No heroic measures

The page came around 2 a.m. It had been a very busy night, with a dozen or so surgical consults from an overflowing emergency department in a large urban hospital. Most of the patients referred to the surgical service were immigrants with a limited knowledge of English. Most were elderly. And most were alone.

I was 2 months out of medical school, on call without a senior resident and with staff backup at home. I struggled to remain awake while catering to the seemingly endless pages from the ward and the emergency department. It was a rite of passage that every intern has had to endure.

The patient was an 85-year-old Cantonese-speaking woman transferred to the emergency department by ambulance from her nursing home. The accompanying note, mostly illegible, suggested that she had been complaining of abdominal pain and distention for the past 2 days and had been initially managed with laxatives.

That afternoon, however, her level of consciousness began to deteriorate and she became febrile and hypotensive, so she was transferred to our hospital. She had a history of atrial fibrillation, hypertension, and advanced Alzheimer’s dementia. She also had an accompanying "Do Not Resuscitate/No Life Support" form.

A CT scan of the abdomen arranged by the emergency department physician identified a clot in the superior mesenteric artery and extensive ischemic changes in most of her small bowel. She had a high white blood cell count, and her serum lactate was alarmingly elevated, despite several boluses of intravenous crystalloid solution. She was also becoming hemodynamically unstable.

I immediately called the staff surgeon to advocate for an emergency laparotomy. Given the patient’s multiple comorbidities and grim prognosis, we decided not to operate. The staff surgeon’s instructions were as abrupt as they were clear: "Turf her to medicine; she’s palliative."

The medical senior resident, however, would have none of it. Equally overwhelmed with consults and not in a particularly good mood, he refused to even see the patient. If she was expected to die overnight because of a surgical issue, he argued, then the surgery team was just as equipped as he to take care of her. The emergency department physician agreed, and so the patient was admitted to the surgical service for her few remaining hours of life.

What followed was agonizing for the entire surgical team. The nurses on the ward were asking some very reasonable questions that I could not answer: Do we keep titrating the patient’s oxygen to keep up with her desaturation? What do we give her for pain control? How do we manage her shortness of breath? Should we continue giving her intravenous fluids? Can you help us find her family members? Should we keep the bladder catheter in place?

I strained to remember what we had learned in our few palliative care lectures back in medical school. Intravenous fluids were OK, but oxygen was not. Or was it the other way around? Google, the ever-faithful guardian of the panicking intern, was unhelpful. I could not find a reputable online resource to help guide the management of this patient and, given the other sick patients who needed attention, I could not sit down to perform a thorough online literature search. The hospital’s switchboard was equally disappointing – there were no palliative care physicians on call, and the palliative team only accepted pages after 8 a.m., an appalling 5 hours away.

Eventually, I decided to support the patient with an oxygen mask and to continue her intravenous fluid resuscitation. I gave her plenty of narcotics and antiemetics to soothe the discomfort. We were unable to reach any family members despite several attempts. She died just after 5 a.m., without any visible signs of discomfort. It was the first death certificate I had ever signed.

Reflecting on this experience, I was upset at my inability to quickly and adequately care for this patient’s end-of-life needs. I was also angry that I had not prepared myself appropriately for that night on call, and I would have done several things differently had I had the chance.

General surgeons take immense pride in being internists who can operate. We enjoy debating antibiotic, diuretics, and anticoagulation choices with the specialists consulting on our patients, but we often simply "switch off" whenever the patient is labeled "palliative" or "end of life" – relying entirely on the palliative care team for help. And yet, we’re the ones who admit, operate on, and develop therapeutic relationships with those patients and their families. It just doesn’t seem right, but there are several reasons for this dilemma.

