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The Relationship Between Surgery and Medicine in Palliative Care
THE SURGEON AND PALLIATIVE CARE
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THE RELATIONSHIP BETWEEN SURGERY AND MEDICINE IN PALLIATIVE CARE Suresh K. Joishy, MD
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I admire surgeons. I have always wondered at their boundless energy while working days and nights with great vigor, performing elective and emergency surgeries. There is hardly any patient in my practice of palliative medicine without one or two surgical scars from coronary artery bypass, cholecystectomy, appendectomy, hysterectomy, laparotomy, or mastectomy. Every one of them has been saved from one of the dangers to life: rupture, hemorrhage, obstruction, loss of function, and sepsis. Patients are grateful to surgeons. They always remember their surgeons for many years after surgery. They feel they have received a gift to live longer. It is a paradox when the same patients are in terminal status, particularly the recently operated cancer patients, they are not visited by the surgeons and their care is left to the physicians. This is the crux of the matter for my discussion in this article. This article discusses the middle ground shared by surgeons and physicians. T h s article analyzes the existing ideals and practice of modern surgery and makes practical suggestions for communication and collaboration between surgeons and physicians that lead to the delivery of the best palliative care to patients. MIDDLE GROUND BETWEEN MEDICINE AND SURGERY
On reviewing the surgical literature, it is astonishingto note the ancient surgeons emphasizing the goodness in surgery that appears identical to From the Department of Oncology/Hematology, Medcenter One, Bismarck, North Dakota
SURGICAL ONCOLOGY CLINICS OF NORTH AMERICA VOLUME 10. IVUMBER 1.JANUARY 2001
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the principles of modern palliative care. One of the greatest surgeons to live on this earth, John Hunter, declared the following. Before undertaking surgery, the surgeon should consider the whole man, his life history, habits, constitutional idiosyncrasies, the previous ailments, interactions of his mind, emotions and body.l8
He could not have described the philosophy of holistic medicine in a better way. Modern surgeons are increasingly recalling these maxims. In his presidential address to a surgical society, Foster" was extremely eloquent on the care of terminally ill patients. He emphasized the importance of comforting the patient and the family members with kindness, truth, humor, sadness, courtesy, and integrity. He considers the attitudes of the surgeons to be more important than surgical skills. He addresses the ways surgeons should understand death and that it deserves more attention and reverence. Several other surgeons have quoted the intellectual personalities in surgery who should still serve as the surgeon's role model (e.g., Hunter, Billroth, Wangestenseen, Bacon, William of Occam, McDowell, Bobs, Beaumont, and G r o s ~ ) . Brewer3 ~ , ~ ~ , advocates ~~ humility and human approach to patients. SchwartzZ9defends elitism of surgeons, not limited to their intellect. Palliative medicine is comfortable in accepting the goodness of surgeons and adopts their philosophy in palliative care. This common ground between medicine and surgery should be the arena for interaction between surgeons and physicians in palliative care as illustrated by Table 1.
Table 1. IDEALS OF THEORY AND PRACTICE OF SURGEONS ARE THE SAME IN PALLIATIVE CARE Surgeon
Surgical Idealisms
Hunterla
Consider whole person Follow patient postoperatively at all convalescent stages Consider interactions of mind, emotions, and body Repair of congenital defects Reconstruction of trauma Mechanical alteration of pathophysiologic pathways Removal and replacement of diseased tissue and organs Establishment of functional continuity Kindness, truth, humor, sadness, courtesy, and integrity applied to comforting the patient and family Death deserves more attention and reverence
Applications to Palliative Surgery -
ShwartzZ9
-
-
Holistic approach to surgical patients
Not applicable Fix pathologic fracture Relief of obstruction; ostomies Debulking, dkbridement Stents Ideals of surgery and palliative care are the same
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MODERN PRACTICE OF SURGERY Influence of High Technology
Preoperative evaluation of patients by CT scans, MR images, ultrasound, angiograms, and cardiopulmonary functions have drastically reduced postoperative mortality. The surgeons can decide precisely the operability and resectability without much guesswork. Radical surgeries are still popular in the United States, but laparoscopic surgeries are becoming increasingly prevalent. More surgeries are carried out in the outpatient setting. Surgeons, however, still shy away from taking care of their patients when they reach advanced stages of the disease or terminal illness. Death is still seen as failure of surgical care. Aloofness, Isolation, and Dehumanization
As a practicing medical oncologist and palliative medicine specialist, I have worked closely with surgeons in the United States and abroad in India, Malaysia, Middle East, and England. Some surgeons are my best friends. In the United States, however, surgeons are aloof, and they have perfected their isolation within the walls of the operating room (called the OR in US) where they perform their art relentlessly and happily, in the operation theater (called the OT in Europe and the East). Once the patient leaves the operating room, the surgeons hardly have much time to spend at the bedside of the patient. History books on surgery glorify the bedside of the patients where the surgeon shall stand.31 Even extremely ill postoperative patients are left to be monitored by the high-technology gadgets of the intensive care units (ICU). There are more varieties of surgical ICUs than the medical ICUs in the hospital (e.g., surgical ICU, cardiothoracic ICU, neurosurgical ICU). The complexities of modern surgical care, its highly specialized nature, fragmentation of care, the death of the general surgery, and lack of time to be at the bedside of the patient have pushed humanism to the background. A surgical operation has been described as a ritual that emphasizes the importance of rigorous attention to minute details of technique^.^^ Interaction of the surgeon with the patient is diminished to a ritual for surgery according to the operating room schedule rather than the readiness of the patient to go under the scalpel. With ritualization of surgery, every surgery is performed successfully, but dehumanization is complete. How can we then expect the surgeon to help in palliative care, which is considered to be the most humane medicine today? Alfred W ~ r c e s t e rlamented ~~ in 1912, "For the highest surgical success, it very likely is necessary that a surgeon should be thus relieved of personal relationship with their patients, and of all acquaintances with their suffering."
The Gap between Surgery and Medicine
The ideals of medicine and surgery were the same when there was no dichotomy and both were practiced by the same person. The degree from medical school qualified one to practice both. Specialization into numerous branches of surgery has caused a gap between surgeons and surgery from medicine. It is a common practice in the United States for the surgeon to request a medical clearance on a patient scheduled to undergo surgery. The incurable patients are referred automatically to the physicians. The communication between the surgeon and physician may end with a few words. THE RELATIONSHIP BETWEEN SURGERY AND MEDICINE Collaboration and lntegration
The title of this article, "The Relationship between Surgery and Medicine in Palliative Care," becomes more meaningful if we can give it a human touch and rewrite it "The Relationship between Surgeon and Physician in the Care of the Palliative Care Patient." It is immediately recognized that the surgeons and physicians are distinct in their ideals, philosophy, and practice. Whether the term relationship means interactionsbetween the specialties or the practitioners needs further clarification. This exercise in semantics is actually not futile. It helps us carry out a meaningful discussion on the two vastly different disciplines of surgery and medicine, all focusing on the palliative care given to the patients (Fig. 1A). The crucial relationship between surgeon and physician should be one of intense communication and collaboration in caring for the patient (Fig. 1B). Finally, good patient care is offering surgical and medical treatments (Fig. 1C). Recapture the Goodness of Surgery and Medicine for Palliative Care
Medicine has re-established humanism after losing it transiently. Books on palliative care, large and small, have been p ~ b l i s h e d . ~Medical ,'~ journals have been relentlessly publishing articles on palliative care, too A. MEDICINE
B.
