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Surgery_Schwartz. age should not 6Brunicardi_Ch47_p2045-p2060.indd 205528/02/19 2:08 PM 2056SPECIFIC CONSIDERATIONSPART IIbe a deterrent, especially considering the potential to increase life expectancy. It has been recommended that the carefully selected, minimally symptomatic octogenarian with aortic ste-nosis should be considered a low-risk patient and be expected to experience an uneventful operative course and expedient recov-ery. More importantly, if elective procedures are delayed until symptoms or left ventricular dysfunction develop, patients may suffer from unnecessary increased operative risk and mortality.75 Early intervention results in a demonstrable improvement in quality of life in these patients, with many improving their NYHA functional classification.Older patients are candidates for mitral valve surgery when ischemic regurgitation is present. Surgery for mitral valve disease carries a higher morbidity and mortality risk than for aortic intervention, with an estimated mortality


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Surgery_Schwartz. mitral valve surgery when ischemic regurgitation is present. Surgery for mitral valve disease carries a higher morbidity and mortality risk than for aortic intervention, with an estimated mortality rate as high as 20%.77 Left ventricular function usually is compromised in patients requiring intervention, leading to a poorer outcome in these patients. The surgical outcome for mitral valve proce-dures depends on the extent of the disease, age of the patient, presence of pulmonary hypertension, and extent of coronary artery disease. The presence of comorbid conditions combined with the emergent nature of surgery in a large percentage of older patients further worsens the outcome. Therefore, a deci-sion regarding management of mitral valve disease should be individualized to each patient. Another concern regarding older patients who are candidates for valve disease surgery is the additional need for coronary revascularization—an important contributor to morbidity and mortality from


Surgery_Schwartz

Surgery_Schwartz. Another concern regarding older patients who are candidates for valve disease surgery is the additional need for coronary revascularization—an important contributor to morbidity and mortality from surgical interven-tion. To mitigate risk, an older patient with multiple comorbid conditions in need of a combined procedure should only have critically stenosed vessels bypassed.79 Neurologic complications from valve surgery are particularly common in older patients. It has been estimated that approximately 30% of patients >70 years old who undergo valve procedures develop either transient or permanent neurologic dysfunction.22 This often is a result of embolism from debris dislodged from the valve during the procedure or from a formed thrombus in the right atrium.An important consideration in valve replacement proce-dures in older patients is the type of prosthesis to be used. Older patients are at increased risk from bleeding-associated anticoagu-lation complications. This risk is


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Surgery_Schwartz. in valve replacement proce-dures in older patients is the type of prosthesis to be used. Older patients are at increased risk from bleeding-associated anticoagu-lation complications. This risk is especially significant in patients who have experienced falls and minor trauma that have resulted in intracranial hemorrhage. To avoid the lifelong requirement for anticoagulants, bioprosthetic valves should be used in place of mechanical valves whenever possible.79 Although the biopros-thetic valves are not as durable as mechanical valves, studies demonstrate excellent structural integrity 10 years post proce-dure, making it an appropriate choice in older patients.Transcatheter aortic valve implantation/replacement (TAVI/TAVR) is increasingly being used to treat aortic stenosis. Initially, this technique was reserved for individuals with high surgical risk. A systematic review of transcatheter aortic valve implantation versus surgical aortic valve replacement revealed that, compared to


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Surgery_Schwartz. this technique was reserved for individuals with high surgical risk. A systematic review of transcatheter aortic valve implantation versus surgical aortic valve replacement revealed that, compared to surgical repair, the transcatheter approach may have similar or better early and midterm outcomes, including among lowto intermediate-risk patients.80 Furthermore, there is increasing evidence that suggests TAVI results in acceptable long-term results in the older adult population.81,82Endovascular Aortic SurgeryWith increasing use of screening abdominal CT scans and ultrasounds for evaluation of various abdominal complaints, abdominal aortic aneurysms (AAA) are being identified with greater frequency, The percentage of AAA rises from about 1% at age 55 to 60 years to approximately 10% in patients 80 years of age or older.83 Historically, very old patients were deemed poor operative candidates for the traditional open repair given the frequent presence of comorbid conditions and limited


