Palliative Care

She presented to the trauma bay after transfer from another hospital. She had fallen out of bed at the nursing home, and they had sent her to the emergency department for evaluation. Her head CT demonstrated a subacute chronic subdural hematoma. She had fallen a month ago and had been seen at the same hospital and was transferred to us then, too, but not as a trauma. Admitted to another service for a few days, she had subsequently been sent to the nursing home with weekly head CT scans for follow-up. Today’s CT showed continued resolution of her subdural hematoma, but since she had fallen and had an abnormal CT scan, she was transferred to us as a trauma for further evaluation.

The patient was elderly, in her 90s, with end-stage dementia. The trauma team descended on her as we do with all traumas – to evaluate for life-threatening injuries. Airway, breathing, circulation. Does she need to be intubated? What is her blood pressure? Place IVs and draw blood. Put her quickly on the monitors, undress her completely. Roll her on her side to examine her back. Make sure she is in a rigid C-collar and cannot move her neck until we are sure it isn’t fractured. She cannot sit up despite her desire to do so, thus requiring us to hold her down, so she doesn’t injure herself or others. In the midst of all this, she kept screaming, "Why do you keep doing this to me?" That was all she said. Repeatedly. As I sorted out the events of the past month, read the radiologist report from the referring institution that documented improvement in her scans, and reviewed all the CTs on disc, I wondered the same, "Why are we doing this to you?" She didn’t need a trauma center or the trauma team. What she needed was a goals of care discussion and POLST (Physician Orders for Life-Sustaining Treatment) document.

We, as doctors, are poor at discussing goals of care. Even for those patients who are expected to do well, we do not address code status, or ask them what they want if things go poorly. Recently, the University of California published their results with a quality improvement program to document advance care planning discussions. Between July 2011 and May 2012 on the medical service, they created an incentive program for documentation of goals of care and identification of a surrogate decision maker. If 75% of patients had the two items documented in the medical record, then the residents received a $400 incentive. Documentation (and likely actual discussion) increased from 22% in July to 90% by October and remained at that level. There were reminders and feedback, and it seems likely a component of peer pressure among the residents to ensure everyone received the incentive. The study did not track outcomes or documentation rates after the program was over. The study did show that behavior of initiating difficult end-of-life (EOL) planning discussions can be improved in a quality improvement program. (JAMA Intern. Med. 2013 [doi: 10.1001/jamainternmed.2013.8158]).

Ideally, the next step would be to document the use of POLST (www.polst.org) orders. POLST is a bright pink form that documents the patient’s preferences for code status, treatment options (full including ICU, limited, or comfort measures including no transport to hospital) artificial nutrition and hydration, and antibiotics. POLST is signed by a physician and, therefore, it can be applied across care settings. If it is signed by the patient, it cannot be overridden by the surrogate, and there are legal protections for health care providers.

We admitted the patient in the trauma bay, not because she needed acute care, but because she needed goals of care defined. We consulted Palliative Medicine and had the social worker identify a decision maker. Palliative Medicine worked with the surrogate decision maker to set goals of care: feeding tube, follow-up scans, code status, and most importantly POLST orders. Regrettably, it took a trip to the Trauma Bay after multiple interactions with the health care system to evaluate what really was in the best interest of the patient and what she would have wanted. She told us as best she could that she did not want what we were doing to her. This time, we listened.

Dr Toevs is a trauma critical care surgeon at Allegheny General Hospital in Pittsburgh, Pa. She has a Masters degree in bioethics and board-certification in hospice and palliative medicine.

She presented to the trauma bay after transfer from another hospital. She had fallen out of bed at the nursing home, and they had sent her to the emergency department for evaluation. Her head CT demonstrated a subacute chronic subdural hematoma. She had fallen a month ago and had been seen at the same hospital and was transferred to us then, too, but not as a trauma. Admitted to another service for a few days, she had subsequently been sent to the nursing home with weekly head CT scans for follow-up. Today’s CT showed continued resolution of her subdural hematoma, but since she had fallen and had an abnormal CT scan, she was transferred to us as a trauma for further evaluation.