PHYSICIAN
C. MEDICAL TREATMENTS
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PALLIATIVE CARE
SURGERY
PATIENT
SURGEON
v
v uSURGICAL 1
PATIENT
TREATMENTS
Figure 1. lntegration of medicine and surgery for palliative care.
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numerous to quote here. Some key references, however, may be especially helpful for surgeon^.^,^^,'^,^^ One of the best sources for principles of pain and symptom management in palliative care is published by the World Health Organization (WHO) and contains recommendations by experts in palliative care.4 Some surgeons have taken a bold step by advocating palliative care to surgical patients in groundbreaking publication^.^, 11,21 One can find role models in medicine for surgeons desiring to participate in surgical care of their patients who have advanced disease or terminal illness. The goodness of medicine was recaptured by Dame Cicely Saunders in the modern day hospice movement across the Atlantic Ocean. She has gained world-wide acclaim and the modern ~alliativecare " movement is an extension of her application of hospice care principle^.^^ In the United States, Dr Alfred Worcester, an equally important advocate of good nursing care, morphine for pain, atropine for death rattle, an electric fan for terminal dyspnea, and support of the family members of the patient, was totally ignored until recently.17Perhaps it was because the dazzling success of the new surgical procedures of the early twentieth century eclipsed his pioneering work in palliative care. His ideas of goodness of medicine should be considered the tenets of palliative care in United States today, and every physician and surgeon should read his book on the care of the aged, the dying, and the dead.33 Collaborative Research
Much research is needed into the patient's selection for surgery because outcome of surgery may be different in identical selection of patients with identical diseases. The medical and surgical variables need to be determined. It needs to be understood clearly what the surgeon means by requesting medical clearance of the patient for surgery by a physician in addition to preoperative evaluation conducted by the anesthesiologist. It is predictable that certain surgeries may lead to certain symptoms, such as post-thoracotomy pain, and research needs to be done on how to avoid this type of additional symptom burden. Cancer and debilitated patients may have signs and symptoms of bowel obstruction, yet radiographic studies may show them as having partial bowel obstruction. Side effects of opioids may cause an identical clinical picture called opioid bowel syndrome.15 There is a void in determining the diet of the postoperative patients, and the patients often are deprived unnecessarily of their favorite foods. We need a clear understanding of diets such as mechanical soft diet or low fiber diet. It is mind boggling to hear some surgeons say the patient should have absolutelyno foods or their favorite cereal because it may cause bowel obstruction. Many of these food items are actually digested by enzymes in the stomach and small bowel. Surgeons can male a contribution in the field of pain management. Their experience in managing acute pain can help acute pain syndromes in palliative care. I have drawn a great deal of information on the only
parenteral nonsteroidal anti-inflammatorydrug (NSAID), ketorolac, so far used exclusively by surgeons. It was found to be one of the best of the opioid-sparing drugs. A major side effect of a high-dose opioid is the opioid bowel syndrome, which is difficult to distinguish from bowel obstruction. Using ketorolac with an opioid may help to reduce the opioid dose and consequently relieve the obstruction.15The opportunities for collaborative research between surgeons and physicians are boundless. Every symptom is a subject for research. Challenges
The physician needs to be proactive and predict symptoms related to surgery. The natural history of many diseases is well known by this time, particularly in cancer. The surgeon faces great challenges whenever he or she operates on cancer patients. The surgeon knows that he or she needs to apply stringent eligibility criteria, such as physical condition, nutrition, symptoms, and other patient related factors. He or she needs to analyze carefully the surgical factors, such as goals, intent of surgery, operability, and resectability. In the palliative care setting, operability and resectability may not be straight forward, and the outcome may be unpredictable. Any time the patient requires surgery in the palliative care setting, the surgeon needs to be cautious even though the pressure to operate may be intense because of the patient's requests and the family members' expectations. The challenges facing the surgeon in the nonpalliative care setting and palliative care setting are compared in Table 2. Symptom-Focused Surgery and Palliative Medicine
If the mechanisms of symptoms are related to disease alone (e.g.,tumor burden) surgery is justified even if it is to remove part of the face to resect Table 2. CHALLENGES FACING THE SURGEON WHEN OPERATING IN THE PALLIATIVE CARE SETTING Eligibility Criteria
Nonpalliative Care Setting
Physical condition Nutrition Complexity of the disease Symptoms
Good/excellent Good Simple/complex Single major symptom
Patient's tolerance
Major surgeries possible
Goal Intent Repeated surgeries DNR status
Long term Curative Feasible No
DNR = do not resuscitate.
Palliative Care Setting
Suboptimal/debilitated Poor Always complex Multiple/undifferentiated symptoms Minimally invasive surgeries with exceptions Short term Palliative Futile Invariably, yes
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a huge fungating, bleeding, and painful tumor." If there are symptoms not related to the tumor, surgical decision and care after surgery should be defined. The surgeon needs to assess the patient carefully, preferably in cooperation with the physician in restoring structure versus function and reconstruction versus removal. There is a need to change such surgical principles of nonacute illness when it is obvious that there is high recurrence rate, immediate or delayed. It is important to analyze if surgery and the resulting longevity have improved the quality of life. It is suggested that no surgery should be undertaken if the patient has complained he or she is not feeling any better than before surgery.31Numerous examples of such surgeries are illustrated in Table 2. This is not to say that the surgery is not indicated. It is important that the surgeon, the physician, and the patient have understood what is ahead after surgery even if the intent was curative. It must be realized that however carefully executed, the surgery is a controlled physical trauma. Somehow,the consequences of surgery are always medical. This is shown by the fact that most of the patients seen in surgical intensive care units suffer from pain, hypotension, sepsis, debility, immobility, and altered consciousness. Multiorgan failure may occur in spite of the fact that the surgery was extremely successful.Death in surgical intensive care units is not uncommon. Guided by ample clinical symptoms and signs, the physician and surgeon possess the knowledge to foresee and predict accurately which patients and what periods of their clinical trajectories they will fall under in the palliative care domain. Numerous metastatic solid tumors, such as lung, colon, pancreas, head and neck, ovaries, esophagus, and high-grade brain tumors, can be predicted to fall into the palliative care domain for symptom control. Noncancer disease, such as ischemic vasculitides, pancreatitis, Crohn's disease, and ulcerative colitis, reaches end-stage if not cured early and needs palliative care. Is there anything that cannot be achieved for the comfort of the patient if the surgeon and the physician accompany him or her? It is hoped that so-called refractory symptoms will disappear from the palliative care vocabulary. Combined Surgical and Medical Protocols in Palliative Care The patient's suffering is prolonged unnecessarily because of the delays in a physician calling the surgeon or a surgeon calling the physician. Surgeons and physicians need to get together and write firm policies and procedures for consultations without delay. The following are a few examples. Physicians or surgeons attempting to carry out stopgap procedures should be discouraged when a large malignant pleural effusion is discovered. It is futile to draw it out with a needle. The patient's comfort is short lived and some physicians repeat the same procedure several times despite rapid reaccumulation of fluid. Complete drainage by thoracotomy tube and pleurodesis is the treatment of choice. Protocol should clearly state the pleurodesis agent of choice, whether instilled by the surgeon or physician
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and how to prevent pain while instilling the agent. Protocol should also state how and when to draw bilateral pleural effusions. Malignant ascites policies are required for placement of permanent peritoneal catheter. Deep vein thrombosis is common in cancer patients with limited mobility. Prolonged anticoagulant medications and monitoring their activity can be stressful to the patients. Clear indications and contraindications for installing inferior vena cava umbrellas to prevent pulmonary embolism are needed. Numerous varieties of stents are available to re-establish patency of esophageal stricture,tracheal compression, and biliary obstruction. Even today, clarity in their use is lacking. Unless clear-cut policies and protocols exist for the simple but effective measures, the whims of physicians or surgeons determine if patients are relieved of their symptoms or not. Define and Establish Protocols and Guidelines for Minimally lnvasive Surgeries