First, the fast pace and busy nature of any surgical service means that trainees and staff are under a lot of pressure to round as quickly and efficiently as possible and get to the operating room early in the morning. Given current trainee work-hour limitations and mandated hand-over, today’s junior staff feel this pressure all the more acutely. There simply isn’t enough time or opportunity for continuity of care. Surgical teams can’t engage palliative patients and their families in the way that dedicated palliative care teams can, and so surgical teams are often more comfortable delegating this responsibility entirely to their palliative care colleagues.

Second, there is an emotional burden to caring for palliative patients and their families. Palliation and end-of-life care imply that surgery is neither possible nor advisable any longer. It can be difficult for the surgeon to make that mental segue and assume the dual role of the psychological and medical care giver. Just as surgeons prefer that cardiologists manage their patients’ arrhythmias and nephrologists their patients’ kidney failures, they may prefer that palliative care specialists manage the emotional and medical needs of the patients on whom they can no longer operate.

Furthermore, surgical trainees have limited exposure to palliative care in the clinical setting. As the field of surgery becomes progressively more complex, palliative care training has not been at the forefront of the educational agenda. While it is taught in medical schools and in the surgical residency curriculum, there are few formalized core rotations that offer the surgical resident an insight into the clinical applications of palliative care, except for those who are particularly interested and seek such learning opportunities out in the form of an elective rotation.

The development of dedicated and multidisciplinary palliative care teams that include staff, nurse practitioners, and palliative fellows has further limited surgical resident exposure to the field. Simply put, the current medical system encourages surgical trainees to sign off on the surgical palliative patient.

This, however, isn’t good enough. Palliative care of the surgical patient needs to be a pillar of surgical training. Trainees need to be as comfortable with managing the symptoms of the dying surgical patient as they are administering fluid boluses and ordering narcotics for postoperative pain, especially late at night when there is no palliative care support.

The American College of Surgeons has responded to this challenge by developing numerous educational initiatives through its Palliative Workgroup. It has published a comprehensive surgical palliative care self-study guide specifically for residents (Surgical Palliative Care: A Residents Guide, available for free download).

There are also several regularly updated online palliative care references available either through subscription websites such as UpToDate or for free, such as the Medical College of Wisconsin’s End of Life/Palliative Education Resource Center, which offers "Fast Facts" on the management of the dying patient.

Palliative care is widely accepted today as an important clinical discipline that provides vital support to a growing proportion of the patient population. Surgical training must keep pace with this evolving reality because, at the end of the day, to be without agony and discomfort is a standard of care that every dying patient expects – not just a heroic measure that we can simply ignore.

Dr. Kayssi is a PGY IV in the general surgery program at the University of Toronto.

Dr. Easson is an ACS Fellow and assistant professor in the department of surgery and the Institute of Health, Policy, Management and Evaluation at the University of Toronto.

The page came around 2 a.m. It had been a very busy night, with a dozen or so surgical consults from an overflowing emergency department in a large urban hospital. Most of the patients referred to the surgical service were immigrants with a limited knowledge of English. Most were elderly. And most were alone.

I was 2 months out of medical school, on call without a senior resident and with staff backup at home. I struggled to remain awake while catering to the seemingly endless pages from the ward and the emergency department. It was a rite of passage that every intern has had to endure.

The patient was an 85-year-old Cantonese-speaking woman transferred to the emergency department by ambulance from her nursing home. The accompanying note, mostly illegible, suggested that she had been complaining of abdominal pain and distention for the past 2 days and had been initially managed with laxatives.

That afternoon, however, her level of consciousness began to deteriorate and she became febrile and hypotensive, so she was transferred to our hospital. She had a history of atrial fibrillation, hypertension, and advanced Alzheimer’s dementia. She also had an accompanying "Do Not Resuscitate/No Life Support" form.

A CT scan of the abdomen arranged by the emergency department physician identified a clot in the superior mesenteric artery and extensive ischemic changes in most of her small bowel. She had a high white blood cell count, and her serum lactate was alarmingly elevated, despite several boluses of intravenous crystalloid solution. She was also becoming hemodynamically unstable.

