Surgeons' workgroup promotes cutting-edge palliative care for discipline

Much progress has been made in last decade

The public and many surgeons may see palliative care as quite separate from the surgical suite, down the hall or a few floors up. But a growing number of surgeons are passionately interested in educating their peers about palliative care and seeing its philosophical approaches being incorporated into surgical care.

This group, which has its roots in a surgeons' workgroup formed nearly 10 years ago, has spread its influence across the surgical field, resulting in continuing palliative care education and activities.

"Palliative care isn't something that normally rises to the forefront of the surgical agenda," says Robert A. Milch, MD, FACS, medical director of the Center for Hospice and Palliative Care in Cheektowaga, NY.

Surgeons typically think in terms of action, not reflection and listening, Milch says.

"Surgeons have not been traditionally trained for so many of the elements that go to the heart of palliative care," Milch notes.

Milch was a co-chair of the surgeons' workgroup for the Promoting Excellence in End-of-Life Care project, launched in 1997 by the Robert Wood Johnson (RWJ) Foundation of Princeton, NJ. The program's duration was less than two years, but the workgroups' activities and changes have endured, including those of the surgeons' workgroup, says Jeanne S. Twohig, MPA, deputy director of the Duke Institute on Care at the End of Life in Durham, NC. Twohig formerly was with the national office of the RWJ Foundation.

"These workgroups turned out to be much more powerful and potent than what we had at the beginning," Twohig notes.

Each workgroup was given 18 months to write recommendations, or initiate changes, that would enhance palliative care in their particular medical discipline, Twohig says.

The surgeons' workgroup drew attention to the subject of palliative care through a series of articles about palliative care and surgery, which were written by surgeons and published monthly over three years in the Journal of the American College of Surgeons, says Geoffrey Dunn, MD, FACS, medical director of the Palliative Care Consultation Service and a senior surgical consultant at Hamot Medical Center in Erie, PA. Dunn was an editor of the series and a co-chair of the surgeons' workgroup.

"First they were written by members of the workgroup, and then they were written by people known to the workgroup," Dunn says. "These were people who collaborated with us on other projects."

As a next step, the surgeons' workgroup encouraged the American College of Surgeons to designate a task force on surgical palliative care, Dunn says.

"We felt we were given the task to educate the surgical community as much as possible about principles and practices of palliative care in surgical practice," Dunn says. "So we went from being an RWJ-funded, free-standing group to being incorporated in the administrative structure of the American College of Surgeons."

The workgroup also hosted and sponsored a series of symposia at the annual meeting of the American College of Surgeons, and this has continued for the past six years, Dunn says.

"Last year the task force sponsored a two-day course for credit about palliative care for surgeons, Dunn adds.

"We persuaded Johns Hopkins Department of Surgery to sponsor a one-day seminar on surgical palliative care in 2005," Dunn says. "That was a huge breakthrough because that's such an influential institution in surgery."

Also, there is a web-based community of surgeons, through the American College of Surgeons, who are interested in palliative care, Dunn says.

"We drafted the college's current policy on palliative care, its statement of principles of palliative care," Dunn says.

The principles were endorsed by the college's board of regents, and they were drafted in a way that makes the college's policies consistent with current palliative care practice, Dunn explains.

"The workgroup was the beginning of many very close friendships and collaborations, spawning some research, and the task force has grown with younger, dynamic members," Dunn says. "You could say the RWJ workgroup gave palliative care a real foothold in institutional surgery."

For example, the American Board of Surgery now recognizes palliative care as one of the areas of expected expertise for certification by the American Board of Surgery.

"Palliative care was never seen as that relevant to surgery," Dunn notes. "What we did was begin a process of making it very relevant to surgery."

Continuing work in palliative care includes online educational materials available at www.eperc.mcw.edu, and a national residency training project in palliative care medicine, Milch says.

"What they did was bring in residency program directors and chief residents and senior residents for two-day seminars, and they set up projects for them to take back tot heir institutions to impact training, care delivery, and all sorts of things," Milch says. "We ended up having 31 different residency training programs participate in this project."

The theory is that real change requires an investment in tomorrow's practitioners, Milch says.

Dunn and Milch explain how surgery and palliative care can fit together:

  • Meaningful conversations: "I think the best tool you can give any surgeon or physician revolves around not the technical skills, but how to have meaningful conversations," Milch says.

"When in the course of your interaction with patients these conversations occur, the first thing to understand is what the goals of care are," Milch adds. "If you understand the patient's priorities and goals, then devising a plan of care becomes so much simpler."

Communication skills become most important in situations in which medical success is difficult to define, such as with patients who linger in the intensive care unit for weeks, Milch explains.

"What are the goals of a surgical intervention, and how can we convey to the patient that we understand their goals, and we'll work together and revisit them over time," Milch says.

Just because a surgeon can do something surgically for a patient isn't the whole answer to the question of whether we should do it, Milch adds.

"The question should be, 'If we do surgery, will it help patients and families meet their goals of care?'" he says.

  • Surgery for palliative, not curative purposes: There are many situations where surgical intervention is welcome to treat patients with terminal disease and life-limiting disease, Dunn says.

"Surgeons need to be reminded that this is not alien to our tradition," Dunn says. "Before we were able to cure things as frequently as we do now, we knew a lot about nonabandonment and relief of suffering, and we were proud of doing it."

Many surgeons think that is as worthy a goal as saving lives, he adds.

The big stumbling block for surgeons who haven't embraced palliative care is the mindset that palliative care and hospice are the end of life, signifying loss of hope, and it's something they don't want to deal with, Dunn says.

  • Exploratory surgery and palliative care: Dunn recently was asked to see a patient who had undergone exploratory laparotomy due to an obstruction and suspicion of malignancy.

"There was no other way to establish the diagnosis," Dunn says. "And he did, indeed, have advanced cancer of the pancreas."

After surgery, the medical team had to manage the patient's pain and nausea, and the family had questions about the man's nutrition, he recalls.

"Then we had to give the patient news of the diagnosis and assess the impact," Dunn says.

It was important that providers be cognizant of how the patient might receive the news and how it was given. Providers' empathy also was an issue, and it was up to the medical team to help the patient preserve hope, Dunn says.

"We preserve hope by giving the patient something to look forward to, even if it's for a short period of time," Dunn explains. "This is all right out of any hospice or end-of-life scenario and out of a surgical care scenario."

  • Benefits to surgeons who practice palliative care: "One thing surgeons will agree to is that no one is happy in the field of surgery now," Dunn says. "It would be trivializing for surgeons to say they're unhappy because of malpractice, because it's much deeper."

There is, among surgeons, a loss of stature, purpose, and true satisfaction because they are evaluating themselves in terms of technical success and not so much on how they impact people's lives, Dunn says.

A palliative care approach can fill that gap for surgeons and help them see how they impact people's lives, Dunn says.

"I tell surgeons that palliative care isn't some exotic import or psychiatry, but it's what we're really all about," Dunn says. "We allowed ourselves to be seduced by power and technology, and we forgot there are other reasons why we're important to people."

Need More Information?

  • Geoffrey Dunn, MD, FACS, Medical Director of the Palliative Care Consultation Service and Senior Surgical Consultant at Hamot Medical Center, 201 State St., Erie, PA 16550-0001.
  • Robert A. Milch, MD, FACS, Medical Director of The Center for Hospice and Palliative Care, 225 Como Park Blvd., Cheektowaga, NY 14227.
  • Jeanne S. Twohig, Deputy Director, Duke Institute on Care at the End of Life, Box 90968, Westbrook Building, Duke University Divinity School, Durham, NC 27708. Email: jtwohig@div.duke.edu.