For the purpose of palliative care, the surgeons need to redefine noninvasive, minimally invasive, or minor surgeries. It is said that there is no such thing as minor surgery, only minor surgeons. The minor surgeries are always performed on the other person. A massive investigation of minimally invasive surgeries and postoperative mortality has shown that minimally invasive surgeries are not minimally stressful to the patient and a major surgery may follow depending on the findings of minimally The National Confidential invasive surgery causing greater m~rtality.~,'~ Enquiry into Perioperative Death (NCEPOD)was conducted in the United Kingdom in 1996 and 1997. Every surgeon and physician should read this study on mortality caused by invasive surgeriesF2 It was found that the surgeons carried out too many operations on dying patient^.^ Modern practice of surgery covers a wide range of minimally invasive procedures and the indications for laparoscopic procedures is multiplying every day. Laparoscopic surgery can be associated with physiologic changes that compromise respiratory and cardiovascular systems.24Some surgeons and physicians are under the misconception that a percutaneous endoscopic gastrostomy (PEG) can be used to prevent aspiration of gastric contents; however, it does notF5 Eliminate the terms minor surgery and noninvasive surgery once and for all, and replace them with the term minimally invasive surgey. Demystify "Surgispeak"
As mentioned earlier, the ritualization of surgery has diminished communication between surgeon and the patient before and after surgery. In reality, the communication from the surgeon takes place in a hurried manner while the patient is still recovering from anesthesia in a side room or a conversation with family members in a corridor adjacent to the operating room. Invariably, the patient and family members remember only four words from the surgeon, "got it all out." These four words obviate the need for further discussion on the part of the surgeon as the patient and
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family are intensely relieved, and they have no further questions. Some surgeons feel they have adequately communicated to the patient by just drawing a diagram on any piece of paper in the chart or anywhere nearby. Some great surgeons are poor artists, and these diagrams and sketches are poorly executed. Not having any knowledge of anatomy, the patients get no idea other than "got it all out." When the patient comes to the palliative care physician sooner or later, they are confused why they have to see a physician rather than a surgeon who told them that he "got it all out." Some surgeons feel it is not necessary to be explicit, to give the details of pathology of cancer and "perform an autopsy in vivo." This is a mistake. It would be helpful to have a glossary of surgical terms commonly used to simplify communication. It is useless to give brochures on surgery before or after because they do not apply to each patient. Very ill patients hardly have the energy to read them, or they may misinterpret and imagine that they have all the complications. Face-to-face communication is best.
Family Meetings Jointly Held by the Surgeon and the Physician Family meetings with the patient and as many family members as possible should be the most important activity besides surgical or medical treatments. The family meeting is the only way the surgeon or physician can communicate all the information at once to all family members and the patient and answer all of the questions. The information should be clear and understandable to the lay person about diagnosis, prognosis, and treatment plans. It may be time consuming but worth the investment. If there is a large number of family members, only one person should be chosen as the spokesperson to the patient, and there would be no further need for each family member to call the physician or the physician to call each family member. The spokesperson's name, address, and telephone numbers must be charted, and the spokesperson is chosen by consensus of the family members. The surgeon and the physician should design a structured family meeting in palliative care. The invitation, however, for surgeons to come and participate in family meetings has been met with cold shoulders. Even the lionhearted surgeons appear to get chickenhearted in facing a large family when the surgery has not cured the patient. Another advantage of the family meeting is almost all of the conflicts arising from the patient or family members can be resolved with a consensus. Otherwise, the patient always replies to the surgeon or the physician in anger; typically by saying "I don't know what's going on."
Avoid Surgical or Medical Nihilism The physician or surgeon should not hesitate to perform a major surgery to relieve major symptoms of obstruction, bleeding, rupture, or fracture to give the patient comfort for a reasonable period of time.
Table 3.THE PALLIATIVE CARE PATIENT SHOULD FEEL BETTER THAN BEFORE SURGERY Symptom Causing Surgeries
System
Head and Neck
Thoracic
Radical: morbidity Tracheostomy G / J tube feeding Loss of speech Pain not relieved Pneumonectomy Post-thoracotomypain Respiratory failure No better than before surgery
Gastrointestinal
Major resections of bowel, liver, pancreas: altered bowel habits, adhesions, wound dehiscence, fistulas, repeated obstructions No better than before surgery
Neurosurgical
Central nervous system: new neuro sequale Spinal: no better than before surgery
Symptom-Relieving Surgeries
Debulking: airway establishment Prevention of vascular catastrophe Relief of pain Drainage of pleural effusion and pleurodesis Tracheal stent Endobronchial resection by laser Esophageal stent Laparoscopic surgery Ostomies to relieve obstruction Biliary stent PEG tube for nutrition Venting gastrostomy Peritoneal catheters Cordotomy and rhizotomy to relieve pain Epidural, intrathecal pumps to control pain
G/J = gastrostomy or jejunostomy; PEG = percutaneous endoscopic gastrostomy.
Statements like "why don't you let the patient die in dignity?" should be dealt with by education. It should be emphasized that dying with suffering is not dying with dignity. Most of the palliative care surgical treatments to relieve symptoms are minimally invasive as outlined in Table 3. Over treatment should be avoided even though it is believed that there is no legal liability for over treatment. The patient should not be sentenced to suffer longer. A large number of patients in intensive care units are kept alive when they cannot speak or eat or move in bed. End-of-Life Care
It is believed the surgeon manages life and the physician manages death. Intraoperative and postoperative death, even in the patient with serious disease and poor risk for surgery, is not acceptable. The surgeon's performance is determined by the postoperative mortality. The surgeon is reluctant to discuss a do not resuscitate (DNR) order. The patient who is terminally ill may spend a considerable amount of time in the surgical ICU before their demise. A proportion of patients in the ICU should not be in a medical or surgical ICU. These patients should receive good palliative care, and the
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family members keeping constant vigil need support and education. The policies and procedures of the hospitals and ICUs lack guidelines for providing appropriate care to dying patients. The medical staff is encouraged to treat the terminal patient aggressively at the expense of the patient's well being and comfort. Policies, procedures, and guidelines need to be written and approved by appropriate overseeing agencies of the hospital staff. Communication with the patient and family on pain management, artificial nutrition and hydration, withdrawal and withholding of technologic interventions, and discussion and writing of DNR orders need to be outlined clearly.14A new concept of saving death equating with saving life has emerged. Saving death helps the patient preserve comfort and dignity despite overwhelming illness, and it helps the family understand the inevitability of death and move forward in the process of berea~ement.~~
INTEGRATION OF SURGICAL AND MEDICAL SERVICES Components for Integration Having identified the components of medical and surgical palliative care services, efforts canbe made to integratethese services in aninstitute or a practice. The model I propose is dynamic and requires equal interaction between surgeons and the physicians. Several practical issues, however, need to be solved first. Is the surgeon prepared to spend some amount of time outside the operating room? Which specialty will be more willing to adopt the ideals of palliative care? Are the younger or older surgeons more interested? Is it true a retired surgeon is more willing to take care of terminally ill patients? Because surgeons interact with oncologistsanyway, will they prefer to work with oncologists, physicians or other specialties interested in palliative care? At what site is the surgeon willing to see patients (hospital only, as outpatients, or in nursing homes)?Any surgeon who is motivated to help terminally ill patients is an asset to a palliative care program.