I immediately called the staff surgeon to advocate for an emergency laparotomy. Given the patient’s multiple comorbidities and grim prognosis, we decided not to operate. The staff surgeon’s instructions were as abrupt as they were clear: "Turf her to medicine; she’s palliative."

The medical senior resident, however, would have none of it. Equally overwhelmed with consults and not in a particularly good mood, he refused to even see the patient. If she was expected to die overnight because of a surgical issue, he argued, then the surgery team was just as equipped as he to take care of her. The emergency department physician agreed, and so the patient was admitted to the surgical service for her few remaining hours of life.

What followed was agonizing for the entire surgical team. The nurses on the ward were asking some very reasonable questions that I could not answer: Do we keep titrating the patient’s oxygen to keep up with her desaturation? What do we give her for pain control? How do we manage her shortness of breath? Should we continue giving her intravenous fluids? Can you help us find her family members? Should we keep the bladder catheter in place?

I strained to remember what we had learned in our few palliative care lectures back in medical school. Intravenous fluids were OK, but oxygen was not. Or was it the other way around? Google, the ever-faithful guardian of the panicking intern, was unhelpful. I could not find a reputable online resource to help guide the management of this patient and, given the other sick patients who needed attention, I could not sit down to perform a thorough online literature search. The hospital’s switchboard was equally disappointing – there were no palliative care physicians on call, and the palliative team only accepted pages after 8 a.m., an appalling 5 hours away.

Eventually, I decided to support the patient with an oxygen mask and to continue her intravenous fluid resuscitation. I gave her plenty of narcotics and antiemetics to soothe the discomfort. We were unable to reach any family members despite several attempts. She died just after 5 a.m., without any visible signs of discomfort. It was the first death certificate I had ever signed.

Reflecting on this experience, I was upset at my inability to quickly and adequately care for this patient’s end-of-life needs. I was also angry that I had not prepared myself appropriately for that night on call, and I would have done several things differently had I had the chance.

General surgeons take immense pride in being internists who can operate. We enjoy debating antibiotic, diuretics, and anticoagulation choices with the specialists consulting on our patients, but we often simply "switch off" whenever the patient is labeled "palliative" or "end of life" – relying entirely on the palliative care team for help. And yet, we’re the ones who admit, operate on, and develop therapeutic relationships with those patients and their families. It just doesn’t seem right, but there are several reasons for this dilemma.

First, the fast pace and busy nature of any surgical service means that trainees and staff are under a lot of pressure to round as quickly and efficiently as possible and get to the operating room early in the morning. Given current trainee work-hour limitations and mandated hand-over, today’s junior staff feel this pressure all the more acutely. There simply isn’t enough time or opportunity for continuity of care. Surgical teams can’t engage palliative patients and their families in the way that dedicated palliative care teams can, and so surgical teams are often more comfortable delegating this responsibility entirely to their palliative care colleagues.

Second, there is an emotional burden to caring for palliative patients and their families. Palliation and end-of-life care imply that surgery is neither possible nor advisable any longer. It can be difficult for the surgeon to make that mental segue and assume the dual role of the psychological and medical care giver. Just as surgeons prefer that cardiologists manage their patients’ arrhythmias and nephrologists their patients’ kidney failures, they may prefer that palliative care specialists manage the emotional and medical needs of the patients on whom they can no longer operate.

Furthermore, surgical trainees have limited exposure to palliative care in the clinical setting. As the field of surgery becomes progressively more complex, palliative care training has not been at the forefront of the educational agenda. While it is taught in medical schools and in the surgical residency curriculum, there are few formalized core rotations that offer the surgical resident an insight into the clinical applications of palliative care, except for those who are particularly interested and seek such learning opportunities out in the form of an elective rotation.

The development of dedicated and multidisciplinary palliative care teams that include staff, nurse practitioners, and palliative fellows has further limited surgical resident exposure to the field. Simply put, the current medical system encourages surgical trainees to sign off on the surgical palliative patient.