The patient was elderly, in her 90s, with end-stage dementia. The trauma team descended on her as we do with all traumas – to evaluate for life-threatening injuries. Airway, breathing, circulation. Does she need to be intubated? What is her blood pressure? Place IVs and draw blood. Put her quickly on the monitors, undress her completely. Roll her on her side to examine her back. Make sure she is in a rigid C-collar and cannot move her neck until we are sure it isn’t fractured. She cannot sit up despite her desire to do so, thus requiring us to hold her down, so she doesn’t injure herself or others. In the midst of all this, she kept screaming, "Why do you keep doing this to me?" That was all she said. Repeatedly. As I sorted out the events of the past month, read the radiologist report from the referring institution that documented improvement in her scans, and reviewed all the CTs on disc, I wondered the same, "Why are we doing this to you?" She didn’t need a trauma center or the trauma team. What she needed was a goals of care discussion and POLST (Physician Orders for Life-Sustaining Treatment) document.

We, as doctors, are poor at discussing goals of care. Even for those patients who are expected to do well, we do not address code status, or ask them what they want if things go poorly. Recently, the University of California published their results with a quality improvement program to document advance care planning discussions. Between July 2011 and May 2012 on the medical service, they created an incentive program for documentation of goals of care and identification of a surrogate decision maker. If 75% of patients had the two items documented in the medical record, then the residents received a $400 incentive. Documentation (and likely actual discussion) increased from 22% in July to 90% by October and remained at that level. There were reminders and feedback, and it seems likely a component of peer pressure among the residents to ensure everyone received the incentive. The study did not track outcomes or documentation rates after the program was over. The study did show that behavior of initiating difficult end-of-life (EOL) planning discussions can be improved in a quality improvement program. (JAMA Intern. Med. 2013 [doi: 10.1001/jamainternmed.2013.8158]).

Ideally, the next step would be to document the use of POLST (www.polst.org) orders. POLST is a bright pink form that documents the patient’s preferences for code status, treatment options (full including ICU, limited, or comfort measures including no transport to hospital) artificial nutrition and hydration, and antibiotics. POLST is signed by a physician and, therefore, it can be applied across care settings. If it is signed by the patient, it cannot be overridden by the surrogate, and there are legal protections for health care providers.

We admitted the patient in the trauma bay, not because she needed acute care, but because she needed goals of care defined. We consulted Palliative Medicine and had the social worker identify a decision maker. Palliative Medicine worked with the surrogate decision maker to set goals of care: feeding tube, follow-up scans, code status, and most importantly POLST orders. Regrettably, it took a trip to the Trauma Bay after multiple interactions with the health care system to evaluate what really was in the best interest of the patient and what she would have wanted. She told us as best she could that she did not want what we were doing to her. This time, we listened.

Dr Toevs is a trauma critical care surgeon at Allegheny General Hospital in Pittsburgh, Pa. She has a Masters degree in bioethics and board-certification in hospice and palliative medicine.

She presented to the trauma bay after transfer from another hospital. She had fallen out of bed at the nursing home, and they had sent her to the emergency department for evaluation. Her head CT demonstrated a subacute chronic subdural hematoma. She had fallen a month ago and had been seen at the same hospital and was transferred to us then, too, but not as a trauma. Admitted to another service for a few days, she had subsequently been sent to the nursing home with weekly head CT scans for follow-up. Today’s CT showed continued resolution of her subdural hematoma, but since she had fallen and had an abnormal CT scan, she was transferred to us as a trauma for further evaluation.

The patient was elderly, in her 90s, with end-stage dementia. The trauma team descended on her as we do with all traumas – to evaluate for life-threatening injuries. Airway, breathing, circulation. Does she need to be intubated? What is her blood pressure? Place IVs and draw blood. Put her quickly on the monitors, undress her completely. Roll her on her side to examine her back. Make sure she is in a rigid C-collar and cannot move her neck until we are sure it isn’t fractured. She cannot sit up despite her desire to do so, thus requiring us to hold her down, so she doesn’t injure herself or others. In the midst of all this, she kept screaming, "Why do you keep doing this to me?" That was all she said. Repeatedly. As I sorted out the events of the past month, read the radiologist report from the referring institution that documented improvement in her scans, and reviewed all the CTs on disc, I wondered the same, "Why are we doing this to you?" She didn’t need a trauma center or the trauma team. What she needed was a goals of care discussion and POLST (Physician Orders for Life-Sustaining Treatment) document.

