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.)


Christian Sinclair said...


Excellent post on a tough subject. I recently have been having some conversations with a local surgeon about how much of surgery is really palliative in nature and not curative when you start looking at therapies with a much broader definition of palliative.

I would almost consider flipping what is the common understanding of what physicians do by saying we are mostly palliative and sometimes curative. (Of course there are many arguments as to why this is not completely true). I think we as doctors do not give our selves enough credit for palliation as an achievable goal of medicine in general.

I agree heartily with your statement and paragraph beginning with "It's imperative both to lead and to follow." For those who trumpet autonomy and deride paternalism, they fail to realize there are times when both are needed and surely times when the two are used exclusively of the other. Therein lies the art of communication in medicine.

I just interviewed a surgeon who authored a book (Final Exam) on mortality in surgery (in fact I posted it this morning). She focuses more on dealing with death in dying and not so much on the issue of palliative surgery in her book. Although she did inform me that the ACS (with Jeff Dunn, I think) is starting to focus on palliative surgery and surgeons can now become board certified in palliative medicine.

For others interested in this book or interview you can see them at Pallimed.

I would offer to interview you on Pallimed Sid, but you have such great writing over here, I usually just direct people here!

If you ever get a chance to discuss how mortality rates and statistics may influence surgeons, I would love to hear your thoughts on that.

Anonymous said...

After eight years of metastasized non-Hodgkins, diagnosed on her 40th birthday, my sister-in-law had palliative surgery, with the result that she managed to live long enough to see her son get married to a girl she adored too. To her and each one of us, that surgery was worth every extra day.

rlbates said...

Dr. Sid, once again you have written beautifully on a difficult subject. I would only echo both the previous comments.

Sid Schwab said...

Dr Sinclair: I read her book, too, and did a review of it for Medscape. It's there, somewhere. I disagreed in some places, particularly her emphasis on doctors' own fear of death preventing relating to the dying.

The subject of mortality statistics affecting surgeons is a good one: I think I've written a little about it, tangentially; but it deserves a post of its own. I did a series on death a while back,


here, and


Amy said...

A very thought provoking post. You gave me a fascinating look into the mind of a surgeon on this topic, and material for my own blog as well. I can only hope that should I ever need more surgery, my surgeon will be as thoughtful as you.

Anonymous said...

Surgeons may wish to come riding in on their white horses over the rough ground, but the best ones dismount and walk beside their horses so that they can look directly into the eyes and hearts of their patients, can hold their hands, and can guide them over the hurdles.

You are one of the rare ones, Dr. Schwab. Thanks for walking that most difficult walk so gracefully and sensitively. :^)

DDx:dx said...

I am just finishing Jay Katz' book from the 1980's "The Silent World of Doctor and Patient". He speaks to the difficulty of informed consent when doctors can't really listen because of the role we are in...Patients put us in, the history of the profession has come to, the training...To truly listen to the patient, their fears, needs, desires, is only possible when we (physicians) are at peace with our own. Alot to ask of non seminary professionals...But still, we do claim a powerful position.
Nice post.
I believe "palliation" (=) comfort is a very noble goal. It just needs to be shared, accepted, understood. "Cure" is the one I am suspicious of....Sounds too much like over promising...

Doctor David said...

Great post, Sid. The line I liked the best is this: "It's not about 'what can I do.' It's about 'what ought I do.' " You're so right. So many times, there are things we can do... but those things may not be the right thing to do. Sometimes "the right thing to do" is nothing... and that can be SO hard for a physician. Even for us pediatrics/medicine types.

Jeffrey Parks MD FACS said...

As per Dr David. The best surgeons will know when NOT to operate, but it's not so easy in every case. Nicely written post.

Anonymous said...

This topic is so fluid, and can and has changed so much. I feel (hope?) that most of my undergrad classmates who went on to med school went there not with the idea of fighting death, but fighting illness. I think there's a big difference, and that for a long time human medicine was more focused on the former rather than the latter.

This is becoming a huge issue even in the veterinary medical field, ironically in the opposite direction. Euthanasia used to be the clearly "right" choice in many situations where now a pet owner may feel pressured to spend the many thousands of dollars on surgical, medical, or (God help us) even CAM care for their animal. I feel very strongly that many people are condemning their animals to a long and painful bout of suffering before inevitable death. I'm all about informed and reasoned consent, (obviously within reason in vet med). An animal is incapable of telling you that they understand that they next few months will be painful, but they want to do everything they can to prolong the time they have left with their family. All they know is that they're in pain. We as veterinarians are clearly not treating our patients, but their owners. It's one of the many reasons I'm not going into small animal practice. I find it very hard to stomach someone coming in for chemotherapy to treat the lymphoma in their 16 year old Boston terrier with congestive heart failure, chronic renal failure, hepatic insufficiency, etc.

Sid Schwab said...

2nd year vet: thanks for another perspective. It's a good example of a dynamic that's not unique to your field.

SeaSpray said...

No one writes like you Dr S. you are obviously such a wonderful doctor and I think these posts do much to enlighten others pursuing surgery.

You would also be an amazing instructor imparting not only the physical techniques but also the emotional perspectives and ethics of the profession.

I couldn't help thinking about our aunt still wrestling with cancer. She has been valiantly fighting it for 19 months now. it is no longer in her breast,groin or neck but still in the liver. it's not better and not worse and they were going to give her a break but she was slurring her words and not feeling right and they found that she has lesions on her brain. So they immediately started her on chemo for that and she started feeling better in a couple of days.

But she is still so weak and thin but with a great attitude and smile. i am amazed at how they keep coming up with something new and tell her they still have other things they can do.

I have a question but I don't want to give power to the words. Besides I think I know the answer anyway.

Anonymous said...

Wonderful post Sid.

As our residents mature and enter their later years in training I occasionally witness the emergence of a resident I know will be destined to be a "master" surgeon. They may not have the best hands of the bunch, but they certainly have the talents to accomplish what needs to be done. What I feel sets them apart as the masters is the fact that they begin to wonder who we should not operate on and begin to question us openly about the cases that they once would have dove right on into without thinking twice. They start to understand that a person has placed themselves in our hands to improve their quality of life and they start to understand the importance of the paternalistic side of medicine so many of us shy away from or deride.


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