1. Karyn Stitzenberg, MD, MPH Associate Professor, Surgical Oncology

2. Should we operate? What is the standard treatment? What is our goal? Is the patient fit for surgery?

3. What is the standard treatment?

4. What is our goal? Cure What’s the likelihood of achieving cure? What are the alternative approaches? What would be the cost? Palliation What symptoms are we trying to relieve? What are the alternative approaches? What problem are we trying to prevent?

5. Is the patient fit for surgery? This is about life expectancy not chronological age. But how do we know?

6. What is the risk of peri-operative death? Incredibly few people die in the operating room. Patients die post-operatively due to failure to recover from the insult of surgery.

7. Factors to Consider Medical factors Other health problems Diabetes Cardiovascular disease Lung disease Tobacco use Weight – over and under Nutrition Regular medical care

8. Factors to Consider Rehabilitation potential / “Performance status” Baseline activity level Physical limitations – existing and potential Cognitive ability / dementia Social support Desire to live / desire to fight It’s not enough for the family to want it, as the patient is the one who has to do the work.

9. Should we operate? Maybe. It is important to take the time to understand goals, risks, expected rehabilitation/recovery and expected outcomes. It is better to do the right thing at the right time than the wrong thing fast.