and humiliated at every turn, women are now a valued cohort of colleagues whose innate caregiving skills are matched by an admirable and unflinching work ethic. Introspection seems more natural for women, something the macho surgical male ought to learn from.

Finally, introspection was seen to be somewhat like the "second effect" in opioid administration (hastening death is justifiable if the intent is to reduce suffering, not to cause death). Because although the intent of introspection is ultimately to improve the care of our patients, an unforeseen consequence of introspection may center on the arrival of profound insight into the meaning of the surgeon’s own life.

The potential role of artistic expression by surgeons such as painting or creative writing was entertained and will be further explored in a similar format at next year’s ACS meeting in San Francisco.

Dr. Page is professor of surgery at Tufts University School of Medicine, Boston, and director of Undergraduate Programs in the department of surgery, Baystate Medical Center, Springfield, Mass.

The Town Hall Meeting held at the Annual Meeting of the American College of Surgeons in Washington, DC, on Oct. 8, entitled, "Introspection – the Next Surgical Time-Out," was cochaired by Geoffrey Dunn, M.D., FACS, and Ann Mosenthal, M.D., FACS, with panelists Dan Hinshaw, M.D., FACS, and David Page, M.D., FACS.

Well-attended, the discussion raised specific issues that addressed the growing need for surgeons to care for themselves in a sometimes chaotic and hostile practice environment. Given a reported 30%-40% burnout rate among surgeons, it was felt prudent to explore a side of the surgical personality too often resistant to self-examination. And like scheduled time-outs before starting a case in the OR, it was felt that a personal time-out before diving into the next procedure or busy office session might blunt the frustration born of time constraints and excessive documentation demands piling up on surgical practitioners of all stripes.

For example, an attendee raised the issue of humanizing the otherwise sterile EHR with personal patient information, perhaps insights about the interior life of the patient unrelated to the diagnosis. Another attendee addressed the need for surgeons to model compassion as well as their reactions to grief for learners at all levels. The notion of using videos to teach introspection was raised and discussed, as was the technique of "reflective" or free (uninhibited) writing and journaling as methods for probing one’s inner landscape and deeper feelings and emotions.

The panel addressed the paradox all surgeons face: the need to confront with objectivity organic surgical disease in all of its anatomic-pathologic complexity, employ technical skills in a time-compressed stressful operating room, interact with other caregivers involved in employing complex technology, and then step away from the operative field and become transformed into a compassionate physician. It is fitting that surgeons understand that draping a patient is both a requirement of sterile technique as well as a metaphorical "hiding of the humanity on the table" in order to shift gears and become engrossed "in the moment," to become focused on the mechanical tasks of cure and not distracted by emotional issues.

What challenges the surgeon in ways he or she may not have anticipated is the act of undraping a wounded human who now needs the surgeon’s empathetic attention as the blood stops flowing. Only self-reflection and a consideration of the profound challenges of these diametrically opposed sides of the surgical personality will sustain surgeons through endless daily lists of complex operations and their associated political, cultural, and psychological burdens. And when cure is no longer possible, confrontation with the patient’s imminent demise too often echoes the confrontation between the surgeon and his or her self-image of invincibility.

Also discussed were two recent changes in the matrix of modern surgical practice that were thought to positively shift the traditional image of surgeons as action hero with relative insensitivity to their patients’ suffering. These features include the minimally invasive surgery revolution which transformed the surgeon from blood-splattered aggressor to a delicate-handed laparoscopic wizard capable of heretofore unseen indirect motor skills maneuvers, a quiet ectomorphic individual rather than the traditional mesomorphic "linebacker" persona. The second change is the rise of women in surgery. Once derided, discouraged, and humiliated at every turn, women are now a valued cohort of colleagues whose innate caregiving skills are matched by an admirable and unflinching work ethic. Introspection seems more natural for women, something the macho surgical male ought to learn from.

Finally, introspection was seen to be somewhat like the "second effect" in opioid administration (hastening death is justifiable if the intent is to reduce suffering, not to cause death). Because although the intent of introspection is ultimately to improve the care of our patients, an unforeseen consequence of introspection may center on the arrival of profound insight into the meaning of the surgeon’s own life.

The potential role of artistic expression by surgeons such as painting or creative writing was entertained and will be further explored in a similar format at next year’s ACS meeting in San Francisco.

