In the past decade, defining a “good death” has become imperative in American health care. Once taboo, aggressive end-of-life care is now regarded as expensive, ineffective, and frequently neither concordant with patients’ goals nor in their best interests.1 Concurrent with this public discourse, palliative care—intervening to relieve suffering and support quality of life for seriously ill patients—is now an independent, growing specialty.2
Palliative intervention is defined by intention. Unlike other specialties, palliative care aims not to cure disease or to prolong life but to improve the quality of a patient’s remaining life. Palliative care in oncology and cardiology is well established, but appropriate palliative care can also be invasive and surgical. This issue of the AMA Journal of Ethics explores palliative surgery as any procedure for which symptom mitigation is the main goal, without causing premature death, in the care of patients with noncurable disease.3 Palliative surgery can include straightforward procedures (eg, placing a feeding tube to enable nutrition) and more complex interventions (eg, partial tumor removal to ease breathing). The stakes are high: in patients with limited life expectancy, complications can be devastating, and noncurative palliative procedures still pose great risk. Palliative surgery is complex and understudied and raises key clinical and ethical questions.
Studies in oncology have shown that most patients receiving palliative chemotherapy believe they are receiving curative treatment, even when educated to the contrary.4 So, we ask in this issue: Should a higher standard of informed consent be required for palliative surgery? When a patient consents to a palliative procedure, should consent be regarded as extending to care needed to remediate complications?5 According to which criteria should we assess whether and when it is just to spend limited resources on surgery that does not prolong life?6 Surgeons and patients routinely balance risks and benefits together, but when cure is not the goal, decisions and decision making change. These questions and ideas are the heart of this theme issue, which brings surgical palliation further into the light in hopes of guiding present and future difficult decisions about what end-of-life palliation means.
Institute of Medicine. Dying in America: Improving Quality and Honoring Individual Preferences Near the End of Life. National Academies Press; 2015.
Palliative care continues its annual growth trend, according to latest center to advance palliative care analysis. News release. Center to Advance Palliative Care™; February 28, 2018. Accessed November 30, 2020. https://www.capc.org/about/press-media/press-releases/2018-2-28/palliative-care-continues-its-annual-growth-trend-according-latest-center-advance-palliative-care-analysis/
- Hofmann B, Håheim LL, Søreide JA. Ethics of palliative surgery in patients with cancer. Br J Surg. 2005;92(7):802-809.
- Weeks JC, Catalano PJ, Cronin A, et al. Patients’ expectations about effects of chemotherapy for advanced cancer. N Engl J Med. 2012;367(17):1616-1625.
- Pecanac KE, Kehler JM, Brasel KJ, et al. It’s big surgery: preoperative expressions of risk, responsibility, and commitment to treatment after high-risk operations. Ann Surg. 2014;259(3):458-463.
Childers CP, Maggard-Gibbons M. Understanding costs of care in the operating room. JAMA Surg. 2018;153(4):e176233.