Commentary

Managing Serious Surgical Illness


 

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.

Geoffrey Dunn, M.D., FACS

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.

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