Dr. Page is professor of surgery at Tufts University School of Medicine, Boston, and director of Undergraduate Programs in the department of surgery, Baystate Medical Center, Springfield, Mass.

We were called to the emergency department to see a young woman, DR, with metastatic endometrial cancer. She had presented with abdominal pain and was found to have evidence of perforation on CT imaging. The CT also demonstrated the unresectable uterus and multiple peritoneal implants. The tumor had not been responsive to the last bout of chemotherapy. DR had been less active, and had lost significant weight over the last several months. A former real estate agent, she hadn’t worked since her diagnosis. She lived with a friend and had a daughter who was very worried about her condition.

I was also worried. After looking at the CT I had told the resident over the phone that operation might not be a great choice. Yes but the family "wants everything done," she replied... CRINGE. "I’ll be over," I said.

Why do we cringe at this statement? Perhaps we feel trapped by a family (or a medical team) who suggests we do everything. There is no out. The die has been cast. This is certainly the case when a non-surgical team has suggested to a family the option of a last-ditch operative intervention. What scares us about the family who wants "everything done"? Often, we don’t think we should be intervening with a surgical operation when the outcome appears dismal. We are concerned with litigation if we don’t try "everything." We fear the communication challenge of speaking with a family with "unrealistic expectations."

But if we take a step back, we might gain some appreciation for the family perspective. Who wouldn’t want everything done to save a loved one, or to prolong our time with a loved one? Who wouldn’t want everything done that might maximize the opportunity for recovery? And who would ever want to do nothing for a loved one in a medical crisis?

I have witnessed (and participated in) two responses to these challenging moments. The first is to acquiesce and perform an operation as a "last-ditch effort." The second is to simply refuse to intervene or even refuse the consult. Neither of these approaches is serves the patient, his or her family, or the health care team (including ourselves). To simply acquiesce puts the patient at increased risk of suffering, gives the family a false notion of hope, and creates moral distress in our team. To simply refuse and walk away leads to patient and family abandonment (with a lack of understanding why operative intervention is not indicated) and leads to conflict within our health care team.

I suggest we enter these situations with the premise that we always do everything and we never do nothing. We do our best to provide treatments to meet the goals and needs of our patients and their loved ones. At times, this may mean a surgical intervention to restore a patient to full premorbid health. At others, this may mean an operation to alleviate suffering, for example, from a malignant bowel obstruction. And sometimes this means not operating as it will only increase or prolong suffering. Yet in the latter situation, there are plenty of appropriate interventions: relieving pain or dyspnea, providing spiritual support, promoting bereavement, and assisting all participants in avoiding complicated grief. These therapies can and should be provided with the same aggressive approach with which we provide operative therapy.

With this approach we are able to reassure our patients and their loved ones that our interests lie in providing the best possible treatments in meeting their goals and needs. And that no matter what, we will find a means to help in some way.

As we sat in the emergency department, we reassured DR that we were there to help and find the best course of action. We admitted our uncertainty with the immediate prognosis with or without operative intervention, but that ultimately she was dying from the cancer. She expressed that she was not ready to die. "I hope we can avoid death as long as possible," I said. "While I am unsure which course of action will prolong your life the most, I am concerned that with operation your death has a higher likelihood of occurring in the midst of a prolonged ICU stay. If we try antibiotic therapy and pain control you might have more of an opportunity to spend time with your daughter and friends." We recommended avoiding operation, focusing on symptom management, and maximizing time with her loved ones.

DR wanted time. She was admitted for antibiotic therapy and aggressive symptom control with a consult to palliative medicine. She stabilized and was able to be transitioned to home hospice with her daughter and friend as caretakers.

This approach is effectively one of risk and benefit, recognition of uncertainty, and adherence to patient values. We recognize the inevitability of death from the beginning of a serious illness and openly discuss with our patients their fears and goals. We join with them in the uncertain future and the hard decisions to come. We work with patients to embrace life-enhancing therapies and to forgo death-avoiding therapies in order to maximize those that work toward patient-centered outcomes. This is a world in which we aggressively do everything to promote health, broadly defined, and ameliorate suffering. We always do everything.

Dr. Weinstein is an ACS Fellow and associate professor of surgery at Thomas Jefferson University in Philadelphia. He is director of the surgical intensive care unit and Executive Medical Co-Director of the Thomas Jefferson University Hospital Center for Critical Care. He is a member of the Palliative Care Task Force of the American College of Surgeons.