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Surgery_Schwartz. 80 years of age or older.83 Historically, very old patients were deemed poor operative candidates for the traditional open repair given the frequent presence of comorbid conditions and limited car-diopulmonary reserve to tolerate a major operation or the many hours of required operative time and general anesthesia. The dissemination of endovascular techniques for repair of AAA, however, has shifted the risk-benefit ratio for operative inter-vention, allowing greater life expectancy for the elective repair of this potentially life-threatening condition with the benefits of a minimally invasive approach.Multiple studies have demonstrated that endovascular aortic repair (EVAR) is feasible and efficacious in older adult patients, including those previously considered unfit for open repair. EVAR is a minimally invasive technique in which a pros-thetic graft is introduced into the aortic lumen via the common femoral artery to exclude the aortic aneurysm sac. EVAR sig-nificantly reduces


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Surgery_Schwartz. EVAR is a minimally invasive technique in which a pros-thetic graft is introduced into the aortic lumen via the common femoral artery to exclude the aortic aneurysm sac. EVAR sig-nificantly reduces operative and anesthesia times, blood loss, intensive care needs, length of stays, and major postoperative morbidity associated with open AAA repair. This procedure also can be done using epidural anesthesia for high-risk candi-dates who may tolerate general anesthesia poorly (Fig. 47-2).Careful consideration of the life expectancy and the risk of rupture dictate the necessity for intervention. EVAR remains a viable option in older adult patients. Nonoperative management is justified in frail older adult patients with multiple comorbidi-ties and reduced life expectancy whose operative risks outweigh the risk of rupture and in those who are unlikely to survive long enough to benefit from the repair.Palliative SurgeryPalliative surgery is defined as surgical intervention targeted to alleviate


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Surgery_Schwartz. the risk of rupture and in those who are unlikely to survive long enough to benefit from the repair.Palliative SurgeryPalliative surgery is defined as surgical intervention targeted to alleviate a patient’s symptoms, thus improving the patient’s quality of life despite minimal impact on the patient’s survival.54 With an increasing number of older patients presenting with advanced disease, surgeons must be familiar with the concept of palliation to control symptoms. This concept focuses on pro-viding the maximal benefit to the patient using the least-invasive intervention. Ideally, this intervention leads to symptom relief and preservation of the quality of life in terminal disease states by alleviating symptoms such as intractable vomiting and severe pain. The success of palliative surgery is a careful bal-ance between achieving symptom relief without the develop-ment of new symptoms from the intervention itself. A recent meta-analysis of outcomes after palliative surgery for


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Surgery_Schwartz. surgery is a careful bal-ance between achieving symptom relief without the develop-ment of new symptoms from the intervention itself. A recent meta-analysis of outcomes after palliative surgery for malignant bowel obstruction from peritoneal carcinomatosis revealed that although palliative surgery can benefit some patients, many patients experience serious complications, incomplete resolu-tion of symptoms, and substantial hospitalization relative to the patient’s remaining survival time.84 It is essential to provide patients with realistic information about expected outcomes after palliative surgery to ensure that this surgical intervention is in line with their care preferences. The core competencies for surgical palliative care are shown in Table 47-5.SUMMARYMajor surgery in older adults requires careful consideration. In addition to chronic medical conditions, many elders have geriat-ric syndromes that put them at high risk for increased morbidity, Brunicardi_Ch47_p2045-p2060.indd