We, as doctors, are poor at discussing goals of care. Even for those patients who are expected to do well, we do not address code status, or ask them what they want if things go poorly. Recently, the University of California published their results with a quality improvement program to document advance care planning discussions. Between July 2011 and May 2012 on the medical service, they created an incentive program for documentation of goals of care and identification of a surrogate decision maker. If 75% of patients had the two items documented in the medical record, then the residents received a $400 incentive. Documentation (and likely actual discussion) increased from 22% in July to 90% by October and remained at that level. There were reminders and feedback, and it seems likely a component of peer pressure among the residents to ensure everyone received the incentive. The study did not track outcomes or documentation rates after the program was over. The study did show that behavior of initiating difficult end-of-life (EOL) planning discussions can be improved in a quality improvement program. (JAMA Intern. Med. 2013 [doi: 10.1001/jamainternmed.2013.8158]).

Ideally, the next step would be to document the use of POLST (www.polst.org) orders. POLST is a bright pink form that documents the patient’s preferences for code status, treatment options (full including ICU, limited, or comfort measures including no transport to hospital) artificial nutrition and hydration, and antibiotics. POLST is signed by a physician and, therefore, it can be applied across care settings. If it is signed by the patient, it cannot be overridden by the surrogate, and there are legal protections for health care providers.

We admitted the patient in the trauma bay, not because she needed acute care, but because she needed goals of care defined. We consulted Palliative Medicine and had the social worker identify a decision maker. Palliative Medicine worked with the surrogate decision maker to set goals of care: feeding tube, follow-up scans, code status, and most importantly POLST orders. Regrettably, it took a trip to the Trauma Bay after multiple interactions with the health care system to evaluate what really was in the best interest of the patient and what she would have wanted. She told us as best she could that she did not want what we were doing to her. This time, we listened.

Dr Toevs is a trauma critical care surgeon at Allegheny General Hospital in Pittsburgh, Pa. She has a Masters degree in bioethics and board-certification in hospice and palliative medicine.

This morbidity and mortality conference was like any other: First, we reviewed the case of a patient with a complication from anticoagulation and then another with an anastomotic leak. Finally, we discussed an elderly patient who had a major emergent procedure to treat complications from an underlying life-limiting condition, only to die in hospital weeks later after developing insurmountable medical, surgical, and infectious complications.

This elderly patient was a man in his mid-70s recently diagnosed with recurrent melanoma. He came to our emergency department with peritonitis and hypotension. His wife of 52 years sat beside him. She was tearful and afraid. "We want everything done," she said. Eight weeks ago, he was working full time and playing golf. But, 6 weeks ago he became confused. A CT scan revealed brain metastasis. He spent 5 of the last 6 weeks in the ICU and in a step-down unit, or a nursing home after a series of complications from his brain biopsy. Now he was back in the hospital with a bowel perforation.

Before our surgical team even saw him, he was told he needed surgery, or he would die. We discussed the surgical risks including the likelihood of a protracted ICU stay, and the high risk he would never go home. Still, he and his wife were unprepared for death and so we went to the operating room.

The following weeks were fraught with complications. His symptoms – including delirium, tumor headaches, and pain – were all difficult to manage on his cocktail of steroids, opiates, and antipsychotics. Occasionally, he would mumble something about dying but we couldn’t determine if he was lucid. His symptoms and "talk about death" were distressing for his family. All in all, our team spent almost an hour each day answering their questions and tending to their anxiety and suffering. It took a high emotional toll on our entire team, as we each worried to ourselves that we were doing more harm than good.