We were called to the emergency department to see a young woman, DR, with metastatic endometrial cancer. She had presented with abdominal pain and was found to have evidence of perforation on CT imaging. The CT also demonstrated the unresectable uterus and multiple peritoneal implants. The tumor had not been responsive to the last bout of chemotherapy. DR had been less active, and had lost significant weight over the last several months. A former real estate agent, she hadn’t worked since her diagnosis. She lived with a friend and had a daughter who was very worried about her condition.

I was also worried. After looking at the CT I had told the resident over the phone that operation might not be a great choice. Yes but the family "wants everything done," she replied... CRINGE. "I’ll be over," I said.

Why do we cringe at this statement? Perhaps we feel trapped by a family (or a medical team) who suggests we do everything. There is no out. The die has been cast. This is certainly the case when a non-surgical team has suggested to a family the option of a last-ditch operative intervention. What scares us about the family who wants "everything done"? Often, we don’t think we should be intervening with a surgical operation when the outcome appears dismal. We are concerned with litigation if we don’t try "everything." We fear the communication challenge of speaking with a family with "unrealistic expectations."

But if we take a step back, we might gain some appreciation for the family perspective. Who wouldn’t want everything done to save a loved one, or to prolong our time with a loved one? Who wouldn’t want everything done that might maximize the opportunity for recovery? And who would ever want to do nothing for a loved one in a medical crisis?

I have witnessed (and participated in) two responses to these challenging moments. The first is to acquiesce and perform an operation as a "last-ditch effort." The second is to simply refuse to intervene or even refuse the consult. Neither of these approaches is serves the patient, his or her family, or the health care team (including ourselves). To simply acquiesce puts the patient at increased risk of suffering, gives the family a false notion of hope, and creates moral distress in our team. To simply refuse and walk away leads to patient and family abandonment (with a lack of understanding why operative intervention is not indicated) and leads to conflict within our health care team.

I suggest we enter these situations with the premise that we always do everything and we never do nothing. We do our best to provide treatments to meet the goals and needs of our patients and their loved ones. At times, this may mean a surgical intervention to restore a patient to full premorbid health. At others, this may mean an operation to alleviate suffering, for example, from a malignant bowel obstruction. And sometimes this means not operating as it will only increase or prolong suffering. Yet in the latter situation, there are plenty of appropriate interventions: relieving pain or dyspnea, providing spiritual support, promoting bereavement, and assisting all participants in avoiding complicated grief. These therapies can and should be provided with the same aggressive approach with which we provide operative therapy.

With this approach we are able to reassure our patients and their loved ones that our interests lie in providing the best possible treatments in meeting their goals and needs. And that no matter what, we will find a means to help in some way.

As we sat in the emergency department, we reassured DR that we were there to help and find the best course of action. We admitted our uncertainty with the immediate prognosis with or without operative intervention, but that ultimately she was dying from the cancer. She expressed that she was not ready to die. "I hope we can avoid death as long as possible," I said. "While I am unsure which course of action will prolong your life the most, I am concerned that with operation your death has a higher likelihood of occurring in the midst of a prolonged ICU stay. If we try antibiotic therapy and pain control you might have more of an opportunity to spend time with your daughter and friends." We recommended avoiding operation, focusing on symptom management, and maximizing time with her loved ones.

DR wanted time. She was admitted for antibiotic therapy and aggressive symptom control with a consult to palliative medicine. She stabilized and was able to be transitioned to home hospice with her daughter and friend as caretakers.

This approach is effectively one of risk and benefit, recognition of uncertainty, and adherence to patient values. We recognize the inevitability of death from the beginning of a serious illness and openly discuss with our patients their fears and goals. We join with them in the uncertain future and the hard decisions to come. We work with patients to embrace life-enhancing therapies and to forgo death-avoiding therapies in order to maximize those that work toward patient-centered outcomes. This is a world in which we aggressively do everything to promote health, broadly defined, and ameliorate suffering. We always do everything.

Dr. Weinstein is an ACS Fellow and associate professor of surgery at Thomas Jefferson University in Philadelphia. He is director of the surgical intensive care unit and Executive Medical Co-Director of the Thomas Jefferson University Hospital Center for Critical Care. He is a member of the Palliative Care Task Force of the American College of Surgeons.

