Palliative Philosophy, History, and Definitions

Much of medical care reflects the widespread expectation of the curative model of disease. According to this model, the goal of medicine is to cure disease, where “cure” is understood as “the eradication of the cause of an illness or disease [or] the … interruption and reversal of the natural history of the disorder”. Patients commonly assume this model when they seek the assistance of a physician. Many physicians, in fact, believe that cure should be the primary goal of all medical or surgical interventions. As appealing as such an approach may seem initially, the curative model pushes physicians to focus on the disease rather than on the patient. The disease focus emphasizes analytic and rationalistic thinking that favors objective facts and empirical knowledge over subjective issues. Such an approach to medical care suggests that physicians have little to offer when cure is not possible. As such, the curative model provides an unacceptably narrow conception of medical and surgical care.

In contrast to the curative model, the palliative model focuses far more on the patient than on the disease or illness itself. The palliative model aims to control symptoms, relieve suffering, and reestablish functional capacity. All these goals are directly related to how the patient experiences the illness. As such, the patient and his or her circle of family and immediate community become central to the palliative model of medicine, and subjective assessments by patients are of critical importance. Although the strict dichotomy between the curative model and the palliative model is somewhat artificial, these opposing approaches emphasize different aspects of the interaction between physician and patient.

Because it stresses the patient’s experience of illness and disease, the palliative model provides a better conceptualization of the central tenets of the surgeon–patient relationship. Every surgical intervention is grounded in an analysis of the risks and benefits of the operation for the particular patient. There can be no meaningful general discussion of the risks and benefits of an operation with a patient. For such a discussion to be meaningful, the surgeon must help patients consider the individual risks and benefits of the particular operation for themselves. The analysis of risks and benefits of an operation are necessarily specific to a particular patient. In fact, one cannot really understand benefits without a particular patient to define what will be of benefit to him or to her. For these reasons, the palliative model is more closely associated with the relationship between surgeons and patients, even though much of surgical thinking about intervention is still currently focused on cure.

Palliative surgery is a topic of recent interest, but in historical context it is the presumption of curative surgery that is recent. Although many surgeons consider cure the usual goal of most operations, this development is recent. Before the last century and a half, illness and disease expressed themselves through signs and symptoms. There was no basis for conceptualizing a disease apart from the symptoms that it caused a patient. As such, surgery was firmly grounded on procedures that were thought to alleviate symptoms. Bloodletting, cauterization, amputations, and extractions of bladder stones are all examples of common surgical procedures from ages past. None of these procedures are curative, yet at one time they were thought to help in the alleviation of symptoms.

Surgery frequently continues to be directed at palliation rather than at cure. In recent decades, the explosion of cardiac surgery to treat coronary artery disease is certainly palliative surgery. Patients with angina are operated on to diminish or eliminate the symptoms of coronary artery disease. Coronary artery bypass grafts are not curative operations. This procedure does nothing to alter the disease process of atherosclerotic narrowing of the coronary vessels, and there is little or no effect on longevity, but quality of life is much improved. The status of peripheral vascular surgery is similar in that the operations seek to find alternate routes around blocked or narrowed arteries. These surgical procedures are designed to be palliative, but they are never curative.

In transplant surgery, for example, the replacement of a failed kidney with a new donor kidney does not cure the underlying cause of the renal failure. The new kidney may be seen as a cure for end-stage renal disease; however, the operation does nothing to alter the disease process that led to the renal failure. Other common examples of palliative surgical procedures are the increasingly common laparoscopic fundoplication procedures to treat gastroesophageal reflux disease and the common bariatric surgical procedures for morbidly obese patients. Both operations aim to improve problematic symptoms and quality of life, and perhaps to palliate, but not to cure the underlying cause of illness.

All these examples should emphasize the fact that although surgeons may tend to think of their procedures as leading to cure, most surgical procedures over the last several hundred years were, at best, palliative. The focus on curative surgery is a phenomenon of the last few decades, even though many procedures still have a strong element or sole goal of palliation. In fact, cancer surgery provides one of the few examples in which an operation may help lead to a cure of a disease.

An important feature of defining palliative surgery as aiming to relieve symptoms is that it has implications for how success and failure are defined. Palliative surgery is directed at alleviating symptoms rather than curing disease. However, the term palliative surgery has had conflicting definitions in the past. The fundamental conflict lay in an understanding of what was being mitigated—disease or symptoms. Easson and colleagues suggest that palliative surgery in oncology has been defined in three distinct ways relative to the extent of resection possible:

• 1
  

  Surgery to relieve symptoms, with knowledge in advance that all the tumor cannot be removed

  
  
• 2
  

  Resection with microscopic or gross residual tumor left in situ at the end of the procedure

  
  
• 3
  

  Resection for recurrent or persistent disease after primary treatment failure

Miner has expanded the definition of palliative surgery for cancer to include quality of life considerations in addition to relief from burdensome symptoms: “a procedure used with the primary intention of improving quality of life or relieving symptoms caused by the advanced malignancy. The effectiveness of a palliative intervention should be judged by the presence and durability of patient-acknowledged symptom resolution”.

