Here are my slides from a recent Surgical Grand Rounds at Baystate Medical Center - about palliative care & surgery.

1. Optimizing care at end of life:
“We will do everything – the question is what kind of everything”
Suzana Makowski, MD MMM FACP FAAHPM
Associate Director of Palliative Care in the Cancer Center of Excellence
Assistant Professor of Medicine
UMass Memorial Medical Center, UMass Medical School

2. “few of us ever
adequately learn
how to care for
patients at the end
of life.”
-Pauline Chen, MD
Liver Transplant Surgeon

3. Overview
Context
Communication skills: nature or nurture?
Collaboration: opportunity and need

4. “Sure, we try to put
out fires. But, if we
can't put out the fire, a
good physician takes
the patient's hand and
walks with him
through the flames.”
- Atul Gawande, MD
Letting go. The New Yorker
July 26, 2010

5. Palliative care
is an approach that
improves the quality of
life of patients and their
families facing the
problem associated with
life-threatening illness,
through the prevention
and relief of suffering
by means of early
identification and
impeccable assessment
WHO
and treatment of pain
and other problems,

6. ACS Board of Regents 2005:
Palliative care aims to relieve physical pain
and psychological social, and spiritual suffering
while supporting the patient’s treatment goals
and respecting the patient’s racial, ethnic,
religious, and cultural values. [...]
Although palliative care includes hospice
care and care near the time of death,
it also embraces the management of
pain and suffering in medical and
surgical conditions throughout life.

7. “It’s not about killing
Granny; it’s about
keeping Granny alive
as long as possible —
with the best quality
of life.”
-Diane Meier, MD
MacArthur Fellow

8. 90,000,000
Americans live with life-limiting illness

9. The number is expected to
double
in the coming years

10. Shifting the paradigm: not just end-of-life care

11. Temel - NEJM 2010, ASCO 2010

12. Temel - NEJM 2010, ASCO 2010

13. Temel - NEJM 2010, ASCO 2010

14. Temel - NEJM 2010, ASCO 2010

15. It’s not about giving up:
Palliative Care can
Improve QOL
Decrease costs
Improve prognosis
Temel - NEJM 2010, ASCO 2010

16. How?
Symptom management
Psychosocial support
Patient-centered EOLcare
Communication
Temel - NEJM 2010, ASCO 2010

17. Communication nature or nurture?

18. Communication
as a procedure

19. Communication
What I recommend:
ask, ask, ask - tell - and ask a whole bunch more

20. Communication
What we do:
tell - ask - and tell, tell, tell
What I recommend:
ask, ask, ask - tell - and ask a whole bunch more

21. Communication
What we do:
tell - ask - and tell, tell, tell
What evidence recommends:
ask - tell - ask
What I recommend:
ask, ask, ask - tell - and ask a whole bunch more

22. Communication
Ask - Tell - Ask
Class: Spikes:
• Context • Setting
• Listen • Perception
• Acknowledge emotions • Invitation
• Strategy management • Knowledge
• Summary • Emotion
• Strategy & summary

23. maximalist
minimalist
? OR
Groopman and Hartzband. Your Medical Mind. 2001. Penguin Press http://www.jeromegroopman.com/how-doctors-think.html

24. fixing problems
reaching goals

25. But doctor, he’s a fighter.
fixing problems
reaching goals

26. But doctor, he’s a fighter.
I don’t want to die.
fixing problems
reaching goals

27. But doctor, he’s a fighter.
I don’t want to die.
I want to go to Aruba next month.
fixing problems
reaching goals

28. But doctor, he’s a fighter.
I don’t want to die.
I want to go to Aruba next month.
I want to be in my garden.
fixing problems
reaching goals

29. Communication: full code or DNR?
JAMA. 2012;307(9):917-918. doi:10.1001/jama.2012.236 http://jama.ama-assn.org/content/307/9/917.extract

30. Massachusetts
MOLST
http://www.molst-ma.org/

31. Addressing the elephant Speaking of dying

32. Communication
40 yo mother from PR
w/ appendiceal carcinoma:
“In theory, we could operate, but should we?”

33. Palliative Care & Surgery

34. Palliative Surgical Care
• Communication
• Palliative surgery
• Alleviating suffering

35. Palliative Surgery
"I hope we have taken
another good step
[gastrectomy] towards
securing unfortunate people
hitherto regarded as incurable
or, if there should be
recurrences of cancer, at least
alleviating their suffering for a
time."
- Theodor Billroth, MD, 1881

36. Young woman with
history of locally
advanced pancreatic
cancer, presenting
with abdominal pain,
nausea/vomiting.
Reviewing a palliative
approach to gastric outlet
obstruction.

37. Alleviation of suffering
There is more we can do

38. Caring for patient at end-of-life
A surgeon’s role?

39. "I thought,
'I'm a doctor; I must
know everything in the
world about death and
dying.'
But, of course, I knew
absolutely nothing."
- Balfour Mount, MD
Surgical Oncologist & Founder of Palliative
Care Movement in N.America speaking on
giving his first talk about Death & Dying

40. from not-knowing
to knowing

41. “So I think healing has to
do with slowing down,
coming into the present,
listening, accepting,
forgiving, entering into
community with, and
healing is prevented by the
opposites of those things.”
- Balfour Mount, MD
Surgical Oncologist & Founder of Palliative
Care Movement in N.America A
Wayfarer’s Journey: Listening to Mahler.
http://www.shoppbs.org/product/index.jsp?

42. CMO ≠continuous morphine only

43. EOL Symptom management
• Continue treatments that alleviate
symptoms today. Stop those that alleviate
potential symptoms in a decade.
• Pain: if it’s there, treat it.
• Eye, mouth, skin care.
• Glycopyrrolate for secretions.
• Educate family.
• Engage chaplaincy and social work.

44. • Complex decision-making
• Unresolved pain
• Complex symptoms
• Psychosocial, cultural, spiritual needs
• Frequent ED visits
• Frequent hospitalizations
• Long hospital stay (LOS) - in or out
of ICU - without improvement
When to consult palliative care?

45. Palliative Pyramid
Fig. 1. The palliative triangle. Interactions between the patient, the family, and the surgeon
guide individual decisions regarding palliative care. The hope for potentially achievable
goals is advanced as each participant of the palliative triangle fulfills specific obligations.

46. Summary
• Surgeons historically have played an
important role in palliative care.
• Communication is both a procedure and an
art.
• Surgery and Palliative Care: A potential
partnership in alleviation of suffering.

47. “Self-knowledge guides us in knowing when
to give up on the hope of combating
disease and when to soldier on; it prevents
us from making decisions in which the real
aim is to shore up our own personal
defenses against insecurity; it shows us the
sources of our own fears of death and
lessens their acuteness; it outs our fears of
passivity and impotence into perspective so
that each failure of therapy is not the
expense of reason. Most importantly, it
enables us to fulfill our pastoral role as
surgeons.
This, and not the technology, is what being a
doctor is all about."
-Nuland S. A surgeon's reflections on the care of the dying. Surg Onc