Levels Of Palliative Care Acute or Tertiary Palliative Care. This level is probably most suitable for surgeons (Fig. 2). The patients are not actively dying, but they suffer actively from complications of advanced cancer. Invariably, patients require hospitalizations for tertiary care. These patients may require major surgeries, such as debulking a huge tumor or fixing a pathologic fracture. It is useful if the surgeon follows these patients along with the physician throughout their remaining life. Hospice Palliative Care. I have seen surgeons devote their full-time or part-time work as medical directors of home or hospital hospices where patients are at the end of their lives. Such surgeons have expressed intense satisfaction in treating terminally ill patients.
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PATIENT
PHYSICIAN
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Figure 2. Service integration for palliative care.
COLLABORATION IN TRAINING YOUNG SURGEONS AND PHYSICIANS Palliative Care Curriculum
Medical textbooks and curricula in the medical schools lack information on palliative care issuese5The trend is being reversed by the establishment of palliative care centers and recently published textbooks.?l4 Careful scrutiny of two well known textbooks in surgery, however, have shown there is no word on palliative care in their in dice^.^^,^^ Morphine for pain control was dealt with in one or two paragraphs only. The conceptual framework of medicine and surgery is based on saving the patient's life and fixing abnormalities. We need future surgeons to understand the palliative care principles in surgery. Compulsory courses should be included in the curricula of surgery and medicine. There is a need to change the equation that physicians manage death and surgeons manage life. The United States has always been in the forefront of developing new subspecialties in medicine or surgery with one exception, palliative care. As recently as 1996, there was no specialty board for palliative medicine. This is not a suggestion to start another specialty in surgery, however. It is sufficient if the goodness in surgery is brought back into practice. SUMMARY
As we look into the future, profound changes in surgery and medicine can be expected. I believe real time surgery can be practiced now using computer-generated models. Robotic surgery is becoming a reality.
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Immortality is being sought by physicians using gene transfer technology called genetic engineeving as though human beings are machines. Immortality may not relieve sufferingfrom diseases, however. Palliative care will be needed much more in the future. The patient population in palliative care is unique. They suffer from physical and emotional distress and spiritual pain. Their symptoms are often complex, multiple, and defy definitions. The amount of care needed by the intensely suffering patient is infinite. No surgeon or physician alone can claim the capacity to provide adequate care to these patients. Surgeons joining the physicians will revitalize the current interdisciplinary teams in palliative care. Several benefits will be derived from the relationship between the surgeon and the physician: (1)the goodness of surgery and medicine combined will humanize surgical and medical practice; (2) care of the advanced cancer patient and the terminally ill will be shared by surgeons and physicians; (3) innovative policies, procedures, and protocols for symptom control will emerge rapidly; (4) combined efforts of surgeons and physicians may help predict symptoms early to be proactive and prevent them from becoming refractory; and (5) the relationship between surgery and medicine in palliative care may become a new paradigm for patient care in any specialty. Physicians just touch the hands of the patients. Surgeons can touch every organ, muscle, nerve, and blood vessel. By establishing relationships with physicians, surgeons will hold the patient's hands with no sterile gloves intervening. ACKNOWLEDGMENTS The author thanks Meredith Gross, Medical Transcriptionist for Medcenter One, Bismarck, North Dakota, for typing the final drafts of this article. The author thanks Kathy Igou, Medical Transcriptionist for Medcenter One, Bismarck, North Dakota, for typing the initial drafts of this article. The author thanks Delphine Marshall, Graphic Artist, Medcenter One, Bismarck, North Dakota, for preparing the computer-generated figures for this article.
References 1. Absolon KB: Hunter-Billroth-Wagensteen, their philosophy and accomplishments. Surgery 62:567-571,1967 2. Baguley I: Minimally invasive abdominal surgery may not be minimally stressful to the patient. The report of the National Confidential Enquiry into Perioperative Deaths (NCEPOD).London, NCEPOD, 1996/1997, p 3-5 3. Brewer LA: Dehumanitate. Am J Surg 118:133-140,1969 4. Cancer Pain Relief and Palliative Care: Report of a WHO Expert Committee. World Health Organization, Geneva, 1990 5. airo on AT, Lynn J, Keany P: End of life care in medical text books. Ann Intern Med 130:92-96,1999 6. Doyle D: Perspectives of palliative medicine. Cancer Treat Rev 22(Suppl A):155-161, 1996 7. Doyle D, Hanks GWC, McDonald N (eds):Oxford Textbook of Palliative Medicine. New York, Oxford University Press, 1993 8. Dunn GP: Surgery and palliative medicine. New Horizons J Palliat Med 1:215-1-9,1998
9. Ferriman A: Surgeons carry out too many operations on dying patients. BMJ 317:1269, 1998 10. Foster JH: Some eastern thoughts of north eastern surgeon. Arch Surg 125:702-706,1990 11. Gaisford JC: Palliative surgery. JAMA 221:83-84,1972 12. Hoile R: Minimally Invasive Surgery (Excluding Gynecology and Urology). The report of the National Confidential Enquiry into Perioperative Deaths. NCEPOD, London, 1996/1997, p 1-3 13. Janssens RMJPA, Zyclicz Z: Articulating and theologicalperspectives. JPalliat Care 15:3844,1999 14. Jett LG: Comfort at the end of life: Palliative care policies. J Nurs Adm 25:55-60,1995 15. Joishy SK, Walsh D: The opioid sparing effect of intravenous ketorolac as an adjuvant analgesic in cancer pain: Application in bone metastasis and the opioid bowel syndrome. J Pain Symptom Manag 16:334-339,1998 16. Joishy SK (ed): Palliative Medicine Secrets. Philadelphia, Hanley and Belfus, 1999 17. Kerr D. Alfred Worcester: A pioneer in palliative care. Am J Hos Pall Care 15:13-14,3638, 1998 18. Kobler J (ed): The Reluctant Surgeon: A Biography of John Hunter. New York, Doubleday, 1960, p 165 19. Latimer EJ: Ethical care at the end of life. CMAJ 158:1741-1747,1998 20. MacDonald N: Cure and care: Interactionbetween cancer centers and palliative care units. Rec Result Cancer Res 121:399407,1991 21. Milch RA, Dunn GP: The surgeon's role in palliative care. Bull Am College Surg 821517,48,1997 22. NCEPOD: The Report of the National Confidential Enquiry into Perioperative Deaths 1996/1997. London, NECEPOD, p 3 5 4 3 23. Nelson JE: Saving lives and saving deaths. Ann Intern Med 130:776-777,1999 24. Rees BI, Hoile R: Laparoscopic General Surgery. The Report of the National Confidential Enquiry into Perioperative Deaths (NCEPOD). London, NCEPOD, 1996/1997, p 9-12 25. Rosin D, Hoile R: Percutaneous Endoscopic Gastrostomy (PEG), The Report of the National Confidential Enquiry into Perioperative Deaths (NCEPOD). London, NCEPOD, 1996/1997, pp 6-8 26. Rosoff L Sr: Presidential Address: Rocer Bacon. William of Occam and Lord Hou~hton: " Guides for the perplexed physician. &I J Surg 141:2-9,1981 27. Sabiston DC (ed): Textbook of Surgery. The Biological Basis of Modem Surgical Practice. Philadelphia, WB Saunders, 1997 28. Saunders C (ed): Hospice and Palliative Care. An Interdisciplinary Approach. London, Edward Arnold, 1990 29. Schwartz SI: General Surgical Association-ThePresidential Address: Eagles and egalitarians. Surgery 92:565-570,1982 30. Schwartz SI (ed): Principles of Surgery. New York, McGraw-Hill, 1999 31. Taylor FH: The complete thoracic surgeon. Ann Thorac Surg 22:310-316,1976 32. Wall LL: Ritual meaning in surgery. Obstet Gynecol88:633437,1996 33. Worcester A (ed): The care of the dying. In Care of the Aged, Dying and the Dead, ed 2. Springfield, IL, Charles C Thomas, 1961 34. Worcester A: Past and present methods in the practice of medicine. Boston Med Surg J 166:159-164,1912 A
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THE RELATIONSHIP BETWEEN SURGERY AND MEDICINE IN PALLIATIVE CARE Suresh K. Joishy, MD