One organ system failed after the other. And finally, after two operations, 10 different consultants, and 3 weeks in the hospital, we stopped talking about organ systems and told the family that this man was dying. That day we consulted palliative care to help us with "goals of care." The next day, he became oliguric, and we shifted our focus to comfort. He died within hours surrounded by his loving extended family.

When we discussed this case at M&M, there were no objections to the decision to operate or how we managed his laundry list of complications. His death was deemed "nonpreventable." But, at then end of the discussion, a colleague asked, with some exasperation, "I never know when to call palliative care. How do you decide when the patient is dying?"

In retrospect, it is clear that this patient was dying when we met him in the emergency department. He was malnourished and disabled from his cancer and treatment. His bowel perforation was caused by the steroids prescribed to treat his underlying terminal disease. The best outcome we could hope for was a good quality of life in his last days, a peaceful and dignified death, and an uncomplicated bereavement for his survivors. Our emergency, life-saving surgery was, in fact, palliative. Death was near, but we just didn’t want him to die this way.

According to the American College of Surgeons code of professional conduct, surgeons play a pivotal role in facilitating the transition from curative to palliative treatment for the patients and the entire health care team. Furthermore, "effective palliation obligates sensitive discussion with patients and their families." These conversations can be particularly onerous for surgeons because we take on tremendous sense of personal responsibility for postoperative outcomes. Once we commit to operating on a patient, their death, especially if it follows complications, can be equated with personal defeat. We may benefit from consulting specialists who can help us set the stage, and smooth the transition for our patients and their families. Surgeons may also personally benefit from the support of other providers to help us cope with these emotionally difficult cases.

Palliative care is a multidisciplinary model of care to address the physical, intellectual, emotional, social, and spiritual needs of patients and families facing serious illness. The goal of palliative care is to support the best possible quality of life for patients at all stages of serious illness, through providing aggressive symptom management, psychosocial and spiritual care, and grief and bereavement counseling before and after death. Palliative care seeks to be life affirming and is based on the understanding of death as a normal life process. It can and should be delivered along with life-prolonging treatment.

In this case, palliative care should have been offered in the emergency department as soon as this patient was admitted to our service. The patient, and his family, would have benefited from a team of physicians, nurses, pharmacists, social workers, and chaplains with the time and expertise to manage distressing symptoms from his cancer, and attend to the grief and suffering that characterized his final weeks. Earlier palliative care may have also steered us away from the slog of high-burden treatments that ultimately offered him little benefit. For the surgeons, palliative care would have provided additional resources to take the best possible care of our patient who, whether or not he made it home, was near the end of his life from an advanced illness.

Dr. Zara Cooper is an ACS Fellow, and assistant professor of surgery, Harvard Medical School, and department of surgery, division of trauma, burns and critical care at Brigham and Women’s Hospital, Boston. Dr. Cooper has no disclosures relevant to this editorial.

This morbidity and mortality conference was like any other: First, we reviewed the case of a patient with a complication from anticoagulation and then another with an anastomotic leak. Finally, we discussed an elderly patient who had a major emergent procedure to treat complications from an underlying life-limiting condition, only to die in hospital weeks later after developing insurmountable medical, surgical, and infectious complications.

This elderly patient was a man in his mid-70s recently diagnosed with recurrent melanoma. He came to our emergency department with peritonitis and hypotension. His wife of 52 years sat beside him. She was tearful and afraid. "We want everything done," she said. Eight weeks ago, he was working full time and playing golf. But, 6 weeks ago he became confused. A CT scan revealed brain metastasis. He spent 5 of the last 6 weeks in the ICU and in a step-down unit, or a nursing home after a series of complications from his brain biopsy. Now he was back in the hospital with a bowel perforation.

Before our surgical team even saw him, he was told he needed surgery, or he would die. We discussed the surgical risks including the likelihood of a protracted ICU stay, and the high risk he would never go home. Still, he and his wife were unprepared for death and so we went to the operating room.

