The importance of palliative care in surgery


Even as a child, I noticed that many people, especially my Depression-era grandmother, feared aging and the imminence of death. Death was no stranger to me growing up; I lost my then best friend, my Nano, and my uncle as a child, both traumatically. Yet, death was sad, but natural.

Because of this, I never understood our society’s stigma against dying, something that I’ve struggled with even in medical school. In an ideal world, we would all die at home with our loved ones caring for us, slowly slipping away in our sleep into the placid beyond, but why doesn’t it happen this way? There’s a dignity to that way because of its organic simplicity. It’s how people used to die prior to modern medicine, before we started needing to always “fix the problem.”

I never anticipated entering the field of surgery when I entered medical school, but everything about the tangible correction of problems, the medicine entailed in general surgery, and its procedural aspects excited me about the field. Yet, all of those things are focused on that goal of “fixing the problem,” which can be boiled down to resectability versus unresectability and doing everything we can to reach that moment of resectability or remission. Surgeons can prolong patients’ lives by examining whether they are surgical candidates.

On an away rotation during my fourth year of medical school, I was at an institution that was well practiced in working with patients with appendiceal mucinous neoplasms that have spread to the peritoneal abdominal cavity. These patients suffer from massive mucin production that accumulates in their bellies, causing them to be nauseous, be unable to eat, and eventually eviscerate from abdominal pressure. It is a horrible quality of life. One patient with this condition presented during my rotation; she was terminal and had eviscerated in two locations, requiring ostomy bags to collect the mucin, and was unable to eat. Her nutritional status was low, and by book standards, she was not a surgical candidate.

This patient did not necessarily fear death, but she wanted to ensure that she had as much time to spend with her family as possible. Yet, I watched her ooze mucin into ostomy bags, stuck in a hospital bed, and unable to eat, and I asked myself, what makes this woman not a surgical candidate? We were not trying to cure her, and she was not asking for that. She just wanted time, and that is something surgery could give her. It no longer became about resectability versus unresectability, remission versus recurrence, etc. This was about quality of life and maximizing time. At that moment, I told my attending we were going to the OR with her; this was a woman that deserved a meal at home with her family without pain and nausea.

I hope that in my future practice as a surgeon, I can stress to those around me the importance that palliative care plays for surgery. We need to have difficult conversations with patients, as a team, and to take their lives into the context of the clinical decision. This patient was not about “the cure” that we all train and strive for in this field. It was about dignity and comfort even in inevitable death. As physicians, we have to be open to seeing those needs as being just as important to our patients in their medical plight; otherwise, we are depriving them regardless. From a surgical colleague: Have the conversation and let’s work to change the stigma about dying.

Adrienne Bruce is a medical student.

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