Clinical Challenges in Surgical Palliative Care: Non-Beneficial Surgery (and How to Avoid it) and Care of the Imminently Dying Patient

Welcome to the fifth of a six-part series focused on the integration of palliative care into the practice of surgery.   In this episode, we discuss nonbeneficial surgery (and how best to avoid it) as well as care of the imminently dying patient.

Nonbeneficial surgery is best defined as surgery that fails to meet the goals of the patient.   As our surgical patients become older and more medically complex, we must be aware of the factors which lead to nonbeneficial surgery – including patient, surrogate, system, and surgeon factors – and how best to approach each of these to avoid causing harm to our patients.  Nonbeneficial surgery not only causes harm to the patient, but can also cause harm to the surgical team, in the form of moral distress/injury.  Focusing on patients’ goals of care can help us to avoid nonbeneficial surgery.

One of the benefits of integrating palliative medicine into the practice of surgery is that there is never “nothing left to do.”  By learning how to recognize and then care for the imminently dying patient, as well as by having a basic understanding of the Medicare hospice benefit, we can support and care for the patient (and the family) beyond the operating room. 

Non-Beneficial Surgery:

Pitfalls in communication that lead to nonbeneficial emergency surgery in elderly patients with serious illness: description of the problem and elements of a solution.
https://pubmed.ncbi.nlm.nih.gov/24866541/

Surgeons’ perspectives on avoiding nonbeneficial treatments in seriously ill older patients with surgical emergencies: a qualitative study.
https://pubmed.ncbi.nlm.nih.gov/27105058/

The association between factors promoting beneficial surgery and moral distress: a national survey of surgeons.
https://pubmed.ncbi.nlm.nih.gov/33214444/

The Imminently Dying Patient and Hospice:

Fast Fact #3:  Syndrome of Imminent Death
https://www.mypcnow.org/fast-fact/syndrome-of-imminent-death/

Fast Fact #82:  Medicare Hospice Benefit – Part 1: Eligibility and Treatment
https://www.mypcnow.org/wp-content/uploads/2019/01/FF-82-Medicare-Hospice.-1-3rd-Ed-1.pdf

Fast Fact #87:  Medicare Hospice Benefit – Part 2: Places of Care and Funding 
https://www.mypcnow.org/wp-content/uploads/2019/01/FF-87-Medicare-Hospic-2-4th-Ed.pdf

Fast Fact #140:  Medicare Hospice Benefit – Levels of Hospice Care
https://www.mypcnow.org/fast-fact/medicare-hospice-benefits-levels-of-hospice-care/

Dr. Red Hoffman (@redmdnd) is an acute care surgeon and associate hospice medical director in Asheville, North Carolina, host of the Surgical Palliative Care Podcast (@surgpallcare) and co-founder of the recently launched Surgical Palliative Care Society (www.spcsociety.org). 

Dr. Zara Cooper (@zaracMD) is an acute care surgeon at Brigham and Women’s Hospital where she serves as Kessler Director for the Center of Surgery and Public Health (@csph_bwh).  She is a Professor of Surgery at Harvard Medical School, associate faculty at Adriane Labs, and adjunct faculty at the Marcus Institute for Aging Research.  

Dr. Amanda Stastny (@manda_plez) is a PGY-2 in the General Surgery program at Mountain Area Health Education Center (MAHEC) in Asheville, NC.

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