The following weeks were fraught with complications. His symptoms – including delirium, tumor headaches, and pain – were all difficult to manage on his cocktail of steroids, opiates, and antipsychotics. Occasionally, he would mumble something about dying but we couldn’t determine if he was lucid. His symptoms and "talk about death" were distressing for his family. All in all, our team spent almost an hour each day answering their questions and tending to their anxiety and suffering. It took a high emotional toll on our entire team, as we each worried to ourselves that we were doing more harm than good.

One organ system failed after the other. And finally, after two operations, 10 different consultants, and 3 weeks in the hospital, we stopped talking about organ systems and told the family that this man was dying. That day we consulted palliative care to help us with "goals of care." The next day, he became oliguric, and we shifted our focus to comfort. He died within hours surrounded by his loving extended family.

When we discussed this case at M&M, there were no objections to the decision to operate or how we managed his laundry list of complications. His death was deemed "nonpreventable." But, at then end of the discussion, a colleague asked, with some exasperation, "I never know when to call palliative care. How do you decide when the patient is dying?"

In retrospect, it is clear that this patient was dying when we met him in the emergency department. He was malnourished and disabled from his cancer and treatment. His bowel perforation was caused by the steroids prescribed to treat his underlying terminal disease. The best outcome we could hope for was a good quality of life in his last days, a peaceful and dignified death, and an uncomplicated bereavement for his survivors. Our emergency, life-saving surgery was, in fact, palliative. Death was near, but we just didn’t want him to die this way.

According to the American College of Surgeons code of professional conduct, surgeons play a pivotal role in facilitating the transition from curative to palliative treatment for the patients and the entire health care team. Furthermore, "effective palliation obligates sensitive discussion with patients and their families." These conversations can be particularly onerous for surgeons because we take on tremendous sense of personal responsibility for postoperative outcomes. Once we commit to operating on a patient, their death, especially if it follows complications, can be equated with personal defeat. We may benefit from consulting specialists who can help us set the stage, and smooth the transition for our patients and their families. Surgeons may also personally benefit from the support of other providers to help us cope with these emotionally difficult cases.

Palliative care is a multidisciplinary model of care to address the physical, intellectual, emotional, social, and spiritual needs of patients and families facing serious illness. The goal of palliative care is to support the best possible quality of life for patients at all stages of serious illness, through providing aggressive symptom management, psychosocial and spiritual care, and grief and bereavement counseling before and after death. Palliative care seeks to be life affirming and is based on the understanding of death as a normal life process. It can and should be delivered along with life-prolonging treatment.

In this case, palliative care should have been offered in the emergency department as soon as this patient was admitted to our service. The patient, and his family, would have benefited from a team of physicians, nurses, pharmacists, social workers, and chaplains with the time and expertise to manage distressing symptoms from his cancer, and attend to the grief and suffering that characterized his final weeks. Earlier palliative care may have also steered us away from the slog of high-burden treatments that ultimately offered him little benefit. For the surgeons, palliative care would have provided additional resources to take the best possible care of our patient who, whether or not he made it home, was near the end of his life from an advanced illness.

Dr. Zara Cooper is an ACS Fellow, and assistant professor of surgery, Harvard Medical School, and department of surgery, division of trauma, burns and critical care at Brigham and Women’s Hospital, Boston. Dr. Cooper has no disclosures relevant to this editorial.

This morbidity and mortality conference was like any other: First, we reviewed the case of a patient with a complication from anticoagulation and then another with an anastomotic leak. Finally, we discussed an elderly patient who had a major emergent procedure to treat complications from an underlying life-limiting condition, only to die in hospital weeks later after developing insurmountable medical, surgical, and infectious complications.

This elderly patient was a man in his mid-70s recently diagnosed with recurrent melanoma. He came to our emergency department with peritonitis and hypotension. His wife of 52 years sat beside him. She was tearful and afraid. "We want everything done," she said. Eight weeks ago, he was working full time and playing golf. But, 6 weeks ago he became confused. A CT scan revealed brain metastasis. He spent 5 of the last 6 weeks in the ICU and in a step-down unit, or a nursing home after a series of complications from his brain biopsy. Now he was back in the hospital with a bowel perforation.