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I admire surgeons. I have always wondered at their boundless energy while working days and nights with great vigor, performing elective and emergency surgeries. There is hardly any patient in my practice of palliative medicine without one or two surgical scars from coronary artery bypass, cholecystectomy, appendectomy, hysterectomy, laparotomy, or mastectomy. Every one of them has been saved from one of the dangers to life: rupture, hemorrhage, obstruction, loss of function, and sepsis. Patients are grateful to surgeons. They always remember their surgeons for many years after surgery. They feel they have received a gift to live longer. It is a paradox when the same patients are in terminal status, particularly the recently operated cancer patients, they are not visited by the surgeons and their care is left to the physicians. This is the crux of the matter for my discussion in this article. This article discusses the middle ground shared by surgeons and physicians. T h s article analyzes the existing ideals and practice of modern surgery and makes practical suggestions for communication and collaboration between surgeons and physicians that lead to the delivery of the best palliative care to patients. MIDDLE GROUND BETWEEN MEDICINE AND SURGERY
On reviewing the surgical literature, it is astonishingto note the ancient surgeons emphasizing the goodness in surgery that appears identical to From the Department of Oncology/Hematology, Medcenter One, Bismarck, North Dakota
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the principles of modern palliative care. One of the greatest surgeons to live on this earth, John Hunter, declared the following. Before undertaking surgery, the surgeon should consider the whole man, his life history, habits, constitutional idiosyncrasies, the previous ailments, interactions of his mind, emotions and body.l8
He could not have described the philosophy of holistic medicine in a better way. Modern surgeons are increasingly recalling these maxims. In his presidential address to a surgical society, Foster" was extremely eloquent on the care of terminally ill patients. He emphasized the importance of comforting the patient and the family members with kindness, truth, humor, sadness, courtesy, and integrity. He considers the attitudes of the surgeons to be more important than surgical skills. He addresses the ways surgeons should understand death and that it deserves more attention and reverence. Several other surgeons have quoted the intellectual personalities in surgery who should still serve as the surgeon's role model (e.g., Hunter, Billroth, Wangestenseen, Bacon, William of Occam, McDowell, Bobs, Beaumont, and G r o s ~ ) . Brewer3 ~ , ~ ~ , advocates ~~ humility and human approach to patients. SchwartzZ9defends elitism of surgeons, not limited to their intellect. Palliative medicine is comfortable in accepting the goodness of surgeons and adopts their philosophy in palliative care. This common ground between medicine and surgery should be the arena for interaction between surgeons and physicians in palliative care as illustrated by Table 1.
Table 1. IDEALS OF THEORY AND PRACTICE OF SURGEONS ARE THE SAME IN PALLIATIVE CARE Surgeon
Surgical Idealisms
Hunterla
Consider whole person Follow patient postoperatively at all convalescent stages Consider interactions of mind, emotions, and body Repair of congenital defects Reconstruction of trauma Mechanical alteration of pathophysiologic pathways Removal and replacement of diseased tissue and organs Establishment of functional continuity Kindness, truth, humor, sadness, courtesy, and integrity applied to comforting the patient and family Death deserves more attention and reverence
Applications to Palliative Surgery -
ShwartzZ9
-
-
Holistic approach to surgical patients
Not applicable Fix pathologic fracture Relief of obstruction; ostomies Debulking, dkbridement Stents Ideals of surgery and palliative care are the same
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MODERN PRACTICE OF SURGERY Influence of High Technology
Preoperative evaluation of patients by CT scans, MR images, ultrasound, angiograms, and cardiopulmonary functions have drastically reduced postoperative mortality. The surgeons can decide precisely the operability and resectability without much guesswork. Radical surgeries are still popular in the United States, but laparoscopic surgeries are becoming increasingly prevalent. More surgeries are carried out in the outpatient setting. Surgeons, however, still shy away from taking care of their patients when they reach advanced stages of the disease or terminal illness. Death is still seen as failure of surgical care. Aloofness, Isolation, and Dehumanization
As a practicing medical oncologist and palliative medicine specialist, I have worked closely with surgeons in the United States and abroad in India, Malaysia, Middle East, and England. Some surgeons are my best friends. In the United States, however, surgeons are aloof, and they have perfected their isolation within the walls of the operating room (called the OR in US) where they perform their art relentlessly and happily, in the operation theater (called the OT in Europe and the East). Once the patient leaves the operating room, the surgeons hardly have much time to spend at the bedside of the patient. History books on surgery glorify the bedside of the patients where the surgeon shall stand.31 Even extremely ill postoperative patients are left to be monitored by the high-technology gadgets of the intensive care units (ICU). There are more varieties of surgical ICUs than the medical ICUs in the hospital (e.g., surgical ICU, cardiothoracic ICU, neurosurgical ICU). The complexities of modern surgical care, its highly specialized nature, fragmentation of care, the death of the general surgery, and lack of time to be at the bedside of the patient have pushed humanism to the background. A surgical operation has been described as a ritual that emphasizes the importance of rigorous attention to minute details of technique^.^^ Interaction of the surgeon with the patient is diminished to a ritual for surgery according to the operating room schedule rather than the readiness of the patient to go under the scalpel. With ritualization of surgery, every surgery is performed successfully, but dehumanization is complete. How can we then expect the surgeon to help in palliative care, which is considered to be the most humane medicine today? Alfred W ~ r c e s t e rlamented ~~ in 1912, "For the highest surgical success, it very likely is necessary that a surgeon should be thus relieved of personal relationship with their patients, and of all acquaintances with their suffering."
The Gap between Surgery and Medicine
The ideals of medicine and surgery were the same when there was no dichotomy and both were practiced by the same person. The degree from medical school qualified one to practice both. Specialization into numerous branches of surgery has caused a gap between surgeons and surgery from medicine. It is a common practice in the United States for the surgeon to request a medical clearance on a patient scheduled to undergo surgery. The incurable patients are referred automatically to the physicians. The communication between the surgeon and physician may end with a few words. THE RELATIONSHIP BETWEEN SURGERY AND MEDICINE Collaboration and lntegration
The title of this article, "The Relationship between Surgery and Medicine in Palliative Care," becomes more meaningful if we can give it a human touch and rewrite it "The Relationship between Surgeon and Physician in the Care of the Palliative Care Patient." It is immediately recognized that the surgeons and physicians are distinct in their ideals, philosophy, and practice. Whether the term relationship means interactionsbetween the specialties or the practitioners needs further clarification. This exercise in semantics is actually not futile. It helps us carry out a meaningful discussion on the two vastly different disciplines of surgery and medicine, all focusing on the palliative care given to the patients (Fig. 1A). The crucial relationship between surgeon and physician should be one of intense communication and collaboration in caring for the patient (Fig. 1B). Finally, good patient care is offering surgical and medical treatments (Fig. 1C). Recapture the Goodness of Surgery and Medicine for Palliative Care
Medicine has re-established humanism after losing it transiently. Books on palliative care, large and small, have been p ~ b l i s h e d . ~Medical ,'~ journals have been relentlessly publishing articles on palliative care, too A. MEDICINE
B.
