Surgery, palliative care, and the American College of Surgeons.

Since the late 1990s, the American College of Surgeons (ACS) has increasingly recognized and advocated palliative care for patients and their families with serious, critical, and terminal illness under surgical care. The college has been the primary catalyst for the recognition of palliative care in the field of surgery in the U.S. and abroad, primarily through educational efforts directed at practicing surgeons and surgeons in training. Roughly 15 years ago a group of surgeons from the fellowship of the college coalesced and then spearheaded these initiatives with invaluable support and advice from leading non-surgeon pioneers of palliative care. This group is now titled, the Committee on Surgical Palliative Care (CSPC). The CSPC's mission is to incorporate the precepts and techniques of palliative care into surgical clinical practice, education, research, and advocacy. This report chronicles the contributions the ACS has made to the evolution of surgical palliative care and details the formation of its CSPC and its role in shaping surgical palliative care today.

Patient-centering approaches for the surgical oncologist: palliative care, patient navigation, and distress screening.

Surgeons can more effectively meet the public's increased expectation of patient-centered care by directing attention to pain, non-pain symptoms, including depression and anxiety, in addition to the patient's personal preferences, resources, and support needs. Patient navigation and palliative care, both pioneered by surgeons, provide complementary frameworks for the screening, assessment and intervention needed to achieve enhanced patient outcomes including adherence to care, improved quality of life and patient satisfaction.

Surgical palliative care: recent trends and developments.

Palliation has been an essential, if not the primary, activity of surgery during much of its history. However, it has been only during the past decade that the modern principles and practices of palliative care developed in the nonsurgical specialties in the United States and abroad have been introduced to surgical institutions, widely varied practice settings, education, and research.

Surgical palliative care: recent trends and developments.

Palliation has been an essential, if not the primary, activity of surgery during much of its history. However, it has been only during the past decade that the modern principles and practices of palliative care developed in the nonsurgical specialties in the United States and abroad have been introduced to surgical institutions, widely varied practice settings, education, and research.

Principles and core competencies of surgical palliative care: an overview.

The concept of palliation is as old as surgery itself, perhaps so old that it has been taken for granted rather than conceptualized as a primary framework for surgical care. The experience and success of the hospice movement in the United States and abroad was followed by the extension of its basic concepts to the much larger population of patients with advanced, but not necessarily terminal, illness. This collective experience has provided the necessary background and stimulus for developing a specific set of principles and competencies applicable to surgical palliative care. Surgical palliative care is the treatment of suffering and the promotion of quality of life for seriously or terminally ill patients under surgical care.

Surgical palliative care of advanced wounds.

The history of surgery is rich with accomplishments in wound care, a legacy that recently has been abandoned by many surgeons only to be taken up by nonsurgical providers. When dealing with advanced wounds at the end of life, such as pressure ulcers or venous stasis ulcers, goals of treatment are relief of pain, elimination of odor, and control of wound exudates and infection. Benefits and risks of surgical intervention must be discussed with the patient and family in terms of the patient's perceived prognosis, extent of tissue necrosis and infection, the rate of deterioration, and the underlying wound pathogenesis. When appropriate, the role of surgery looms large in the treatment of chronic, advanced wounds, especially when minimally invasive surgical techniques are used.

Prospective integration of cultural consideration in biomedical research for patients with advanced cancer: recommendations from an international conference on malignant bowel obstruction in palliative care.

In the setting of an international conference on malignant bowel obstruction as a model for randomized controlled trials (RCTs) in palliative care, we discuss the importance of incorporating prospective cultural considerations into research design. The approach commonly used in biomedical research has traditionally valued the RCT as the ultimate "way of knowing" about how to best treat a medical condition. The foremost limitation of this approach is the lack of recognition of the impact of cultural viewpoints on research outcomes. We propose that interest relevant to cultural viewpoints should be emphasized in conceptualizing and interpreting research questions, designs, and results. In addition to recognizing our cultural biases as individuals and researchers, we recommend two major shifts in designing and implementing RCTs: 1) inclusion of a multidisciplinary team of researchers to inform the diversity of perspectives and expertise brought to the research, and 2) use of mixed methods of inquiry, reflecting both deductive and inductive modes of inference.

Palliative care in the surgical intensive care unit: where least expected, where most needed.

