Surgical palliative care

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<ol><li> 1. Surgical Palliative Care SCOA01 03/29/2004 10:04 AM Page i </li><li> 2. Supportive Care Series Volumes in the series: Supportive care for the respiratory patient Edited by S.H. Ahmedzai and M. Muers Supportive care for the renal patient Edited by J. Chambers, M. Germain, and E. Brown SCOA01 03/29/2004 10:04 AM Page ii </li><li> 3. Surgical Palliative Care Edited by Geoffrey P. Dunn Attending Surgeon, Department of Surgery, Hamot Medical Center; Medical Director, Great Lakes Hospice, Erie, USA and Alan G. Johnson Emeritus Professor of Surgery, University of Sheffield, UK SCOA01 03/29/2004 10:04 AM Page iii </li><li> 4. Great Clarendon Street, Oxford OX2 6DP Oxford University Press is a department of the University of Oxford. It furthers the Universitys objective of excellence in research, scholarship, and education by publishing worldwide in Oxford New York Auckland Bangkok Buenos Aires Cape Town Chennai Dar es Salaam Delhi Hong Kong Istanbul Karachi Kolkata Kuala Lumpur Madrid Melbourne Mexico City Mumbai Nairobi So Paulo Shanghai Taipei Tokyo Toronto Oxford is a registered trade mark of Oxford University Press in the UK and in certain other countries Published in the United States by Oxford University Press Inc., New York Oxford University Press, 2004 The moral rights of the author have been asserted Database right Oxford University Press (maker) First published 2004 All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, without the prior permission in writing of Oxford University Press, or as expressly permitted by law, or under terms agreed with the appropriate reprographics rights organization. Enquiries concerning reproduction outside the scope of the above should be sent to the Rights Department, Oxford University Press, at the address above You must not circulate this book in any other binding or cover and you must impose this same condition on any acquirer British Library Cataloguing in Publication Data Data available ISBN 0-19-851000-4 10 9 8 7 6 5 4 3 2 1 Typeset by Integra Software Services Pvt., Ltd, Pondicherry, India Printed in Great Britain on acid-free paper by Biddles Ltd., Kings Lynn, UK SCOA01 03/29/2004 10:04 AM Page iv </li><li> 5. Foreword ix John L. Cameron List of contributors xi Part I 1 Introduction: is surgical palliative care a paradox? 3 Geoffrey P. Dunn 2 Selection and preparation of patients for surgical palliation 16 Alexander Ng and Alexandra M. Easson 3 The ethics of interventional care 33 Peter Angelos 4 The physiological response to surgical trauma 39 Matthew D. Barber and Kenneth C.H. Fearon 5 Psychological response to surgery 54 Laurie Stevens 6 Spirituality and surgery 65 Peter Ravenscroft and Elizabeth Ravenscroft 7 Interdisciplinary care 85 Anne Mosenthal, David Price, and Patricia Murphy 8 Quality of life issues in palliative surgery 94 Michael Koller, Christoph Nies, and Wilfried Lorenz 9 Anaesthesia and perioperative pain management 112 Karen H. Simpson and Dudley J. Bush Part II 10 Symptom palliation of diseases of the head and neck (including dentistry) 135 Simon Rogers 11 The surgical relief of the symptomatic chest 152 Bill Nelems 12 Surgery for the control of symptoms in the abdomen 159 Alan G. Johnson 13 Symptom control in urological malignancy 173 Alan P. Doherty and Joe M. OSullivan 14 Wound and reconstructive problems in advanced disease 191 Thomas J. Krizek Contents SCOA01 03/29/2004 10:04 AM Page v </li><li> 6. 15 Neurosurgical palliation 207 Dennis L. Johnson 16 The role of the ophthalmologist in advanced disease 227 David Yorston 17 Perspectives from the developing world and diverse societies 239 Arjuna Aluwihare 18 Epilogue: a message to all surgeons 248 Geoffrey P. Dunn and Alan G. Johnson Index 261 CONTENTSvi SCOA01 03/29/2004 10:04 AM Page vi </li><li> 7. SCOA01 03/29/2004 10:04 AM Page vii This page intentionally left blank </li><li> 8. Oxford University Press makes no representation, express or implied, that the drug dosages in this book are correct. Readers must therefore always check the product information and clinical procedures with the most up to date published product information and data sheets provided by the manufacturers and the most recent codes of conduct and safety regulations. The authors and the publishers do not accept responsibility or legal liability for any errors in the text or for the misuse or misapplication of material in this work. SCOA01 03/29/2004 10:04 AM Page viii </li><li> 9. From its earliest beginnings, much of surgery has been aimed at palliation. Initially, most early attempts were to relieve pain or stop bleeding. As surgical techniques became more sophisti- cated, particularly after the introduction of general anaesthesia in 1846, palliation of obstruc- tion also became a common indication for surgery. Today much of surgery can be considered palliative. For example, when a patient with incurable adenocarcinoma of the pancreas presents with