PHYSICIAN
C. MEDICAL TREATMENTS
-
PALLIATIVE CARE
SURGERY
PATIENT
SURGEON
v
v uSURGICAL 1
PATIENT
TREATMENTS
Figure 1. lntegration of medicine and surgery for palliative care.
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numerous to quote here. Some key references, however, may be especially helpful for surgeon^.^,^^,'^,^^ One of the best sources for principles of pain and symptom management in palliative care is published by the World Health Organization (WHO) and contains recommendations by experts in palliative care.4 Some surgeons have taken a bold step by advocating palliative care to surgical patients in groundbreaking publication^.^, 11,21 One can find role models in medicine for surgeons desiring to participate in surgical care of their patients who have advanced disease or terminal illness. The goodness of medicine was recaptured by Dame Cicely Saunders in the modern day hospice movement across the Atlantic Ocean. She has gained world-wide acclaim and the modern ~alliativecare " movement is an extension of her application of hospice care principle^.^^ In the United States, Dr Alfred Worcester, an equally important advocate of good nursing care, morphine for pain, atropine for death rattle, an electric fan for terminal dyspnea, and support of the family members of the patient, was totally ignored until recently.17Perhaps it was because the dazzling success of the new surgical procedures of the early twentieth century eclipsed his pioneering work in palliative care. His ideas of goodness of medicine should be considered the tenets of palliative care in United States today, and every physician and surgeon should read his book on the care of the aged, the dying, and the dead.33 Collaborative Research
Much research is needed into the patient's selection for surgery because outcome of surgery may be different in identical selection of patients with identical diseases. The medical and surgical variables need to be determined. It needs to be understood clearly what the surgeon means by requesting medical clearance of the patient for surgery by a physician in addition to preoperative evaluation conducted by the anesthesiologist. It is predictable that certain surgeries may lead to certain symptoms, such as post-thoracotomy pain, and research needs to be done on how to avoid this type of additional symptom burden. Cancer and debilitated patients may have signs and symptoms of bowel obstruction, yet radiographic studies may show them as having partial bowel obstruction. Side effects of opioids may cause an identical clinical picture called opioid bowel syndrome.15 There is a void in determining the diet of the postoperative patients, and the patients often are deprived unnecessarily of their favorite foods. We need a clear understanding of diets such as mechanical soft diet or low fiber diet. It is mind boggling to hear some surgeons say the patient should have absolutelyno foods or their favorite cereal because it may cause bowel obstruction. Many of these food items are actually digested by enzymes in the stomach and small bowel. Surgeons can male a contribution in the field of pain management. Their experience in managing acute pain can help acute pain syndromes in palliative care. I have drawn a great deal of information on the only
parenteral nonsteroidal anti-inflammatorydrug (NSAID), ketorolac, so far used exclusively by surgeons. It was found to be one of the best of the opioid-sparing drugs. A major side effect of a high-dose opioid is the opioid bowel syndrome, which is difficult to distinguish from bowel obstruction. Using ketorolac with an opioid may help to reduce the opioid dose and consequently relieve the obstruction.15The opportunities for collaborative research between surgeons and physicians are boundless. Every symptom is a subject for research. Challenges
The physician needs to be proactive and predict symptoms related to surgery. The natural history of many diseases is well known by this time, particularly in cancer. The surgeon faces great challenges whenever he or she operates on cancer patients. The surgeon knows that he or she needs to apply stringent eligibility criteria, such as physical condition, nutrition, symptoms, and other patient related factors. He or she needs to analyze carefully the surgical factors, such as goals, intent of surgery, operability, and resectability. In the palliative care setting, operability and resectability may not be straight forward, and the outcome may be unpredictable. Any time the patient requires surgery in the palliative care setting, the surgeon needs to be cautious even though the pressure to operate may be intense because of the patient's requests and the family members' expectations. The challenges facing the surgeon in the nonpalliative care setting and palliative care setting are compared in Table 2. Symptom-Focused Surgery and Palliative Medicine
If the mechanisms of symptoms are related to disease alone (e.g.,tumor burden) surgery is justified even if it is to remove part of the face to resect Table 2. CHALLENGES FACING THE SURGEON WHEN OPERATING IN THE PALLIATIVE CARE SETTING Eligibility Criteria
Nonpalliative Care Setting
Physical condition Nutrition Complexity of the disease Symptoms
Good/excellent Good Simple/complex Single major symptom
Patient's tolerance
Major surgeries possible
Goal Intent Repeated surgeries DNR status
Long term Curative Feasible No
DNR = do not resuscitate.
Palliative Care Setting
Suboptimal/debilitated Poor Always complex Multiple/undifferentiated symptoms Minimally invasive surgeries with exceptions Short term Palliative Futile Invariably, yes
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a huge fungating, bleeding, and painful tumor." If there are symptoms not related to the tumor, surgical decision and care after surgery should be defined. The surgeon needs to assess the patient carefully, preferably in cooperation with the physician in restoring structure versus function and reconstruction versus removal. There is a need to change such surgical principles of nonacute illness when it is obvious that there is high recurrence rate, immediate or delayed. It is important to analyze if surgery and the resulting longevity have improved the quality of life. It is suggested that no surgery should be undertaken if the patient has complained he or she is not feeling any better than before surgery.31Numerous examples of such surgeries are illustrated in Table 2. This is not to say that the surgery is not indicated. It is important that the surgeon, the physician, and the patient have understood what is ahead after surgery even if the intent was curative. It must be realized that however carefully executed, the surgery is a controlled physical trauma. Somehow,the consequences of surgery are always medical. This is shown by the fact that most of the patients seen in surgical intensive care units suffer from pain, hypotension, sepsis, debility, immobility, and altered consciousness. Multiorgan failure may occur in spite of the fact that the surgery was extremely successful.Death in surgical intensive care units is not uncommon. Guided by ample clinical symptoms and signs, the physician and surgeon possess the knowledge to foresee and predict accurately which patients and what periods of their clinical trajectories they will fall under in the palliative care domain. Numerous metastatic solid tumors, such as lung, colon, pancreas, head and neck, ovaries, esophagus, and high-grade brain tumors, can be predicted to fall into the palliative care domain for symptom control. Noncancer disease, such as ischemic vasculitides, pancreatitis, Crohn's disease, and ulcerative colitis, reaches end-stage if not cured early and needs palliative care. Is there anything that cannot be achieved for the comfort of the patient if the surgeon and the physician accompany him or her? It is hoped that so-called refractory symptoms will disappear from the palliative care vocabulary. Combined Surgical and Medical Protocols in Palliative Care The patient's suffering is prolonged unnecessarily because of the delays in a physician calling the surgeon or a surgeon calling the physician. Surgeons and physicians need to get together and write firm policies and procedures for consultations without delay. The following are a few examples. Physicians or surgeons attempting to carry out stopgap procedures should be discouraged when a large malignant pleural effusion is discovered. It is futile to draw it out with a needle. The patient's comfort is short lived and some physicians repeat the same procedure several times despite rapid reaccumulation of fluid. Complete drainage by thoracotomy tube and pleurodesis is the treatment of choice. Protocol should clearly state the pleurodesis agent of choice, whether instilled by the surgeon or physician
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and how to prevent pain while instilling the agent. Protocol should also state how and when to draw bilateral pleural effusions. Malignant ascites policies are required for placement of permanent peritoneal catheter. Deep vein thrombosis is common in cancer patients with limited mobility. Prolonged anticoagulant medications and monitoring their activity can be stressful to the patients. Clear indications and contraindications for installing inferior vena cava umbrellas to prevent pulmonary embolism are needed. Numerous varieties of stents are available to re-establish patency of esophageal stricture,tracheal compression, and biliary obstruction. Even today, clarity in their use is lacking. Unless clear-cut policies and protocols exist for the simple but effective measures, the whims of physicians or surgeons determine if patients are relieved of their symptoms or not. Define and Establish Protocols and Guidelines for Minimally lnvasive Surgeries
