1. Palliative Care and Surgery Elizabeth Whiteman MD

2. Goals and Objectives Understanding the role of Palliative Surgery Discussing risk and benefits of palliative surgery What types of surgery are appropriate to palliate symptoms Is there a role for preventative surgeries in palliative care? Assist in care need for continued palliative symptom management even if patient is a surgical candidate

3. Common palliative surgeries Abdominal ▫Bowel resection, bypass ▫Liver and billiary ▫Drainage tubes Limb ▫Ischemic, cancer, prevent extension GYN GU

4. Reasons for Palliative Surgery Relieve pain Relieve Nausea, Vomiting Decrease risk of spread Debulking for possible further treatment

5. Decision to operate Likely effectiveness Risk surgical morbidity Durability of surgery Life expectancy

6. Case 1 Mr. S is a 70 year old male with metastatic colon ca. He has been in the hospital for pain and N/V. He is found to have SBO. He has already been treated with colectomy, had radiation and chemo. The escalation of narcotics increased his N/V. NG tube temporarily helps, but when clamped he has further N/V?

7. Treatments Consider octreotide trial to see if symptoms improve Assess if decompression tube can help relieve symptoms Consider for surgery bypass to relieve obstruction

8. Conclusion Mr. S symptoms do not improve on octreotide. Surgery ahs assessed him and he has minimal cardiac risk factors. He is still ambulatory and was eating, despite ongoing wt loss. He tolerated surgery and went home, able to tolerate PO, but continued expected decline. 6 months later he decided to go on hospice and died comfortable in his home.

9. Palliative surgeries can effectively improve symptoms in the right patients Palliative surgery may decrease distress in pts They unlikely change the expected decline in QOL in patients and may not add to life expectancy Always consider non surgical options first and set realistic goals with patient

10. Management of Pain Thorough assessment and plan Appropriate and adequate trial of drug therapy Reassessment and revision of plan Assess for other non surgical treatments ▫Radiation, epidural, nerve block

11. Goals In 1 survey surgeons estimated that palliative goals was for 20% of all cancer operations Goals ▫Pain relief ▫Symptom relief ▫Maintaining pt independence ▫Improving pt survival was least important goal McCahill LE, Krouse R, Chu D et al., Indications and Use of Palliative surgery-results of society of surgical oncology study. Ann Surg Oncol 2002;9(1):104-12.

12. Case 2 JS is a 27 year old male with end stage renal disease from primary hyperoxaluria diagnosed as a child. He has ESRD due to chronic nephrolithiasis is post Left nephrectomy and on chronic HD. He was admitted to the ICU with a new CVA and is found to now hypercoaguable with a DVT and recent Right ischemic limb. His ischemic leg is causing significant pain and narcotics and adjuvant pain medications are appropriately being increased as needed.

13. He is becoming more lethargic due to the renal failure and progressive ischemia of his limb is worrisome for sepsis. Pain is ongoing and patient is able to appropriately ask for additional PRN pain medication. However the leg continues to become more ischemic daily. Surgery has been consulted for possible amputation of the limb.

14. Questions Overall Goals of Care Surgical Risks/benefit Pain and symptom control Life expectancy

15. After discussion with the patient, his family, the surgeon and the ICU team patient was clear he had a limited life expectancy-days to weeks. He decided that surgery, although may help relieve pain would not improve his overall prognosis and life expectancy is very limited (days to weeks) He decided to not have amputation and to continue to work with palliative care for pain control, but to continue his current other treatments such as antibiotics and dialysis.

16. 2 weeks later patient continued to decline, his pain was well controlled on IV narcotics, he eventually was unable to tolerate hemodialysis. He was placed on comfort protocol in the hospital and died a day later.

17. Ideally should clearly define goals Pt and Dr should discuss benefit and risks Also limitation of surgery especially if it is palliative

18. Caution Advanced, incurable GI cancers ▫Ascites ▫Carcinomatosis ▫Palpable intrabdominal mass ▫Multiple areas of bowel obstruction ▫Poor overall health

19. References Dunn G, Surgical Palliative Care: Recent Trends and Developments, Surg ClinN Am, 91 (2011) 277-292. Hanna,N, Bellavance E, Keay T, Palliative Surgical Oncology, Surgical Clinics of N Am, 91 (2011) 343-353. McCahill L, Ferrell B, Palliative Surgery for cancer pain, West J Med, 2002; 176:107-110. McCahill LE, Krouse R, Chu D et al., Indications and Use of Palliative surgery-results of society of surgical oncology study. Ann Surg Oncol 2002;9(1):104-12. Podnos Y, Juarez G, Pameijer C, et al, Surgical Palliation of Advanced Gastrointestinal tumors, Journal of Palliative medicine, Vol 10, No 4, 2007.