How Is Palliative Care Best Integrated Into Surgical Services?

Introduction and Scope of the Problem

In 2005, the American College of Surgeons (ACS) recognized the need to provide seriously ill surgical patients with palliative care concurrent to routine surgical care. The ACS emphasized that palliative care is not synonymous with end-of-life care and should be delivered to patients throughout all phases of treatment. In recent years, the palliative care needs of surgical patients have gained greater recognition among both surgeons and palliative care clinicians. Nonetheless, studies have demonstrated that palliative care remains under-utilized in surgery. Surgeons continue to view palliative care consultation as synonymous with end-of-life care and cite concern that patients will believe ­palliative care consultation is a sign of giving up. This false perception results in deferred palliative care consultation and relegation of its role to older, critically ill, and imminently dying surgical patients.

Integrating palliative care into surgery requires a gradual shift in surgical culture. This chapter explores aspects of surgical culture that pose barriers to integrating palliative care, describes some of the unique challenges to providing palliative care to surgical patients, and presents an overview of existing models for integrating palliative care and surgery.

Surgical Culture

Research from the social sciences offers insights into the cultural roots of surgeons’ enduring resistance to palliative care. In the landmark ethnographic work Forgive and Remember: Managing Medical Failure , Bosk employs thick description to frame the social milieu in which surgical residents are groomed to become competent, independent surgeons with a heightened sense of responsibility to their patients. In her ethnographic work in a surgical intensive care unit (ICU), Cassell defines the surgical covenant —a bond between patient and surgeon, rooted in their shared hope, in which the surgeon pledges to do all that can be done in order to achieve a desirable outcome and the patient entrusts their life to the surgeon. Accordingly, while surgeons’ involvement in patient care may be limited to weeks or months, the high stakes, physical vulnerability, and multitude of stressors during this period make the surgeon–patient relationship one of exceptional importance and profound confidence. Surgeons’ elevated accountability to their patients fosters this uniquely intimate, trusting relationship. While this may seem admirable, it can also be detrimental to surgeons when their patients experience complications. Within this culture, allowing a patient to die after a major complication is akin to abandonment; an unforgivable breach of social norms that poses a threat to one’s personal and professional identity. Consequently, the misinformed view that palliative care represents “giving up” on the patient makes consultation a threat to professional identity and poses a significant barrier to concurrent palliative care. This is demonstrated in surgeons’ unwillingness to honor families’ request to withdraw life-sustaining treatments for a patient who was rendered critically ill by a surgical complication.

Surgeons may also resist limitations on treatment when they believe they are acting according to the patient’s wishes. While many clinicians are involved in managing critically ill surgical patients, surgeons are often the only providers on the inpatient team who met with the patient and family before the hospitalization. During these preoperative conversations, surgeons adopt a “fix-it” model to communication in which they characterize disease as an aberrancy that can be corrected, often failing to acknowledge when a complete return to normalcy is unlikely. When discussing risks of surgery, surgeons may convey potential risks in anatomical terms that patients don’t understand and then, when consent is obtained, they have the expectation that the patient and family have bought into whatever postoperative care is deemed necessary, including life-sustaining treatments, even though this was not explicitly addressed. This belief in surgical buy-in can lead to friction between surgeons and other clinicians who might question whether therapies that restrict quality of life are concordant with patients’ wishes.

Another barrier to integration of palliative care is the “rescue culture” of surgery. Surgical culture focuses on fixing problems and curing disease, whereas palliative medicine is frequently viewed as the last resort when rescue efforts have failed. As such, surgical care and palliative care are seen as consecutive approaches along a continuum. The best approach to integrating palliative care and surgery is to actively challenge the view that it is isolated end-of-life care and demonstrate its effectiveness for managing symptoms, supporting decisions, and optimizing quality of life at all phases of surgical illness.

Surgical Patients

Most palliative care clinicians were trained in nonsurgical fields and may be unfamiliar with the perioperative care of surgical patients. In contrast with most medical specialists (e.g., cardiologists, oncologists), the majority of patients’ interactions with their surgeons take place within the hospital. In the case of trauma or emergency general surgery, the entirety of the relationship may take place during a single admission. This predominantly inpatient relationship occurs during periods of significant and sudden decline with many emotional, physical, and social demands. For patients with a complicated surgical course, the number of doctor–patient interactions during one hospital stay may exceed the cumulative number of encounters with outpatient specialists that they have over the course of several years. Because of this, the bulk of patients’ palliative care needs occur in the hospital, which can pose logistical challenges for predominantly outpatient palliative care teams who may have limited resources for inpatient care.

Surgical patients have a variety of palliative care needs, including managing symptoms, delineating goals of care, and aligning treatment decisions with patients’ priorities. While surgeons are comfortable managing physical pain, they are inexperienced with addressing fatigue, refractory nausea, and existential distress. The interdisciplinary team approach of palliative care can also benefit patients who are facing sudden, major alterations in their baseline health trajectory. For patients who have high illness burden prior to undergoing major surgical operations, there is an increased risk of postoperative complications, prolonged or incomplete recovery, and mortality in the year after surgery. For cases in which surgery is an inflection point leading to new, worse health status, palliative care social workers can offer added support to patients and families.

Surgical intervention for both oncological and nononcological palliative indications occurs in many surgical subspecialties. Patients who are considering palliative surgery have substantial palliative care needs. Palliative surgery represents 13% of all operations performed at tertiary cancer centers and 40% of inpatient consultations on a surgical oncology service. A study using a national population-based dataset found that 25% of older adult patients diagnosed with stage IV cancer underwent an invasive procedure in the last month of life. Decision making for palliative procedures is nuanced due to the high risk of complications and uncertain outcomes in this patient population. Palliative care clinicians provide expertise in complex, refractory symptom management and in ensuring that treatments align with patients’ goals of care.