Monday, March 17, 2008
Time For Tears, Tears For Time
Palliative surgery is tough stuff. Nobody wins much, and it often challenges one's ability to think clearly, let alone to tell the truth. Sometimes, I think, it borders on the deceptive; it makes me wonder who's the object of comfort. And yet, when there's nothing else to do, it's often just the right thing. I hate it.
To be clear: we're talking about surgery to relieve some sort of specific problem, to reduce pain, to improve quality of life or to prolong it, when it's apparent that cure is out of the question and that life will end within a shortened amount of time. Most frequently the diagnosis is cancer, and the problem is one of tumor blocking something, or pressing on something, or causing pain. The surgeon -- who would much rather be riding a white horse, victorious and lauded -- is called upon to ameliorate a lousy situation; incrementally, briefly, often minimally, maybe even with a near-equal risk of making things worse. I abhor it.
As it is with even the worst of situations, there is narrow pleasure to be found, sometimes. The solutions to specific anatomic problems can be ingenious in their simplicity, or rewarding in their technical demands or need for creative problem-solving. In someone very sick from obstructive jaundice due to an unresectable pancreatic cancer, you can make a small incision, reach in, and sew a loop of upper intestine to hugely distended gallbladder, providing instant relief. In addition, you might staple or sew a couple of places, keeping food out of the biliary system. (In choosing that approach, you will have rejected, based on many impossible calculations, a more complicated but possibly more long-lasting operation: removing the gallbladder and sewing the bowel to the main bile duct. You will also have opted against the endoscopic placing of a stent, which is non-operative, but carries some increased risk of infection, and is prone to earlier failure.)
When there are multiple tumors in multiple places in the gut, if you can find a way to work around, hook this to that, leaving enough bowel in the circuit to maintain nutrition, you can feel -- in some small way -- satisfied. And then... well, and then what? To what sort of life have you consigned that person? Will there be gratitude, or regret? If it's true -- and it is -- that virtually every decision a physician makes is no more than a (hopefully) sophisticated game of odds-playing, that game is at its most intense and ephemeral and unruled when it comes to palliation, looking beyond the surgical options and possible outcomes. I loathe it.
And yet, if ever there is a situation that requires everything a good surgeon has to offer beyond mere technique, this is it. It's not about "what can I do." It's about "what ought I do." It gets to the essence of our craft and of who we are. Of course, there's no archetype, no algorithm or manual. Each situation is as unique as the person within it. Age, general condition, stage of tumor, predictability (such as it is) of prognosis. Most important: the person's (and the family's) wishes. Less tangible, less easy to apply: how realistic are those wishes. Clearly -- and I think this is the core of it -- what happens going in and coming out will vary not only with all of the preceding factors, but with the surgeon who answers the call. In that, I embrace it.
There are no more difficult conversations. There are none that require more ability and willingness to find balance among counsel and comfort, guidance and openness, realism and fantasy, hope and despair. One's own and one's patients needs. Dogmatism, that staple of surgical stereotype, serves none but the surgeon. One person's futility is another's possibility. For some, the ability to do something -- anything at all -- always trumps the option of comfort care, no matter the situation. For others, the idea of prolonging life can demand a profound look inward. And outward. Sometimes, as I wrote, it works out much better than expected. Other times, it makes you and your patient wish you'd not tried. The decision, affirmative or negative, is often easily made; when it isn't, your values are tested along with your skills.
If I were giving advice to those coming this way, I'd say to remember (and to convince yourself it's true) that your obligation is to your patient, and not to your own discomforts. To me, that means looking beyond personal prejudices, be they religious or societal. "Always" and "never" comprise the easy way out: prolong life at all costs; "no one should die with a bowel obstruction;" "I refuse to..." Many physicians feel safest only when enumerating options and staying completely out of the process of choosing. To me, that's abdication. It's our obligation to state as clearly as possible what we think the situation is, what the options are -- including all forms of intervention and non-intervention -- and then to find a way into the thoughts of the patient and family. I think most want guidance; they need our best sense of likely outcomes, based on experience and knowledge. And of course they need to understand that there's virtually never a way to be certain. In most cases, I think it's possible to discern to what extent they want direction; sometimes it's as simple as asking.
It's imperative both to lead and to follow. In many conversations with families of a person with minimal prospects, I've sensed that there's no desire to prolong the inevitable, but none wants to bear the responsibility of making the decision. There can be relief when the surgeon -- or any of the involved doctors -- takes the lead in turning toward comfort care. But in virtually none of those situations would I close the door on going for that one-in-a-thousand chance if that's the direction desired. And yet: it's exactly that situation in which I have the most discomfort and uncertainty. A part of me wants to say it's foolishness and to refuse to do the operation; another recognizes that the thought of not doing everything possible is one with which some of those left behind would have trouble living. Which gets back to the beginning: who am I treating, and why?
(It may be obvious: the time is coming, I think, when such choices will no longer be available. When the string is fully run out on reimbursement cuts, this most costly of all areas -- namely futile and end-of-life care -- will have to be addressed philosophically and economically. Lines will be drawn. The question will be where, and by whom. For now, it's still between us; and we must dig deeply.)