Although cure is always the hope, unfortunately some conditions are incurable, complications occur, and death is inevitable. The philosophy of palliative care provides patients with serious illness relief from suffering and the best quality of life possible at all stages of disease from diagnosis to end-of-life. Palliative care ideally is provided in conjunction with standard care whereas hospice is limited to patients in the final phases of a terminal illness with the focus on comfort, allowing a natural death to occur. For surgeons, caring for the seriously-ill patient is not uncommon. Surgical procedures are often conceived and performed not only with the intent to cure, but in many instances to alleviate suffering. Despite this integral aspect of surgical practice, significant differences exist in palliative care for surgical patients when compared to medical patients including decreased palliative care and hospice utilization, and greater inhospital and ICU death rates.1,2 As this variation in care becomes ever present in surgical patients, we sought to explore how palliative and end-of-life care is addressed in surgical education and training. As such, we propose potential approaches for improving the care surgeons deliver through interventions at the trainee level.
SUPPORT FOR PALLIATIVE AND END-OF-LIFE CARE FOR SURGICAL PATIENTS
In recent years, palliative and end-of-life care have become increasingly important topics in health care. Incorporating palliative care with traditional medical and surgical care has been shown to improve quality of life, reduce unwanted interventions, and improve health care costs.3 The need for improvement in the quality of care delivered to seriously-ill patients has been highlighted in the Institute of Medicine's report on “Dying in America” and supported by the Centers for Medicare and Medicaid Services, who recently announced reimbursement to physicians for advanced care planning discussions with patients. Moreover, the importance of palliative and end-of-life care for surgical patients has been recognized by the American College of Surgeons (ACS) and reflected in the “Statement of Principles Guiding Care at the End-of-Life” and the “Statement of Principles of Palliative Care,” which provide standards for care provided to seriously-ill patients and their families. Relief of suffering and improving quality of life are increasingly recognized as critical elements in the care of seriously-ill and dying patients. Yet it remains unclear whether young surgeons are being effectively trained to embrace these aspects of care.
SURGICAL EDUCATION AND TRAINING IN PALLIATIVE AND END-OF-LIFE CARE
Many physicians first encounter death early in the course of their training, either as medical student or junior resident. However, there is little if any guidance before these initial encounters. Some of these deficits in surgical education regarding end-of-life care have been explored in a survey of surgical residents. The results of the survey noted that although caring for a dying patient is sadly not uncommon, junior residents indicated limited involvement with their attending surgeons during conversations with dying patients. A quarter of surveyed residents felt unprepared to care for the terminal patient after residency, and the majority of the residents expressed openness to more formal teaching in this area.4 Interestingly, this lack of curricula and concern for being underprepared is seen in advanced training as well. A recent report on palliative care education in surgical oncology and hepatobiliary fellowships noted similar issues amongst fellows: lack of training, lack of feedback on their skills, and the need for formal instruction in the principles of palliative care.5 By not adequately teaching and honing these skills for trainees, we are observing a concerning deficit that is continuing into practice, as professional attitudes and behaviors are most often established during postgraduate education.6 Although this deficit may be alarming, when the current state of surgical training is evaluated it should not be surprising. Despite the increasing presence of palliative and end-of-life care topics in surgical texts, trainees may not have the opportunity to meaningfully apply these principles. In addition, although the number of publications on palliative surgery has improved, it remains a poorly represented topic in quality peer-reviewed manuscripts.
HOW CAN WE IMPROVE THE CARE OF SERIOUSLY-ILL AND DYING SURGICAL PATIENTS?
As demonstrated in the aforementioned studies and by our own experiences, surgical residents are inadequately prepared to care for patients at the end-of-life, and many would welcome further education. Although there is no substitute for on-the-job training, there is utility in structured teaching. Bradley et al7 were able to utilize their own expertise within palliative care and surgery to create a structured curriculum for junior residents including didactics, participation in moderated discussions, and an objective structured clinical examination simulating a family conference. The authors were able to demonstrate that junior residents achieved a knowledge level comparable with their senior residents who had not participated in the curriculum.7 Although junior residents did not achieve an equivalent level of comfort as their senior counterparts, the authors argue that early palliative care instruction may make clinical experiences in palliative care more meaningful and possibly more impactful.7 Incorporating a structured course such as that described above within an existing surgical curriculum offers an opportunity for didactic teaching as well as an opportunity to establish a solid foundation for expanding knowledge and skills in palliative and end-of-life care for years to follow.
