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Surgical Grand Rounds: Palliative Care


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

Published in: Health & Medicine

Surgical Grand Rounds: Palliative Care

  1. 1. Optimizing care at end of life:“We will do everything – the question is what kind of everything” Suzana Makowski, MD MMM FACP FAAHPMAssociate Director of Palliative Care in the Cancer Center of Excellence Assistant Professor of Medicine UMass Memorial Medical Center, UMass Medical School
  2. 2. “few of us everadequately learnhow to care forpatients at the endof life.”-Pauline Chen, MDLiver Transplant Surgeon
  3. 3. OverviewContextCommunication skills: nature or nurture?Collaboration: opportunity and need
  4. 4. “Sure, we try to putout fires. But, if wecant put out the fire, agood physician takesthe patients hand andwalks with himthrough the flames.”- Atul Gawande, MDLetting go. The New YorkerJuly 26, 2010
  5. 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. 6. ACS Board of Regents 2005:Palliative care aims to relieve physical painand psychological social, and spiritual sufferingwhile supporting the patient’s treatment goalsand respecting the patient’s racial, ethnic,religious, and cultural values. [...]Although palliative care includes hospicecare and care near the time of death,it also embraces the management ofpain and suffering in medical andsurgical conditions throughout life.
  7. 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, MDMacArthur Fellow
  8. 8. 90,000,000Americans live with life-limiting illness
  9. 9. The number is expected todoublein the coming years
  10. 10. Shifting the paradigm: not just end-of-life care
  11. 11. Temel - NEJM 2010, ASCO 2010
  12. 12. Temel - NEJM 2010, ASCO 2010
  13. 13. Temel - NEJM 2010, ASCO 2010
  14. 14. Temel - NEJM 2010, ASCO 2010
  15. 15. It’s not about giving up: Palliative Care can Improve QOL Decrease costs Improve prognosisTemel - NEJM 2010, ASCO 2010
  16. 16. How? Symptom management Psychosocial support Patient-centered EOLcare CommunicationTemel - NEJM 2010, ASCO 2010
  17. 17. Communication nature or nurture?
  18. 18. Communicationas a procedure
  19. 19. CommunicationWhat I recommend: ask, ask, ask - tell - and ask a whole bunch more
  20. 20. CommunicationWhat we do: tell - ask - and tell, tell, tellWhat I recommend: ask, ask, ask - tell - and ask a whole bunch more
  21. 21. CommunicationWhat we do: tell - ask - and tell, tell, tellWhat evidence recommends: ask - tell - askWhat I recommend: ask, ask, ask - tell - and ask a whole bunch more
  22. 22. Communication Ask - Tell - AskClass: Spikes: • Context • Setting • Listen • Perception • Acknowledge emotions • Invitation • Strategy management • Knowledge • Summary • Emotion • Strategy & summary
  23. 23. maximalist minimalist ? ORGroopman and Hartzband. Your Medical Mind. 2001. Penguin Press
  24. 24. fixing problemsreaching goals
  25. 25. But doctor, he’s a fighter.fixing problemsreaching goals
  26. 26. But doctor, he’s a fighter. I don’t want to die.fixing problemsreaching goals
  27. 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. 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. 29. Communication: full code or DNR?JAMA. 2012;307(9):917-918. doi:10.1001/jama.2012.236
  30. 30. MassachusettsMOLST
  31. 31. Addressing the elephant Speaking of dying
  32. 32. Communication 40 yo mother from PR w/ appendiceal carcinoma: “In theory, we could operate, but should we?”
  33. 33. Palliative Care & Surgery
  34. 34. Palliative Surgical Care• Communication• Palliative surgery• Alleviating suffering
  35. 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. 36. Young woman withhistory of locallyadvanced pancreaticcancer, presentingwith abdominal pain,nausea/vomiting.Reviewing a palliativeapproach to gastric outletobstruction.
  37. 37. Alleviation of sufferingThere is more we can do
  38. 38. Caring for patient at end-of-life A surgeon’s role?
  39. 39. "I thought,Im a doctor; I mustknow everything in theworld about death anddying.But, of course, I knewabsolutely nothing."- Balfour Mount, MDSurgical Oncologist & Founder of PalliativeCare Movement in N.America speaking ongiving his first talk about Death & Dying
  40. 40. from not-knowing to knowing
  41. 41. “So I think healing has todo with slowing down,coming into the present,listening, accepting,forgiving, entering intocommunity with, andhealing is prevented by theopposites of those things.”- Balfour Mount, MDSurgical Oncologist & Founder of PalliativeCare Movement in N.America AWayfarer’s Journey: Listening to Mahler.
  42. 42. CMO ≠continuous morphine only
  43. 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. 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 improvementWhen to consult palliative care?
  45. 45. Palliative PyramidFig. 1. The palliative triangle. Interactions between the patient, the family, and the surgeonguide individual decisions regarding palliative care. The hope for potentially achievablegoals is advanced as each participant of the palliative triangle fulfills specific obligations.
  46. 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. 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 adoctor is all about."-Nuland S. A surgeons reflections on the care of the dying. Surg Onc