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Surgery_Schwartz. requires careful consideration. In addition to chronic medical conditions, many elders have geriat-ric syndromes that put them at high risk for increased morbidity, Brunicardi_Ch47_p2045-p2060.indd 205628/02/19 2:08 PM 2057SURGICAL CONSIDERATIONS IN OLDER ADULTSCHAPTER 47Figure 47-2. Endovascular repair of abdominal aortic aneurysms (AAAs) has gained favor for suitable older adult patients to prevent rupture. Through minimal groin incisions, this 82-year-old patient underwent repair of an AAA and right iliac artery aneurysm and was discharged on post-op day 2.mortality, and poor functional recovery after surgery. Screen-ing for and optimization of multiple domains of vulnerability is essential to improve outcomes in this vulnerable population. Furthermore, the incorporation of palliative care principles into the surgical care of frail elders will improve patient-centered decision-making, symptom management, and quality of life.REFERENCESEntries highlighted in bright blue are key


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Surgery_Schwartz. care principles into the surgical care of frail elders will improve patient-centered decision-making, symptom management, and quality of life.REFERENCESEntries highlighted in bright blue are key references. 1. McRae PJ, Peel NM, Walker PJ, de Looze JW, Mudge AM. Geri-atric syndromes in individuals admitted to vascular and urology surgical units. J Am Geriatr Soc. 2014;62(6):1105-1109. 2. McRae PJ, Walker PJ, Peel NM, et al. Frailty and geriatric syndromes in vascular surgical ward patients. Ann Vasc Surg. 2016;35:9-18. 3. Flacker JM. What is a geriatric syndrome anyway? J Am Geri-atr Soc. 2003;51(4):574-576. 4. Fried LP. Frailty. In: Medina-Walpole A, Pacala JT, Potter JF, eds. Geriatric Review Syllabus. 9th ed. New York: American Geriatrics Society; 2016. 5. Makary MA, Segev DL, Pronovost PJ, et al. Frailty as a pre-dictor of surgical outcomes in older patients. J Am Coll Surg. 2010;210(6):901-908. 6. Suskind AM, Jin C, Cooperberg MR, et al. Preoperative frailty is associated with


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Surgery_Schwartz. PJ, et al. Frailty as a pre-dictor of surgical outcomes in older patients. J Am Coll Surg. 2010;210(6):901-908. 6. Suskind AM, Jin C, Cooperberg MR, et al. Preoperative frailty is associated with discharge to skilled or assisted living facili-ties after urologic procedures of varying complexity. Urology. 2016;97:25-32. 7. Suskind AM, Walter LC, Jin C, et al. Impact of frailty on compli-cations in patients undergoing common urological procedures: a study from the American College of Surgeons National Surgical Quality Improvement database. BJU Int. 2016;117(5):836-842. 8. Robinson TN, Wu DS, Pointer L, Dunn CL, Cleveland JC Jr, Moss M. Simple frailty score predicts postoperative complica-tions across surgical specialties. Am J Surg. 2013;206(4):544-550. 9. Robinson TN, Wu DS, Sauaia A, et al. Slower walking speed forecasts increased postoperative morbidity and 1-year mortal-ity across surgical specialties. Ann Surg. 2013;258(4):582-588; discussion 588-590. 10. Revenig LM, Canter DJ, Kim


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Surgery_Schwartz. Slower walking speed forecasts increased postoperative morbidity and 1-year mortal-ity across surgical specialties. Ann Surg. 2013;258(4):582-588; discussion 588-590. 10. Revenig LM, Canter DJ, Kim S, et al. Report of a simplified frailty score predictive of short-term postoperative morbidity and mortality. J Am Coll Surg. 2015;220(5):904-911 e901. 11. Revenig LM, Canter DJ, Master VA, et al. A prospective study examining the association between preoperative frailty and postoperative complications in patients undergoing minimally invasive surgery. J Endourol. 2014;28(4):476-480. 12. Fried LP, Tangen CM, Walston J, et al. Frailty in older adults: evidence for a phenotype. J Gerontol A Biol Sci Med Sci. 2001;56(3):M146-M156. 13. Mitnitski AB, Mogilner AJ, Rockwood K. Accumulation of def-icits as a proxy measure of aging. Sci World J. 2001;1:323-336. 14. Sternberg SA, Wershof Schwartz A, Karunananthan S, Bergman H, Mark Clarfield A. The identification of frailty: a systematic literature