For the purpose of palliative care, the surgeons need to redefine noninvasive, minimally invasive, or minor surgeries. It is said that there is no such thing as minor surgery, only minor surgeons. The minor surgeries are always performed on the other person. A massive investigation of minimally invasive surgeries and postoperative mortality has shown that minimally invasive surgeries are not minimally stressful to the patient and a major surgery may follow depending on the findings of minimally The National Confidential invasive surgery causing greater m~rtality.~,'~ Enquiry into Perioperative Death (NCEPOD)was conducted in the United Kingdom in 1996 and 1997. Every surgeon and physician should read this study on mortality caused by invasive surgeriesF2 It was found that the surgeons carried out too many operations on dying patient^.^ Modern practice of surgery covers a wide range of minimally invasive procedures and the indications for laparoscopic procedures is multiplying every day. Laparoscopic surgery can be associated with physiologic changes that compromise respiratory and cardiovascular systems.24Some surgeons and physicians are under the misconception that a percutaneous endoscopic gastrostomy (PEG) can be used to prevent aspiration of gastric contents; however, it does notF5 Eliminate the terms minor surgery and noninvasive surgery once and for all, and replace them with the term minimally invasive surgey. Demystify "Surgispeak"
As mentioned earlier, the ritualization of surgery has diminished communication between surgeon and the patient before and after surgery. In reality, the communication from the surgeon takes place in a hurried manner while the patient is still recovering from anesthesia in a side room or a conversation with family members in a corridor adjacent to the operating room. Invariably, the patient and family members remember only four words from the surgeon, "got it all out." These four words obviate the need for further discussion on the part of the surgeon as the patient and
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family are intensely relieved, and they have no further questions. Some surgeons feel they have adequately communicated to the patient by just drawing a diagram on any piece of paper in the chart or anywhere nearby. Some great surgeons are poor artists, and these diagrams and sketches are poorly executed. Not having any knowledge of anatomy, the patients get no idea other than "got it all out." When the patient comes to the palliative care physician sooner or later, they are confused why they have to see a physician rather than a surgeon who told them that he "got it all out." Some surgeons feel it is not necessary to be explicit, to give the details of pathology of cancer and "perform an autopsy in vivo." This is a mistake. It would be helpful to have a glossary of surgical terms commonly used to simplify communication. It is useless to give brochures on surgery before or after because they do not apply to each patient. Very ill patients hardly have the energy to read them, or they may misinterpret and imagine that they have all the complications. Face-to-face communication is best.
Family Meetings Jointly Held by the Surgeon and the Physician Family meetings with the patient and as many family members as possible should be the most important activity besides surgical or medical treatments. The family meeting is the only way the surgeon or physician can communicate all the information at once to all family members and the patient and answer all of the questions. The information should be clear and understandable to the lay person about diagnosis, prognosis, and treatment plans. It may be time consuming but worth the investment. If there is a large number of family members, only one person should be chosen as the spokesperson to the patient, and there would be no further need for each family member to call the physician or the physician to call each family member. The spokesperson's name, address, and telephone numbers must be charted, and the spokesperson is chosen by consensus of the family members. The surgeon and the physician should design a structured family meeting in palliative care. The invitation, however, for surgeons to come and participate in family meetings has been met with cold shoulders. Even the lionhearted surgeons appear to get chickenhearted in facing a large family when the surgery has not cured the patient. Another advantage of the family meeting is almost all of the conflicts arising from the patient or family members can be resolved with a consensus. Otherwise, the patient always replies to the surgeon or the physician in anger; typically by saying "I don't know what's going on."
Avoid Surgical or Medical Nihilism The physician or surgeon should not hesitate to perform a major surgery to relieve major symptoms of obstruction, bleeding, rupture, or fracture to give the patient comfort for a reasonable period of time.
Table 3.THE PALLIATIVE CARE PATIENT SHOULD FEEL BETTER THAN BEFORE SURGERY Symptom Causing Surgeries
System
Head and Neck
Thoracic
Radical: morbidity Tracheostomy G / J tube feeding Loss of speech Pain not relieved Pneumonectomy Post-thoracotomypain Respiratory failure No better than before surgery
Gastrointestinal
Major resections of bowel, liver, pancreas: altered bowel habits, adhesions, wound dehiscence, fistulas, repeated obstructions No better than before surgery
Neurosurgical
Central nervous system: new neuro sequale Spinal: no better than before surgery
Symptom-Relieving Surgeries
Debulking: airway establishment Prevention of vascular catastrophe Relief of pain Drainage of pleural effusion and pleurodesis Tracheal stent Endobronchial resection by laser Esophageal stent Laparoscopic surgery Ostomies to relieve obstruction Biliary stent PEG tube for nutrition Venting gastrostomy Peritoneal catheters Cordotomy and rhizotomy to relieve pain Epidural, intrathecal pumps to control pain
G/J = gastrostomy or jejunostomy; PEG = percutaneous endoscopic gastrostomy.
Statements like "why don't you let the patient die in dignity?" should be dealt with by education. It should be emphasized that dying with suffering is not dying with dignity. Most of the palliative care surgical treatments to relieve symptoms are minimally invasive as outlined in Table 3. Over treatment should be avoided even though it is believed that there is no legal liability for over treatment. The patient should not be sentenced to suffer longer. A large number of patients in intensive care units are kept alive when they cannot speak or eat or move in bed. End-of-Life Care
It is believed the surgeon manages life and the physician manages death. Intraoperative and postoperative death, even in the patient with serious disease and poor risk for surgery, is not acceptable. The surgeon's performance is determined by the postoperative mortality. The surgeon is reluctant to discuss a do not resuscitate (DNR) order. The patient who is terminally ill may spend a considerable amount of time in the surgical ICU before their demise. A proportion of patients in the ICU should not be in a medical or surgical ICU. These patients should receive good palliative care, and the
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family members keeping constant vigil need support and education. The policies and procedures of the hospitals and ICUs lack guidelines for providing appropriate care to dying patients. The medical staff is encouraged to treat the terminal patient aggressively at the expense of the patient's well being and comfort. Policies, procedures, and guidelines need to be written and approved by appropriate overseeing agencies of the hospital staff. Communication with the patient and family on pain management, artificial nutrition and hydration, withdrawal and withholding of technologic interventions, and discussion and writing of DNR orders need to be outlined clearly.14A new concept of saving death equating with saving life has emerged. Saving death helps the patient preserve comfort and dignity despite overwhelming illness, and it helps the family understand the inevitability of death and move forward in the process of berea~ement.~~
INTEGRATION OF SURGICAL AND MEDICAL SERVICES Components for Integration Having identified the components of medical and surgical palliative care services, efforts canbe made to integratethese services in aninstitute or a practice. The model I propose is dynamic and requires equal interaction between surgeons and the physicians. Several practical issues, however, need to be solved first. Is the surgeon prepared to spend some amount of time outside the operating room? Which specialty will be more willing to adopt the ideals of palliative care? Are the younger or older surgeons more interested? Is it true a retired surgeon is more willing to take care of terminally ill patients? Because surgeons interact with oncologistsanyway, will they prefer to work with oncologists, physicians or other specialties interested in palliative care? At what site is the surgeon willing to see patients (hospital only, as outpatients, or in nursing homes)?Any surgeon who is motivated to help terminally ill patients is an asset to a palliative care program.