obstructive jaundice, obstruction of the duodenum, and severe back pain, the ensuing surgical procedure is obviously palliative. One would perform a hepatico-jejunostomy to relieve the jaundice, a gastrojejunostomy to bypass the obstruction, and a chemical splanch- nicecetomy to palliate the pain. However, even patients who present with potentially curable adenocarcinoma of the pancreas, in many ways are merely being palliated. When one performs a pancreaticoduodenectomy in such a patient, one is aware that 20% will survive 5 years, but the remaining 80% will not. Therefore the pancreaticoduodenectomy in the majority of patients upon whom it is performed, could be called a palliative procedure. It relieves biliary and duodenal obstruction as well as pain. Therefore surgical palliation is certainly not a new field. What is new, however, is the empha- sis that is being placed on the palliative role of the surgeon and the palliative function of the surgical procedures that are performed. Now, in many parts of the world a major emphasis is being placed on the importance of appropriate and humane surgical palliative care. This book that Geoffrey Dunn and Alan Johnson have so beautifully edited consists of a series of chapters by contributors from around the world. The first section explains the philosophy and ration- ale as well as the history of palliative care, with the second part providing a series of surgical examples based on the different anatomical regions of the body. For too long surgeons have been considered non-caring technicians, interested only in the surgical procedure itself, and the immediate outcome. This book emphasizes that the surgeon has a much broader role in being certain that all of the bothersome and disabling symptoms that the patient has are appropriately addressed. Today we have excellent quality of life tools with which to measure our surgical results. This has allowed surgical palliation to be quantita- tive, and we are now better able to evaluate our success in our attempts at surgical palliation. Hopefully this book will be read not only by surgeons, but also by non-surgeons participating in the care of patients who require some form of palliation. Surgeons need to be fully aware of the importance of surgical palliation, but our colleagues also need to be aware of our role, and what we are capable of delivering. This book is a pioneering contribution in an old area of surgery that finally has had the spotlight placed on it, and for the first time is receiving the visibility and attention that it richly deserves. Dr Dunn and Professor Johnson have done a marvellous job in bringing this topic to the forefront. John L. Cameron, MD, FACS The Alfred Blalock Distinguished Professor of Surgery The Johns Hopkins Hospital Foreword SCOA01 03/29/2004 10:04 AM Page ix </li><li> 10. SCOA01 03/29/2004 10:04 AM Page x This page intentionally left blank </li><li> 11. Arjuna Aluwihare, Professor of Surgery, University of Peradeniya, Kandy, Sri Lanka Peter Angelos, Associate Professor of Surgery and Associate Professor of Medical Humanities and Bioethics, Northwestern University Medical School, Chicago, USA Matthew D. Barber, Specialist Registrar in Surgery, Department of Clinical and Surgical Sciences (Surgery), Royal Infirmary of Edinburgh, Edinburgh, UK Dudley J. Bush, Consultant in Pain Medicine, Pain Management Service, St James University Hospital, Leeds, UK Alan P. Doherty, Consultant Urological Surgeon, Queen Elizabeth Medical Centre, Birmingham, UK Geoffrey P. Dunn, Attending Surgeon, Department of Surgery, Hamot Medical Center; Medical Director Great Lakes Hospice, Erie, Pennsylvania, USA Alexandra M. Easson, Assistant Professor of Surgery, Department of Surgical Oncology, Princess Margaret Hospital, Toronto, Ontario, Canada Kenneth C.H. Fearon, Professor of Surgical Oncology, Department of Clinical and Surgical Sciences (Surgery), Royal Infirmary of Edinburgh, Edinburgh, UK Alan G. Johnson, Emeritus Professor of Surgery, University of Sheffield, Sheffield, UK Dennis L. Johnson, Professor of Medicine, Surgery and Pediatrics, Department of Medicine, Penn State College of Medicine, Hershey, PA, USA Michael Koller, Institute of Theoretical Surgery, Philipps-University Marburg, Marburg, Germany Thomas J. Krizek, Courtesy Professor of Religious Studies and Professor of Surgery and Medicine (Ethics), University of South Florida, Tampa, Florida, USA Wilfried Lorenz, Professor, Institute of Theoretical Surgery, Philipps-University Marburg, Marburg, Germany Anne Mosenthal, Associate Professor of Surgery, UMDNJ New Jersey Medical School, Newark, New Jersey, USA Patricia Murphy, Advanced Practice Nurse for Ethics and Bereavement, UMDNJ New Jersey Medical School, Newark, New Jersey, USA Bill Nelems, Professor of Surgery, University of British Columbia; Thoracic Surgeon, Interior Health Authority, Kelowna General Hospital, British Columbia, Canada Christoph Nies, Professor of Surgery, Department of Surgery, Marien Hospital, Osnabrck, Germany