Utilizing Available Resources
In addition to surgical texts containing information regarding palliative and end-of-life care for surgical patients, there are a growing number of resources available such as the ACS publication, Surgical Palliative Care: A Resident's Guide (https://www.facs.org/education/roles/residents), which demonstrates how the principles of palliative care can be applied within specific surgical contexts.8 This publication is available to all students, residents, and practicing surgeons. Additional texts specific to palliative care and surgical patients include Surgical Palliative Care (Oxford University Press, editors Dunn, Johnson, 2004) and Palliative Surgery (Springer, editors Wichmann, Matthias, Maddern, Guy, 2014).
Mentors in Surgery
The mentorship of senior surgeons is an invaluable component of surgical training. Many surgeons can draw upon the experience of caring for seriously-ill and dying patients to advise trainees. This mentorship may involve observation, guidance, and feedback during conversations with patients, difficult family meetings, and after a patient's death. These combined experiences serve to increase trainees’ comfort level and help to create a template for approaching the care of seriously-ill and dying patients.
Additional Training for Surgeons
Surgeons who wish to pursue dedicated, advanced training in palliative care have the opportunity to complete a fellowship within hospice and palliative medicine either after surgery residency (traditional sequence) or during the trainees’ academic or “lab” time. Both tracks offer opportunities for surgeons to gain expertise in palliative care and the ability to share their knowledge with their surgical colleagues. Although completing additional fellowship training adds a significant time commitment to an already extensive training period, other flexible programs exist for obtaining mentorship and instruction. The Harvard Medical School Center for Palliative Care offers an intensive Palliative Care Education and Practice course to further develop one's palliative care skills in addition to gaining expertise in leading and educating on the principles of palliative care. During the ACS Clinical Congress, a Palliative Surgical Care course is offered to surgeons to improve skills in conducting palliative surgical consultations and end-of-life conversations, and to learn and practice performing palliative procedures. VitalTalk is a nationally-recognized course designed to develop and improve advanced communication skills when discussing serious illness and end-of-life care. Finally, the American Academy of Hospice and Palliative Medicine has a wealth of on-line resources dedicated to palliative care education. Thus, although there may not be one optimal way to educate surgeons in palliative and end-of-life care, many opportunities and resources can be utilized to satisfy this training need.
Collaboration With Local Experts
Although each institution may not have an expert in palliative medicine and surgery, with only 69 individuals currently boarded in both areas, the majority of hospitals do have palliative medicine services. By connecting with palliative care experts locally, surgeons can collaborate and develop learning experiences for trainees.
For all, death is a certain outcome of life that even the best of clinicians cannot ultimately prevent. However, surgeons are privileged with both the insight to discuss therapeutic and palliative options with patients and their families, and the technical skills to pursue palliative interventions. Surgeons also have the opportunity to minimize suffering and help provide a “good” death by actively participating in challenging discussions, and learning and honing their skills in palliative and end-of-life care.
The current system for educating surgical trainees enjoys well-deserved acclaim for producing thoughtful and technically skilled individuals, but continues to inadequately prepare and train young surgeons to care for seriously-ill and dying patients. Accordingly, a dramatic change to structure palliative and end-of-life care into surgical training and the willingness of practicing surgeons to actively participate in this care are essential. A focus on trainees will yield a generation of surgeons empowered to shift the culture of surgery away from a cure-focused model toward a more patient-centered stance. The ultimate goal is to better equip all surgeons the skills to manage all stages of disease including care at the end-of-life.
The authors thank Justin B. Dimick and Ari C. Reichstein for their editorial input.
1. Olmsted CL, Johnson AM, Kaboli P, et al Use of palliative care and hospice among surgical and medical specialties in the Veterans Health Administration. JAMA Surg
2. Wallace SK, Waller DK, Tilley BC, et al Place of death among hospitalized patients with cancer at the end of life. J Palliat Med
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6. Cruess RL, Cruess SR, Boudreau JD, et al A schematic representation of the professional identity formation and socialization of medical students and residents: a guide for medical educators. Acad Med
7. Bradley CT, Webb TP, Schmitz CC, et al Structured teaching versus experiential learning of palliative care for surgical residents. Am J Surg