Based on this description, a failed curative operation will not necessarily become a palliative operation. A noncurative operation is not a palliative operation. In the realm of cancer surgery, one must be especially careful to distinguish a noncurative resection from an operation that has been designed and performed as a method of relieving the patient’s symptoms. Some procedures are both curative and palliative, others are neither curative nor palliative, and yet others are palliative but not curative. For example, if a patient has obstructing colon cancer and carcinomatosis, resection could certainly be palliative even though it is not curative. However, if a patient has a localized low rectal carcinoma that is resected but the margins are found to be positive, this procedure becomes part of a diagnostic process and possibly part of a treatment plan, but it is neither curative nor strictly palliative.

When considering whether to proceed with a palliative operation, the surgeon must carefully assess what symptoms the operation may be able to palliate. As with any surgical intervention, a careful assessment of risks and benefits to the patient must be undertaken. This consideration requires the surgeon to assess the patient’s symptoms and then, with the patient’s input, consider whether the symptoms can be alleviated by an operation. As a general rule, localized symptoms are more amenable to palliative surgical intervention than systemic symptoms. Patients are often more willing to accept higher risks of morbidity and mortality if the potential benefit is cure, but each individual case is different and requires that the surgeon and patient communicate about the risks and potential benefits of the procedure.

Patients must fully understand the goals of an operation before they consent to the procedure. If the goal is palliative resection of bleeding gastric carcinoma, the patient should not expect that curative resection will be the outcome. Sometimes if curative resection is not possible, a palliative operation will be performed. For example, in patients with obstructing jaundice from cancer of the head of the pancreas, most surgeons plan a palliative choledochojejunostomy if a potentially curative pancreaticoduodenectomy is not possible. In such a situation, it is important for the patient to understand the likelihood of a curative resection relative to the possible nonoperative means of alleviating symptoms.

It is also important for patients to understand the potential time frame for palliation. For example, it may be very significant for a patient to know that the alleviation of symptoms from an operation would be expected to last for a few weeks rather than for a few months. If a patient has a short life expectancy, then the longer hospital stay may offset the benefit of a palliative procedure. Similarly, the appeal to a patient of a palliative procedure may diminish if there is a high risk that the patient will not survive until discharge from the hospital.

These considerations demonstrate that it is essential for surgeons to understand the patient’s goals when any intervention is considered. To give recommendations about what procedure is best for a patient with a potentially incurable disease, the surgeon must first fully understand the patient’s goals so the benefits of the procedure can be suitably assessed. Pathologists, for instance, routinely evaluate the outcome of the procedure by the extent of residual cancer, but a palliative procedure can be deemed a success only relative to the patient’s goal for alleviation of symptoms.

The previously conflicting definitions of palliative surgery are indicative of the need for a comprehensive philosophy of surgical care that addresses the needs of the seriously and incurably ill beyond a repertoire of procedures. Palliative surgery is only a component of the armamentarium available to the surgeon working in the broad context of surgical palliative care. Surgical palliative care describes the appropriate context in which palliative surgery occurs. Not all patients with life-limiting illness who are under surgical care will undergo surgery, yet their needs with respect to relief of suffering and promotion of quality of life will require the unique expertise and experience of a surgeon. Surgical palliative care is defined as the treatment of suffering and the promotion of quality of life for seriously or terminally ill patients under surgical care.

Goals of Palliative Surgery

In determining whether a palliative operation should be performed, the surgeon and patient should consider how the procedure would benefit the patient. Many different procedures may be performed related to multiple different organ systems, yet the procedures can be broadly categorized as directed toward four general symptom-related goals: local control of disease; control of pain; control of other disturbing symptoms; and other goals related to the relief of suffering.

A mastectomy to remove a fungating breast carcinoma that is performed on a patient with distant metastases is an example of a palliative procedure directed solely at control of local disease symptoms. Although the operation will not cure the disease, it may alleviate major problems associated with the local extension of the tumor through the skin.

The well-proven benefits of celiac plexus block for unresectable pancreatic carcinoma illustrate how a palliative procedure can be directed specifically at alleviation of pain.

The broadest categories of palliative procedures are those directed at control or alleviation of disturbing symptoms other than pain. Procedures such as bypasses to relieve intestinal or vascular obstructions, tumor resections to control bleeding, and drainage of pleural effusions to alleviate dyspnea are all important palliative measures that are directed at alleviating diverse, specific symptoms.

Sometimes other goals are met by palliative procedures. For example, the placement of a feeding jejeunostomy tube may allow parenteral nutrition that could facilitate a patient’s discharge from the hospital.

Palliative Surgery by All Surgeons

The most recent American College of Surgeons (ACS) Statement of Principles of Palliative Care ( Box 31-1 ) is an important document that seeks to define the manner in which palliative care is integral to the comprehensive care of all surgical patients.

All surgical textbooks contain descriptions of the techniques utilized for these numerous palliative procedures. However, it is critical for the surgeon to apply those techniques in a manner that best benefits individual patients. To do so, the surgeon must think broadly of the impact that the procedure will have on the patient’s symptoms.

Because virtually any surgical intervention may be palliative for some patients, every surgeon must be fully competent in how to make decisions about palliative surgery. Unlike internal medicine, which has defined palliative care as a specialty, all surgeons must be able to apply the techniques of their particular anatomic area of expertise to the goal of palliation of patient’s symptoms. Although surgeons should consult appropriate palliative care specialists to aid in the treatment of their patients, every surgeon should be prepared to apply surgical techniques to palliate symptoms. Indeed, part of the skill of surgery is to make intraoperative decisions to allow the greatest relief of patients’ symptoms.