Despite dramatic improvements in survival from a broad range of afflictions seen in the surgical critical care unit, the problem of suffering in its many forms and its long-term consequences will remain as long as mortality characterizes the human condition. Palliative care in the surgical intensive care unit is an extension of time-honoured surgical principles and traditions that aims to relieve suffering and improve quality of life associated with serious illness as an end in it self or as part of treatment to save and prolong life.

Palliative care for surgical patients.

Over the past decade, surgeons and surgical institutions have shown increased attention to palliative care for their patients. This has been part of the increased worldwide recognition of palliative care as a legitimate framework of medical care. Owing to the critical role of pharmacotherapeutics for both palliative care and the practice of surgery, the advent of this philosophy of care will inevitably result in new challenges and opportunities for all three of these entities. While anesthetic agents, antibiotics and immunosuppressants have extended the scope and length of surgery, drug-based therapies used to achieve palliative goals have the potential to extend the moral scope of surgical care.

Palliating patients who have unresectable colorectal cancer: creating the right framework and salient symptom management.

The last phases of colorectal malignant illness may be the most challenging and saddening for all involved, but they offer opportunities to become the most rewarding. This transformation of hopelessness to fulfillment requires a willingness by surgeon, patient, and patient's family to trust one another to realistically set goals of care, stick together, and not let the treatment of the disease become a surrogate for treating the suffering that characterizes grave illness.

Palliative care: a promising philosophical framework for gastroenterology.

Since the 1970s, much has happened to establish palliative care asa health philosophy that will enrich the practice of gastroenterology;conversely, developments in gastroenterology have already improved palliative care. Several recent concepts from the field of gastroenterology such as "the second brain" and "intestinal failure" fit well within the conceptual framework of palliative care. This type of synergy will ultimately encourage the application of this philosophy to a much broader spectrum of patients than those deemed to be at "end of life." This broader spectrum of care can be described as palliative gastroenterology.

Surgical palliative care: an enduring framework for surgical care.

Thomas R. Russell [49], Executive Director of the ACS pointed out ina recent editorial that the culture of surgery is changing and evolving, along with long-held values. He notes, "No longer is it 'my' patient, but it is 'our'patient." This shared responsibility for the surgical patient is not without peril, although this ethic has a positive application in the interdisciplinary model of palliative care. The principle of autonomy suggests that the patient, himself, shares some responsibility for a good QOL outcome. Although the focus of his remarks is fundamental change in residency training, his comments apply equally to the norms of surgical practice,especially palliative care: "We can start by building a sense of mutual respect for the broad range of individuals [including the patient and his family] involved in the care of our surgical patients, from nurses to allied health care professionals, from anesthesiologists to environmental service workers. As surgeons we must improve our communication and leadership skills, so these individuals will view us in a more positive light." Surgical palliative care is a philosophy of care that can answer this challenge. Surgeons have always been up to the challenges of their era. They never have disappointed those whom they serve in their degree of courage,practicality, and innovation, but the changing landscape of illness and culture offer new opportunities for other insights and strengths to emerge.

Transplantation and palliative care: the convergence of two seemingly opposite realities.

One of the authors once asked a great transplant surgeon what came to his mind when asked about palliative care. He had two answers: the first,was somewhat simplistic; the second was profound. He said that this type of service was helpful in the ICU when there was not much more to be done surgically for a patient who was dying; the second, was a story about an individual whom he had transplanted three times (who survived!) because he and his team did not want the patient and family to give up hope. The second answer is fundamentally more in keeping with the philosophy of palliative care, despite the extraordinary specific circumstances. The surgeon demonstrated ongoing presence and non abandonment. This patient was palliated, although few surgeons could have accomplished this by doing two retransplantations! Fortunately, for the less gifted and lucky, there are many ways in which to continue a meaningful presence to an ailing or dying patient on a transplant service that do not require a transplantation procedure. One wonders why palliative care and transplantation have not been more formally acquainted in the past given the extensive overlap of the populations served, the nature of the day-to-day problems, and the intensity of the commitment to the patient. The time is ripe for a formal mutual acquaintance between palliative care specialists and transplant teams,perhaps in the format of a work group that is similar to the work groups that promoted excellence in palliative care, such as the End Stage Renal Disease Workgroup, that were grant funded by the Robert Wood Johnson Foundation. The fields of transplantation and palliative care have a treasure trove of experience that is lacking in the other that could be exchanged profitably with a great sense of satisfaction for all.