Before our surgical team even saw him, he was told he needed surgery, or he would die. We discussed the surgical risks including the likelihood of a protracted ICU stay, and the high risk he would never go home. Still, he and his wife were unprepared for death and so we went to the operating room.

The following weeks were fraught with complications. His symptoms – including delirium, tumor headaches, and pain – were all difficult to manage on his cocktail of steroids, opiates, and antipsychotics. Occasionally, he would mumble something about dying but we couldn’t determine if he was lucid. His symptoms and "talk about death" were distressing for his family. All in all, our team spent almost an hour each day answering their questions and tending to their anxiety and suffering. It took a high emotional toll on our entire team, as we each worried to ourselves that we were doing more harm than good.

One organ system failed after the other. And finally, after two operations, 10 different consultants, and 3 weeks in the hospital, we stopped talking about organ systems and told the family that this man was dying. That day we consulted palliative care to help us with "goals of care." The next day, he became oliguric, and we shifted our focus to comfort. He died within hours surrounded by his loving extended family.

When we discussed this case at M&M, there were no objections to the decision to operate or how we managed his laundry list of complications. His death was deemed "nonpreventable." But, at then end of the discussion, a colleague asked, with some exasperation, "I never know when to call palliative care. How do you decide when the patient is dying?"

In retrospect, it is clear that this patient was dying when we met him in the emergency department. He was malnourished and disabled from his cancer and treatment. His bowel perforation was caused by the steroids prescribed to treat his underlying terminal disease. The best outcome we could hope for was a good quality of life in his last days, a peaceful and dignified death, and an uncomplicated bereavement for his survivors. Our emergency, life-saving surgery was, in fact, palliative. Death was near, but we just didn’t want him to die this way.

According to the American College of Surgeons code of professional conduct, surgeons play a pivotal role in facilitating the transition from curative to palliative treatment for the patients and the entire health care team. Furthermore, "effective palliation obligates sensitive discussion with patients and their families." These conversations can be particularly onerous for surgeons because we take on tremendous sense of personal responsibility for postoperative outcomes. Once we commit to operating on a patient, their death, especially if it follows complications, can be equated with personal defeat. We may benefit from consulting specialists who can help us set the stage, and smooth the transition for our patients and their families. Surgeons may also personally benefit from the support of other providers to help us cope with these emotionally difficult cases.

Palliative care is a multidisciplinary model of care to address the physical, intellectual, emotional, social, and spiritual needs of patients and families facing serious illness. The goal of palliative care is to support the best possible quality of life for patients at all stages of serious illness, through providing aggressive symptom management, psychosocial and spiritual care, and grief and bereavement counseling before and after death. Palliative care seeks to be life affirming and is based on the understanding of death as a normal life process. It can and should be delivered along with life-prolonging treatment.

In this case, palliative care should have been offered in the emergency department as soon as this patient was admitted to our service. The patient, and his family, would have benefited from a team of physicians, nurses, pharmacists, social workers, and chaplains with the time and expertise to manage distressing symptoms from his cancer, and attend to the grief and suffering that characterized his final weeks. Earlier palliative care may have also steered us away from the slog of high-burden treatments that ultimately offered him little benefit. For the surgeons, palliative care would have provided additional resources to take the best possible care of our patient who, whether or not he made it home, was near the end of his life from an advanced illness.

Dr. Zara Cooper is an ACS Fellow, and assistant professor of surgery, Harvard Medical School, and department of surgery, division of trauma, burns and critical care at Brigham and Women’s Hospital, Boston. Dr. Cooper has no disclosures relevant to this editorial.

Editor's Note: This article is the first in a series on surgical palliative care that will appear periodically in Surgery News. The series, which will include contributions from members of the American College of Surgeons' Surgical Palliative Care Task Force, is intended to inform readers about the variety of issues involved in managing patients with serious or terminal illnesses and the role surgeons can play in providing the best possible care for these individuals.

