Patient selection in palliative surgery: Defining value

Cohen, Joshua T.

doi:10.1002/jso.25512

Cited by 21 publications

(17 citation statements)

References 51 publications

(100 reference statements)

Supporting

Mentioning

Contrasting

Order By: Relevance

“…While surgery is often assumed to come at a cost to quality of life, at least during the immediate recovery, a study of palliative surgery patients showed no diminution in quality of life postoperatively, even in those who did not experience tangible benefits (27). In fact, the significant improvements in physical and functional well-being postoperatively are present even in a study where 54% of patients did not achieve the desired operative result (18). The best judge of the value of palliative surgery may be the patients themselves.…”

Section: Risks and Benefits Of Palliative Surgerymentioning

confidence: 97%

“…Even operations that are generally lowrisk can have substantial risks when applied to palliative patients. The overall mortality rate for percutaneous endoscopic gastrostomy (PEG) tube placement is 0.2% (18). Yet in a retrospective study of patients with malignancyin which 27% of PEG tube placements were for palliative decompression-the procedure was associated with 20% in-hospital mortality (19).…”

Section: Risks and Benefits Of Palliative Surgerymentioning

confidence: 99%

“…Palliative transurethral prostate resection, for instance, has a lower morbidity and a 70% success rate without requiring the urinary diversion common to more extensive urinary tract operations (33). For malignant bowel obstruction, both surgical and endoscopic procedures, when feasible, allowed resumption of eating, though only operation also restored bowel function (18). Perhaps because endoscopic procedures are more frequently applied in those patients with shorter life expectancy, they do not show mortality benefits over surgical interventions (12,23).…”

Section: Surgical Judgement In Palliative Proceduresmentioning

confidence: 99%

“…This makes it imperative that the palliative team include a surgeon in their discussion so that any options presented to the patient are considered, individualized and achievable. After an informed discussion with a surgeon, 15.7% of patients considering palliative surgery felt the risks of complications were too high (18). The surgeon can bring clarity to the discussion, which benefits the patient.…”

Section: What Surgeons Can Bring To the Palliative Care Teammentioning

confidence: 99%

“…In a study of 227 patients, those selected for operative management using the palliative triangle had lower 30-day morbidity and mortality as well as superior symptom improvement. Indeed, 90.7% of those selected using the palliative triangle were found to have symptom improvement (18). This team dynamic need not necessarily be limited to the fields of surgery and palliative care.…”

Section: What Surgeons Can Bring To the Palliative Care Teammentioning

confidence: 99%

See 4 more Smart Citations

Palliative surgery and the surgeon’s role in the palliative care team: a review

Louie¹,

Miner²

2022

Ann Palliat Med

Self Cite

View full text Add to dashboard Cite

This review focuses on the role of palliative surgery in the care of the palliative care patient, and the appropriate role of the surgeon. The surgeon has much to bring to the palliative care team. The surgeon's role goes beyond the technical requirements of the palliative procedure, which itself must be strictly defined, and has recognized utility for improving quality of life in selected patients. These benefits may be substantial, but come at significant risk; requiring careful balancing of risks and benefits that is most completely understood by the surgeon. The surgeon's judgement can help determine which procedure best meets a patient's goals. The complex dialogue involved in the decision to undergo a palliative operation requires excellent communication between the palliative care team, the patient, and their family. Integrating the surgeon into the palliative care team could help with earlier initiation of those palliative discussions, and assist deliberation of palliative surgery. Surgeons also understand the importance of communication around palliative surgical interventions and have adapted several teaching models to the specifics of this crucial communication. A palliative team combining both surgeons and palliative care physicians may promote goalconcordant decision-making and remove barriers to communication and team engagement. The future of palliative surgery research will involve measures of success that go beyond physiology or mortality, to include more evaluations of communication and patient goals.

show abstract

Section: Risks and Benefits Of Palliative Surgerymentioning

confidence: 97%

Section: Risks and Benefits Of Palliative Surgerymentioning

confidence: 99%

Section: Surgical Judgement In Palliative Proceduresmentioning

confidence: 99%

Section: What Surgeons Can Bring To the Palliative Care Teammentioning

confidence: 99%

Section: What Surgeons Can Bring To the Palliative Care Teammentioning

confidence: 99%

See 3 more Smart Citations

Palliative surgery and the surgeon’s role in the palliative care team: a review

Louie¹,

Miner²

2022

Ann Palliat Med

Self Cite

View full text Add to dashboard Cite

show abstract

Who Should Decide When Palliative Surgery Is Justifiable?

Cohen

2021

AMA Journal of Ethics

View full text Add to dashboard Cite

No one person has the right or ability to make decisions about to whom or according to which criteria palliative surgery should be offered. Instead, patient and surgeon together must consider symptom severity, goals of care, and the value palliative surgery could add to the patient's health experience or quality of life. Case Mr J had a slow-growing facial tumor, which had rendered him essentially housebound: the tumor was fungating, rotting from the inside out, and causing a terrible odor and unrelenting pain. He was becoming increasingly unable to go out in public. His doctors had told him that the tumor could not be removed in its entirety due to its involvement of his carotid artery and the proximity of the tumor to his brain; cure, therefore, was impossible. Nevertheless, at each clinic visit, Mr J pressed his surgeon, Dr G, to cut out as much of the tumor as he safely could. Mr J had already undergone maximal "noninvasive" therapy with radiation, but the tumor continued to grow. Eventually, he was told that the tumor would kill him-by eroding a major vessel and causing a lifeending bleed or by compressing his brainstem and causing him to stop breathing-but that the tumor's growth was slow and nobody could tell him how much time he had left.

show abstract

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

Binkley

2021

AMA Journal of Ethics

View full text Add to dashboard Cite

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.

show abstract

Patient selection in palliative surgery: Defining value

Cited by 21 publications

References 51 publications

Palliative surgery and the surgeon’s role in the palliative care team: a review

Palliative surgery and the surgeon’s role in the palliative care team: a review

Who Should Decide When Palliative Surgery Is Justifiable?

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

Contact Info

Product

Resources

About