Levels Of Palliative Care Acute or Tertiary Palliative Care. This level is probably most suitable for surgeons (Fig. 2). The patients are not actively dying, but they suffer actively from complications of advanced cancer. Invariably, patients require hospitalizations for tertiary care. These patients may require major surgeries, such as debulking a huge tumor or fixing a pathologic fracture. It is useful if the surgeon follows these patients along with the physician throughout their remaining life. Hospice Palliative Care. I have seen surgeons devote their full-time or part-time work as medical directors of home or hospital hospices where patients are at the end of their lives. Such surgeons have expressed intense satisfaction in treating terminally ill patients.
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PATIENT
PHYSICIAN
'
'
SURGEON
Figure 2. Service integration for palliative care.
COLLABORATION IN TRAINING YOUNG SURGEONS AND PHYSICIANS Palliative Care Curriculum
Medical textbooks and curricula in the medical schools lack information on palliative care issuese5The trend is being reversed by the establishment of palliative care centers and recently published textbooks.?l4 Careful scrutiny of two well known textbooks in surgery, however, have shown there is no word on palliative care in their in dice^.^^,^^ Morphine for pain control was dealt with in one or two paragraphs only. The conceptual framework of medicine and surgery is based on saving the patient's life and fixing abnormalities. We need future surgeons to understand the palliative care principles in surgery. Compulsory courses should be included in the curricula of surgery and medicine. There is a need to change the equation that physicians manage death and surgeons manage life. The United States has always been in the forefront of developing new subspecialties in medicine or surgery with one exception, palliative care. As recently as 1996, there was no specialty board for palliative medicine. This is not a suggestion to start another specialty in surgery, however. It is sufficient if the goodness in surgery is brought back into practice. SUMMARY
As we look into the future, profound changes in surgery and medicine can be expected. I believe real time surgery can be practiced now using computer-generated models. Robotic surgery is becoming a reality.
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Immortality is being sought by physicians using gene transfer technology called genetic engineeving as though human beings are machines. Immortality may not relieve sufferingfrom diseases, however. Palliative care will be needed much more in the future. The patient population in palliative care is unique. They suffer from physical and emotional distress and spiritual pain. Their symptoms are often complex, multiple, and defy definitions. The amount of care needed by the intensely suffering patient is infinite. No surgeon or physician alone can claim the capacity to provide adequate care to these patients. Surgeons joining the physicians will revitalize the current interdisciplinary teams in palliative care. Several benefits will be derived from the relationship between the surgeon and the physician: (1)the goodness of surgery and medicine combined will humanize surgical and medical practice; (2) care of the advanced cancer patient and the terminally ill will be shared by surgeons and physicians; (3) innovative policies, procedures, and protocols for symptom control will emerge rapidly; (4) combined efforts of surgeons and physicians may help predict symptoms early to be proactive and prevent them from becoming refractory; and (5) the relationship between surgery and medicine in palliative care may become a new paradigm for patient care in any specialty. Physicians just touch the hands of the patients. Surgeons can touch every organ, muscle, nerve, and blood vessel. By establishing relationships with physicians, surgeons will hold the patient's hands with no sterile gloves intervening. ACKNOWLEDGMENTS The author thanks Meredith Gross, Medical Transcriptionist for Medcenter One, Bismarck, North Dakota, for typing the final drafts of this article. The author thanks Kathy Igou, Medical Transcriptionist for Medcenter One, Bismarck, North Dakota, for typing the initial drafts of this article. The author thanks Delphine Marshall, Graphic Artist, Medcenter One, Bismarck, North Dakota, for preparing the computer-generated figures for this article.
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9. Ferriman A: Surgeons carry out too many operations on dying patients. BMJ 317:1269, 1998 10. Foster JH: Some eastern thoughts of north eastern surgeon. Arch Surg 125:702-706,1990 11. Gaisford JC: Palliative surgery. JAMA 221:83-84,1972 12. Hoile R: Minimally Invasive Surgery (Excluding Gynecology and Urology). The report of the National Confidential Enquiry into Perioperative Deaths. NCEPOD, London, 1996/1997, p 1-3 13. Janssens RMJPA, Zyclicz Z: Articulating and theologicalperspectives. JPalliat Care 15:3844,1999 14. Jett LG: Comfort at the end of life: Palliative care policies. J Nurs Adm 25:55-60,1995 15. Joishy SK, Walsh D: The opioid sparing effect of intravenous ketorolac as an adjuvant analgesic in cancer pain: Application in bone metastasis and the opioid bowel syndrome. J Pain Symptom Manag 16:334-339,1998 16. Joishy SK (ed): Palliative Medicine Secrets. Philadelphia, Hanley and Belfus, 1999 17. Kerr D. Alfred Worcester: A pioneer in palliative care. Am J Hos Pall Care 15:13-14,3638, 1998 18. Kobler J (ed): The Reluctant Surgeon: A Biography of John Hunter. New York, Doubleday, 1960, p 165 19. Latimer EJ: Ethical care at the end of life. CMAJ 158:1741-1747,1998 20. MacDonald N: Cure and care: Interactionbetween cancer centers and palliative care units. Rec Result Cancer Res 121:399407,1991 21. Milch RA, Dunn GP: The surgeon's role in palliative care. Bull Am College Surg 821517,48,1997 22. NCEPOD: The Report of the National Confidential Enquiry into Perioperative Deaths 1996/1997. London, NECEPOD, p 3 5 4 3 23. Nelson JE: Saving lives and saving deaths. Ann Intern Med 130:776-777,1999 24. Rees BI, Hoile R: Laparoscopic General Surgery. The Report of the National Confidential Enquiry into Perioperative Deaths (NCEPOD). London, NCEPOD, 1996/1997, p 9-12 25. Rosin D, Hoile R: Percutaneous Endoscopic Gastrostomy (PEG), The Report of the National Confidential Enquiry into Perioperative Deaths (NCEPOD). London, NCEPOD, 1996/1997, pp 6-8 26. Rosoff L Sr: Presidential Address: Rocer Bacon. William of Occam and Lord Hou~hton: " Guides for the perplexed physician. &I J Surg 141:2-9,1981 27. Sabiston DC (ed): Textbook of Surgery. The Biological Basis of Modem Surgical Practice. Philadelphia, WB Saunders, 1997 28. Saunders C (ed): Hospice and Palliative Care. An Interdisciplinary Approach. London, Edward Arnold, 1990 29. Schwartz SI: General Surgical Association-ThePresidential Address: Eagles and egalitarians. Surgery 92:565-570,1982 30. Schwartz SI (ed): Principles of Surgery. New York, McGraw-Hill, 1999 31. Taylor FH: The complete thoracic surgeon. Ann Thorac Surg 22:310-316,1976 32. Wall LL: Ritual meaning in surgery. Obstet Gynecol88:633437,1996 33. Worcester A (ed): The care of the dying. In Care of the Aged, Dying and the Dead, ed 2. Springfield, IL, Charles C Thomas, 1961 34. Worcester A: Past and present methods in the practice of medicine. Boston Med Surg J 166:159-164,1912 A
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Address reprint requests to Suresh K. Joishy, MD Department Of Oncology/Hematology Kaiser Permanente 7300 North Fresno Street Fresno, CA 93720-2942