If I were asked what has made the biggest impact on the field of surgery during my 30-year career, I would say the transition to evidence-based practice as a benchmark of quality and the recognition of quality of life outcomes as meaningful measures of care have been equally important. These represent an evolution from the surgeon-centric practice of the past to the patient-centered practice of the present.

But I believe we are at the point of another pendulum swing, because the "patient-centeredness" concept not only has failed to prevent vast and often ineffectual health care expenditures, but might actually be contributing to them.

I recently asked a physically and emotionally exhausted family member of an "ICU to nowhere" patient why he thought patients get "stuck" in the ICU. He answered eloquently, "People just don’t think they should die."

The current conceptual framework for care of the seriously ill is unable to respond to the psychological and spiritual questions raised by this comment. Disease management alone will not break this type of gridlock, nor will it leave patients and families with a lasting sense of support.

Surgical palliative care is an evidence-based and interdisciplinary approach (consisting of surgery, nursing, social work, chaplaincy, counseling, and others) to caring for patients who are seriously or terminally ill.

Palliative care includes communication skills (disclosure of prognosis, setting goals, advance care planning), pain and non-pain symptom management, ethics and conflict resolution, and self-awareness. Palliative care emphasizes continuity of care across clinical settings and services, attention to spiritual needs, psychosocial support for patients and families, and bereavement support for families of the deceased and team members who cared for them.

Although the origins of palliative care are identifiable in the modern hospice movement, its applicability goes far beyond the hospice-appropriate population. For example, in my own in-hospital practice, only about half of my palliative care consultations are appropriate for hospice referral. Some patients I have subsequently referred for liver and kidney transplantation; numerous others have proceeded to primary surgical management of cancer; and still others have returned to work following trauma rehabilitation.

During the past 15 years, the American College of Surgeons has strongly supported the concept of palliative care through position statements, ACS Bulletin articles, and education initiatives for surgeons. The Commission on Cancer has endorsed palliative care in its Cancer Program Standards 2012 by requiring the availability of palliative care services. The ABS has joined nine other member boards of the American Board of Medical Specialties (ABMS) in offering subspecialty certification in Hospice and Palliative Medicine (HPM). Although the number of surgeons specializing in palliative medicine will be very small, the need for expertise in this area will grow as the public and practitioners recognize the rewards of an evidence-based palliative care for seriously ill patients, their families, and surgical practitioners.

Dr. Dunn, an ACS Fellow based in Erie, Pa., is chair of the ACS Surgical Palliative Care Task Force.

Editor's Note: This article is the first in a series on surgical palliative care that will appear periodically in Surgery News. The series, which will include contributions from members of the American College of Surgeons' Surgical Palliative Care Task Force, is intended to inform readers about the variety of issues involved in managing patients with serious or terminal illnesses and the role surgeons can play in providing the best possible care for these individuals.

If I were asked what has made the biggest impact on the field of surgery during my 30-year career, I would say the transition to evidence-based practice as a benchmark of quality and the recognition of quality of life outcomes as meaningful measures of care have been equally important. These represent an evolution from the surgeon-centric practice of the past to the patient-centered practice of the present.

But I believe we are at the point of another pendulum swing, because the "patient-centeredness" concept not only has failed to prevent vast and often ineffectual health care expenditures, but might actually be contributing to them.

I recently asked a physically and emotionally exhausted family member of an "ICU to nowhere" patient why he thought patients get "stuck" in the ICU. He answered eloquently, "People just don’t think they should die."

The current conceptual framework for care of the seriously ill is unable to respond to the psychological and spiritual questions raised by this comment. Disease management alone will not break this type of gridlock, nor will it leave patients and families with a lasting sense of support.

Surgical palliative care is an evidence-based and interdisciplinary approach (consisting of surgery, nursing, social work, chaplaincy, counseling, and others) to caring for patients who are seriously or terminally ill.

Palliative care includes communication skills (disclosure of prognosis, setting goals, advance care planning), pain and non-pain symptom management, ethics and conflict resolution, and self-awareness. Palliative care emphasizes continuity of care across clinical settings and services, attention to spiritual needs, psychosocial support for patients and families, and bereavement support for families of the deceased and team members who cared for them.

