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Palliative surgical care

Caring for patients with progressive, incurable or terminal illness is part of the practice of most surgeons. Although surgery aims to cure patients with minimal morbidity and mortality, many patients present with incurable disease. The surgeon is then challenged to relieve symptoms and improve quality of life (QoL) – the essence of palliation. In the context of cancer treatment, palliative surgery has been considered as any resection where gross or microscopic tumour tissue is left behind after surgery, or where an operation is performed for persistent or recurrent disease after treatment failure. A clearer definition of palliative surgery has emerged, however, in parallel with principles established in non-surgical palliative care. Palliative surgery is defined as a surgical procedure used with the primary intention of improving QoL or relieving symptoms caused by advanced disease1. The effectiveness of palliative surgery is therefore judged by the presence and durability of patient-reported symptom resolution. In contrast, noncurative surgery comprises operations employed with curative intent that result in residual disease or positive margins1. Although indications for palliative surgical intervention to alleviate symptoms are usually obvious, many experienced surgeons encounter demanding situations in which assessment of the patient’s situation and extent of disease, along with type and timing of interventions, calls for careful clinical judgement. Patients, carers and families all have expectations that ‘something must be done’. Surgeons have to balance this against the risk of employing futile interventions, where the potential for harm outweighs benefit2–8. Ethical issues include a reliable forecast of possible positive effects of the suggested intervention, prediction of unintended side-effects, concerns with regard to informed consent and compliance with the proposed plan of action. All of these issues need to be part of the decision to recommend a palliative operation. A critical issue is careful communication with the patient and, where possible, carers and relatives, as well as other specialists and healthcare professionals involved in the team1,7. Technical requirements, skills and awareness by the surgical team employing a palliative procedure should be no different from those for surgery undertaken with curative intent. Procedure-related morbidity and mortality of palliative interventions must be low – consistent with the goals and definition of palliative surgery1. The literature on palliative surgery is hampered by numerous observational studies, often with small and heterogeneous study populations and ill defined endpoints. Validated QoL instruments have been employed only sporadically6 and traditional clinical endpoints may not be relevant to research in palliative care. Prospective randomized controlled trials (RCTs) remain the exception, mainly owing to unwarranted practical and ethical concerns7. There is no strong evidence base to answer many important clinical questions. Consequently, the practice of palliative surgery has been guided more by surgeons’ personal experience and institutional traditions rather than by scientific evidence. Recent results, however, from RCTs and systematic reviews have been able to clarify the value of some interventions, such as coeliac plexus block in patients with non-resectable pancreatic cancer9, management of solitary brain metastases10, palliation of gastric outlet obstruction11, and treatment of asymptomatic colorectal cancer and synchronous non-resectable colorectal metastases8. These studies indicate that well designed prospective studies can be done. They also confirm that it is possible to include patients from a heterogeneous palliative group into clinical research protocols. Wider appreciation of designing these types of study is needed. Most surgeons acknowledge the importance of good palliative care, although some may be less willing than others when it comes to their own personal involvement to provide it. Palliation for the surgical patient is often still regarded as the responsibility of a few fellow surgeons, or individuals from other specialties devoted to, or specifically educated, in the management of such patients. For the majority of surgeons, however, their professional duty should be to contribute to the care of these patients by taking responsibility within multidisciplinary teams and collaborating with other health professionals to deliver palliative care of a high standard12. Surgical training places much emphasis on treatments designed to cure. Less attention has been paid to how to care when cure is impossible, how to identify and respond to physical needs and emotional concerns, or