This, however, isn’t good enough. Palliative care of the surgical patient needs to be a pillar of surgical training. Trainees need to be as comfortable with managing the symptoms of the dying surgical patient as they are administering fluid boluses and ordering narcotics for postoperative pain, especially late at night when there is no palliative care support.

The American College of Surgeons has responded to this challenge by developing numerous educational initiatives through its Palliative Workgroup. It has published a comprehensive surgical palliative care self-study guide specifically for residents (Surgical Palliative Care: A Residents Guide, available for free download).

There are also several regularly updated online palliative care references available either through subscription websites such as UpToDate or for free, such as the Medical College of Wisconsin’s End of Life/Palliative Education Resource Center, which offers "Fast Facts" on the management of the dying patient.

Palliative care is widely accepted today as an important clinical discipline that provides vital support to a growing proportion of the patient population. Surgical training must keep pace with this evolving reality because, at the end of the day, to be without agony and discomfort is a standard of care that every dying patient expects – not just a heroic measure that we can simply ignore.

Dr. Kayssi is a PGY IV in the general surgery program at the University of Toronto.

Dr. Easson is an ACS Fellow and assistant professor in the department of surgery and the Institute of Health, Policy, Management and Evaluation at the University of Toronto.

The page came around 2 a.m. It had been a very busy night, with a dozen or so surgical consults from an overflowing emergency department in a large urban hospital. Most of the patients referred to the surgical service were immigrants with a limited knowledge of English. Most were elderly. And most were alone.

I was 2 months out of medical school, on call without a senior resident and with staff backup at home. I struggled to remain awake while catering to the seemingly endless pages from the ward and the emergency department. It was a rite of passage that every intern has had to endure.

The patient was an 85-year-old Cantonese-speaking woman transferred to the emergency department by ambulance from her nursing home. The accompanying note, mostly illegible, suggested that she had been complaining of abdominal pain and distention for the past 2 days and had been initially managed with laxatives.

That afternoon, however, her level of consciousness began to deteriorate and she became febrile and hypotensive, so she was transferred to our hospital. She had a history of atrial fibrillation, hypertension, and advanced Alzheimer’s dementia. She also had an accompanying "Do Not Resuscitate/No Life Support" form.

A CT scan of the abdomen arranged by the emergency department physician identified a clot in the superior mesenteric artery and extensive ischemic changes in most of her small bowel. She had a high white blood cell count, and her serum lactate was alarmingly elevated, despite several boluses of intravenous crystalloid solution. She was also becoming hemodynamically unstable.

I immediately called the staff surgeon to advocate for an emergency laparotomy. Given the patient’s multiple comorbidities and grim prognosis, we decided not to operate. The staff surgeon’s instructions were as abrupt as they were clear: "Turf her to medicine; she’s palliative."

The medical senior resident, however, would have none of it. Equally overwhelmed with consults and not in a particularly good mood, he refused to even see the patient. If she was expected to die overnight because of a surgical issue, he argued, then the surgery team was just as equipped as he to take care of her. The emergency department physician agreed, and so the patient was admitted to the surgical service for her few remaining hours of life.

What followed was agonizing for the entire surgical team. The nurses on the ward were asking some very reasonable questions that I could not answer: Do we keep titrating the patient’s oxygen to keep up with her desaturation? What do we give her for pain control? How do we manage her shortness of breath? Should we continue giving her intravenous fluids? Can you help us find her family members? Should we keep the bladder catheter in place?

I strained to remember what we had learned in our few palliative care lectures back in medical school. Intravenous fluids were OK, but oxygen was not. Or was it the other way around? Google, the ever-faithful guardian of the panicking intern, was unhelpful. I could not find a reputable online resource to help guide the management of this patient and, given the other sick patients who needed attention, I could not sit down to perform a thorough online literature search. The hospital’s switchboard was equally disappointing – there were no palliative care physicians on call, and the palliative team only accepted pages after 8 a.m., an appalling 5 hours away.