Although the origins of palliative care are identifiable in the modern hospice movement, its applicability goes far beyond the hospice-appropriate population. For example, in my own in-hospital practice, only about half of my palliative care consultations are appropriate for hospice referral. Some patients I have subsequently referred for liver and kidney transplantation; numerous others have proceeded to primary surgical management of cancer; and still others have returned to work following trauma rehabilitation.

During the past 15 years, the American College of Surgeons has strongly supported the concept of palliative care through position statements, ACS Bulletin articles, and education initiatives for surgeons. The Commission on Cancer has endorsed palliative care in its Cancer Program Standards 2012 by requiring the availability of palliative care services. The ABS has joined nine other member boards of the American Board of Medical Specialties (ABMS) in offering subspecialty certification in Hospice and Palliative Medicine (HPM). Although the number of surgeons specializing in palliative medicine will be very small, the need for expertise in this area will grow as the public and practitioners recognize the rewards of an evidence-based palliative care for seriously ill patients, their families, and surgical practitioners.

Dr. Dunn, an ACS Fellow based in Erie, Pa., is chair of the ACS Surgical Palliative Care Task Force.

Editor's Note: This article is the first in a series on surgical palliative care that will appear periodically in Surgery News. The series, which will include contributions from members of the American College of Surgeons' Surgical Palliative Care Task Force, is intended to inform readers about the variety of issues involved in managing patients with serious or terminal illnesses and the role surgeons can play in providing the best possible care for these individuals.

If I were asked what has made the biggest impact on the field of surgery during my 30-year career, I would say the transition to evidence-based practice as a benchmark of quality and the recognition of quality of life outcomes as meaningful measures of care have been equally important. These represent an evolution from the surgeon-centric practice of the past to the patient-centered practice of the present.

But I believe we are at the point of another pendulum swing, because the "patient-centeredness" concept not only has failed to prevent vast and often ineffectual health care expenditures, but might actually be contributing to them.

I recently asked a physically and emotionally exhausted family member of an "ICU to nowhere" patient why he thought patients get "stuck" in the ICU. He answered eloquently, "People just don’t think they should die."

The current conceptual framework for care of the seriously ill is unable to respond to the psychological and spiritual questions raised by this comment. Disease management alone will not break this type of gridlock, nor will it leave patients and families with a lasting sense of support.

Surgical palliative care is an evidence-based and interdisciplinary approach (consisting of surgery, nursing, social work, chaplaincy, counseling, and others) to caring for patients who are seriously or terminally ill.

Palliative care includes communication skills (disclosure of prognosis, setting goals, advance care planning), pain and non-pain symptom management, ethics and conflict resolution, and self-awareness. Palliative care emphasizes continuity of care across clinical settings and services, attention to spiritual needs, psychosocial support for patients and families, and bereavement support for families of the deceased and team members who cared for them.

Although the origins of palliative care are identifiable in the modern hospice movement, its applicability goes far beyond the hospice-appropriate population. For example, in my own in-hospital practice, only about half of my palliative care consultations are appropriate for hospice referral. Some patients I have subsequently referred for liver and kidney transplantation; numerous others have proceeded to primary surgical management of cancer; and still others have returned to work following trauma rehabilitation.

During the past 15 years, the American College of Surgeons has strongly supported the concept of palliative care through position statements, ACS Bulletin articles, and education initiatives for surgeons. The Commission on Cancer has endorsed palliative care in its Cancer Program Standards 2012 by requiring the availability of palliative care services. The ABS has joined nine other member boards of the American Board of Medical Specialties (ABMS) in offering subspecialty certification in Hospice and Palliative Medicine (HPM). Although the number of surgeons specializing in palliative medicine will be very small, the need for expertise in this area will grow as the public and practitioners recognize the rewards of an evidence-based palliative care for seriously ill patients, their families, and surgical practitioners.

Dr. Dunn, an ACS Fellow based in Erie, Pa., is chair of the ACS Surgical Palliative Care Task Force.