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.