Eventually, I decided to support the patient with an oxygen mask and to continue her intravenous fluid resuscitation. I gave her plenty of narcotics and antiemetics to soothe the discomfort. We were unable to reach any family members despite several attempts. She died just after 5 a.m., without any visible signs of discomfort. It was the first death certificate I had ever signed.

Reflecting on this experience, I was upset at my inability to quickly and adequately care for this patient’s end-of-life needs. I was also angry that I had not prepared myself appropriately for that night on call, and I would have done several things differently had I had the chance.

General surgeons take immense pride in being internists who can operate. We enjoy debating antibiotic, diuretics, and anticoagulation choices with the specialists consulting on our patients, but we often simply "switch off" whenever the patient is labeled "palliative" or "end of life" – relying entirely on the palliative care team for help. And yet, we’re the ones who admit, operate on, and develop therapeutic relationships with those patients and their families. It just doesn’t seem right, but there are several reasons for this dilemma.

First, the fast pace and busy nature of any surgical service means that trainees and staff are under a lot of pressure to round as quickly and efficiently as possible and get to the operating room early in the morning. Given current trainee work-hour limitations and mandated hand-over, today’s junior staff feel this pressure all the more acutely. There simply isn’t enough time or opportunity for continuity of care. Surgical teams can’t engage palliative patients and their families in the way that dedicated palliative care teams can, and so surgical teams are often more comfortable delegating this responsibility entirely to their palliative care colleagues.

Second, there is an emotional burden to caring for palliative patients and their families. Palliation and end-of-life care imply that surgery is neither possible nor advisable any longer. It can be difficult for the surgeon to make that mental segue and assume the dual role of the psychological and medical care giver. Just as surgeons prefer that cardiologists manage their patients’ arrhythmias and nephrologists their patients’ kidney failures, they may prefer that palliative care specialists manage the emotional and medical needs of the patients on whom they can no longer operate.

Furthermore, surgical trainees have limited exposure to palliative care in the clinical setting. As the field of surgery becomes progressively more complex, palliative care training has not been at the forefront of the educational agenda. While it is taught in medical schools and in the surgical residency curriculum, there are few formalized core rotations that offer the surgical resident an insight into the clinical applications of palliative care, except for those who are particularly interested and seek such learning opportunities out in the form of an elective rotation.

The development of dedicated and multidisciplinary palliative care teams that include staff, nurse practitioners, and palliative fellows has further limited surgical resident exposure to the field. Simply put, the current medical system encourages surgical trainees to sign off on the surgical palliative patient.

This, however, isn’t good enough. Palliative care of the surgical patient needs to be a pillar of surgical training. Trainees need to be as comfortable with managing the symptoms of the dying surgical patient as they are administering fluid boluses and ordering narcotics for postoperative pain, especially late at night when there is no palliative care support.

The American College of Surgeons has responded to this challenge by developing numerous educational initiatives through its Palliative Workgroup. It has published a comprehensive surgical palliative care self-study guide specifically for residents (Surgical Palliative Care: A Residents Guide, available for free download).

There are also several regularly updated online palliative care references available either through subscription websites such as UpToDate or for free, such as the Medical College of Wisconsin’s End of Life/Palliative Education Resource Center, which offers "Fast Facts" on the management of the dying patient.

Palliative care is widely accepted today as an important clinical discipline that provides vital support to a growing proportion of the patient population. Surgical training must keep pace with this evolving reality because, at the end of the day, to be without agony and discomfort is a standard of care that every dying patient expects – not just a heroic measure that we can simply ignore.

Dr. Kayssi is a PGY IV in the general surgery program at the University of Toronto.

Dr. Easson is an ACS Fellow and assistant professor in the department of surgery and the Institute of Health, Policy, Management and Evaluation at the University of Toronto.