How Should Surgeons Communicate About Palliative and Curative Intentions, Purposes, and Outcomes?

Abstract

How surgeons describe procedures should be accurate, precise, and concordant with patients' values. By focusing on intention rather than realistic goals, terms like curative and palliative, when applied to highstakes operations, such as a Whipple pancreaticoduodenectomy, can be confusing to patients. This case commentary argues that surgeons' language choices can influence patients' decisions and experiences.The American Medical Association designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 Credit™ available through the AMA Ed Hub TM . Physicians should claim only the credit commensurate with the extent of their participation in the activity.Case LL is a 66-year-old patient with a pancreatic head adenocarcinoma. In consultation, Dr B recommended that LL undergo a Whipple pancreaticoduodenectomy and indicated that his "intention in doing this procedure is to cure your cancer." There were no postoperative complications, and LL completed adjuvant chemotherapy. But 18 months later, surveillance computed tomography imaging revealed a 3 cm mass in LL's right liver. Metastatic pancreatic cancer was confirmed by biopsy.LL returned to see Dr B and asked why her operation wasn't curative. Dr B explained that most often pancreatic cancer recurs and that the operation was palliative. CommentaryIn 1978, C. Gardner Child, former chairman of surgery at the University of Michigan, published a summary of 55 Whipple pancreaticoduodenectomies (PDs) he had performed from 1960 to 1978, mostly for malignancy. Child observed that the operation was "primarily a palliative surgical procedure." 1 More than 40 years later, the same operation is still being referred to in many cases as palliative. 2 However, the basis of the current designation is much different than what Child meant by palliative. Given advances in addressing major symptoms of malignancies treated by a PD, the role of true surgical palliation is significantly limited. 3,4 Palliative Whipple is thus a description that should be used with precision, as imprecise usage can compromise patient autonomy, informed consent, and physician truthfulness.