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.