Alexander Ng, Surgical Oncology Fellow, Department of Surgical Oncology, Princess Margaret Hospital, Toronto, Ontario, Canada Joe M. OSullivan, Senior Clinical Research Fellow, Academic Unit of Radiotherapy and Clinical Oncology, Institute of Cancer Research and the Royal Marsden NHS Trust, Sutton, UK David Price, Clinical Bioethicist, UMDNJ New Jersey Medical School, Newark, New Jersey, USA List of contributors SCOA01 03/29/2004 10:04 AM Page xi </li><li> 12. LIST OF CONTRIBUTORSxii Elizabeth Ravenscroft, Pastoral Care Associate, Department of Pastoral Care, Newcastle Mater Hospital, Newcastle, New South Wales, Australia Peter Ravenscroft, Professor of Palliative Care, University of Newcastle and Director of Palliative Care, Newcastle Mater Hospital and Hunter Area Health Service, Newcastle, New South Wales, Australia Simon Rogers, Consultant and Hon. Reader, Regional Maxillofacial Unit, University Hospital Aintree, Liverpool, UK Karen H. Simpson, Consultant in Pain Medicine, Pain Management Service, St James University Hospital, Leeds, UK Laurie Stevens, Associate Clinical Professor of Psychiatry, Columbia University College of Physicians and Surgeons, New York, USA David Yorston, Specialist Registrar, Moorfields Eye Hospital, London, UK SCOA01 03/29/2004 10:04 AM Page xii </li><li> 13. Part I SCOC01 03/29/2004 10:08 AM Page 1 </li><li> 14. SCOC01 03/29/2004 10:08 AM Page 2 This page intentionally left blank </li><li> 15. Chapter 1 Introduction: is surgical palliative care a paradox? Geoffrey P. Dunn Surgeons and palliative care: cultural conflict? During my hospice teams discussion about a patient not long ago, one of the team members exclaimed, Dont let the surgeons get their hands on him, all they want to do is operate! Despite the fact I was considered a friendly surgeon by the team no longer operating, unarmed as it were, and one who was trusted not to take such a comment personally my blood began to boil. The case under discussion, an individual with hip pain and an impending pathological fracture, was actually one in which operative intervention promised not only relief but also protection from impending disaster. Yet, there were reasons for the comment, some trivial and entertaining and others profound and troubling. I sensed a cultural conflict occur- ring on a much deeper level than one of debate on optimum pain management. Adding to the difficulty in understanding cultural differences between surgery and non-surgical medical care was the fact that the philosophy of all medical interventions on behalf of individuals with advanced disease was in a process of change. Experience with interdisciplinary teamwork had already convinced me that some of the most intractable problems we had had with patients and care-givers were rooted in cultural differences. The greatest barrier to introducing surgical means for the relief of suffering is not the unavailability of surgical expertise or repertoire but the stereotypes surgeons, non-surgical practitioners, and patients/families have of each other and the conditions they treat. The concern shared by all of these parties is the compatibility of surgery and surgeons with the vision of palliative care. The increasing reach of palliative care has raised important ques- tions regarding the place of surgery and surgeons in the continuum of this type of care, not only for non-surgeons but also among surgeons themselves. To many the image of the sur- geon is one who is frequently right, never in doubt. If this stereotype is true, how can this personality be incorporated in the practice of palliative care where empathy and consensus are such vital elements of success? Some surgeons may freely admit their discomfort with advanced, incurable illness and cringe at the degree of empathy and introspection required to respond appropriately to the words of a dying patient, Im frightened, doctor. Can you help me? There are undoubtedly surgeons who feel they are unsuited to provide palliative care despite the fact its importance to surgeons has been demonstrated.1 Limited expectations regarding the surgeons capability to respond sensitively and adroitly in these instances overlook the rich- ness of surgical history and letters, some of the positive aspects of surgical character, the unique nature of the surgical encounter, and changing perceptions by patients and practitioners regarding the meaning of chronic and life-limiting illness. SCOC01 03/29/2004 10:08 AM Page 3 </li><li> 16. A brief history of palliation in surgery: innovations and personalities The concept of palliation, the relief of suffering, is not new to surgery and may well have had its origins in a surgical procedure, such as reducing a markedly angulated fracture or extrac- tion of a missile from a mortal wound. Ancient skulls showing partially healed trephination sites may be evidence of attempts to relieve some form of spiritual, psychological, or social anguish rather than attempts to reverse a physical condition...</li></ol>