We were called to the emergency department to see a young woman, DR, with metastatic endometrial cancer. She had presented with abdominal pain and was found to have evidence of perforation on CT imaging. The CT also demonstrated the unresectable uterus and multiple peritoneal implants. The tumor had not been responsive to the last bout of chemotherapy. DR had been less active, and had lost significant weight over the last several months. A former real estate agent, she hadn’t worked since her diagnosis. She lived with a friend and had a daughter who was very worried about her condition.

I was also worried. After looking at the CT I had told the resident over the phone that operation might not be a great choice. Yes but the family "wants everything done," she replied... CRINGE. "I’ll be over," I said.

Why do we cringe at this statement? Perhaps we feel trapped by a family (or a medical team) who suggests we do everything. There is no out. The die has been cast. This is certainly the case when a non-surgical team has suggested to a family the option of a last-ditch operative intervention. What scares us about the family who wants "everything done"? Often, we don’t think we should be intervening with a surgical operation when the outcome appears dismal. We are concerned with litigation if we don’t try "everything." We fear the communication challenge of speaking with a family with "unrealistic expectations."

But if we take a step back, we might gain some appreciation for the family perspective. Who wouldn’t want everything done to save a loved one, or to prolong our time with a loved one? Who wouldn’t want everything done that might maximize the opportunity for recovery? And who would ever want to do nothing for a loved one in a medical crisis?

I have witnessed (and participated in) two responses to these challenging moments. The first is to acquiesce and perform an operation as a "last-ditch effort." The second is to simply refuse to intervene or even refuse the consult. Neither of these approaches is serves the patient, his or her family, or the health care team (including ourselves). To simply acquiesce puts the patient at increased risk of suffering, gives the family a false notion of hope, and creates moral distress in our team. To simply refuse and walk away leads to patient and family abandonment (with a lack of understanding why operative intervention is not indicated) and leads to conflict within our health care team.

I suggest we enter these situations with the premise that we always do everything and we never do nothing. We do our best to provide treatments to meet the goals and needs of our patients and their loved ones. At times, this may mean a surgical intervention to restore a patient to full premorbid health. At others, this may mean an operation to alleviate suffering, for example, from a malignant bowel obstruction. And sometimes this means not operating as it will only increase or prolong suffering. Yet in the latter situation, there are plenty of appropriate interventions: relieving pain or dyspnea, providing spiritual support, promoting bereavement, and assisting all participants in avoiding complicated grief. These therapies can and should be provided with the same aggressive approach with which we provide operative therapy.

With this approach we are able to reassure our patients and their loved ones that our interests lie in providing the best possible treatments in meeting their goals and needs. And that no matter what, we will find a means to help in some way.

As we sat in the emergency department, we reassured DR that we were there to help and find the best course of action. We admitted our uncertainty with the immediate prognosis with or without operative intervention, but that ultimately she was dying from the cancer. She expressed that she was not ready to die. "I hope we can avoid death as long as possible," I said. "While I am unsure which course of action will prolong your life the most, I am concerned that with operation your death has a higher likelihood of occurring in the midst of a prolonged ICU stay. If we try antibiotic therapy and pain control you might have more of an opportunity to spend time with your daughter and friends." We recommended avoiding operation, focusing on symptom management, and maximizing time with her loved ones.

DR wanted time. She was admitted for antibiotic therapy and aggressive symptom control with a consult to palliative medicine. She stabilized and was able to be transitioned to home hospice with her daughter and friend as caretakers.

This approach is effectively one of risk and benefit, recognition of uncertainty, and adherence to patient values. We recognize the inevitability of death from the beginning of a serious illness and openly discuss with our patients their fears and goals. We join with them in the uncertain future and the hard decisions to come. We work with patients to embrace life-enhancing therapies and to forgo death-avoiding therapies in order to maximize those that work toward patient-centered outcomes. This is a world in which we aggressively do everything to promote health, broadly defined, and ameliorate suffering. We always do everything.

Dr. Weinstein is an ACS Fellow and associate professor of surgery at Thomas Jefferson University in Philadelphia. He is director of the surgical intensive care unit and Executive Medical Co-Director of the Thomas Jefferson University Hospital Center for Critical Care. He is a member of the Palliative Care Task Force of the American College of Surgeons.