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Surgery_Schwartz. as a proxy measure of aging. Sci World J. 2001;1:323-336. 14. Sternberg SA, Wershof Schwartz A, Karunananthan S, Bergman H, Mark Clarfield A. The identification of frailty: a systematic literature review. J Am Geriatr Soc. 2011;59(11):2129-2138. 15. Velanovich V, Antoine H, Swartz A, Peters D, Rubinfeld I. Accumulating deficits model of frailty and postoperative mor-tality and morbidity: its application to a national database. J Surgical Res. 2013;183(1):104-110. 16. Inouye SK, Studenski S, Tinetti ME, Kuchel GA. Geriatric syndromes: clinical, research, and policy implications of a core geriatric concept. J Am Geriatr Soc. 2007;55(5):780-791. 17. Berry SD, Kiel DP. Falls. In: Medina-Walpole A, Pacala JT, Potter JF, eds. Geriatric Review Syllabus. 9th ed. New York: American Geriatrics Society; 2016. 18. Kronzer VL, Jerry MR, Ben Abdallah A, et al. Preoperative falls predict postoperative falls, functional decline, and surgical complications. EBioMedicine.


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Surgery_Schwartz. York: American Geriatrics Society; 2016. 18. Kronzer VL, Jerry MR, Ben Abdallah A, et al. Preoperative falls predict postoperative falls, functional decline, and surgical complications. EBioMedicine. 2016;12:302-308.Brunicardi_Ch47_p2045-p2060.indd 205728/02/19 2:08 PM 2058SPECIFIC CONSIDERATIONSPART II 19. Marcantonio ER. Delirium. In: Medina-Walpole A, Pacala JT, Potter JF, eds. Geriatric Review Syllabus. 9th ed. New York: American Geriatrics Society; 2016. 20. Christmas C, Pacala JT. Perioperative care. In: Medina-Walpole A, Pacala JT, Potter CT, eds. Geriatric Review Syllabus. 9th ed. New York: American Geriatrics Society; 2016. 21. McCusker J, Cole M, Abrahamowicz M, Primeau F, Belzile E. Delirium predicts 12-month mortality. Arch Int Med. 2002;162(4):457-463. 22. Chow WB, Rosenthal RA, Merkow RP, et al. Optimal preop-erative assessment of the Surgeons National Surgical Qual-ity Improvement Program and the American Geriatrics Society. J Am Coll Surg.


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Surgery_Schwartz. JI, et al. Redefining geri-atric preoperative assessment using frailty, disability and co-morbidity. Ann Surg. 2009;250(3):449-455. 27. Graf C. The Lawton instrumental activities of daily liv-ing (IADL) scale. http://ConsultGeri/try-this/issue-23.pdf, January 14, 2016. 28. Robinson TN, Wallace JI, Wu DS, et al. Accumulated frailty characteristics predict postoperative discharge institutionaliza-tion in the geriatric patient. J Am Coll Surg. 2011;213(1):37-42; discussion 42-34. 29. Steffens DC, Fisher GG, Langa KM, Potter GG, Plassman BL. Prevalence of depression among older Americans: the Aging, Demographics and Memory Study. Int Psychogeriatr. 2009;21(5):879-888. 30. Cole MG, Dendukuri N. Risk factors for depression among older adult community subjects: a systematic review and meta-analysis. Am J Psychiatry. 2003;160(6):1147-1156. 31. Li C, Friedman B, Conwell Y, Fiscella K. Validity of the Patient Health Questionnaire 2 (PHQ-2) in identifying major depres-sion in older people. J Am


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Surgery_Schwartz. Am J Psychiatry. 2003;160(6):1147-1156. 31. Li C, Friedman B, Conwell Y, Fiscella K. Validity of the Patient Health Questionnaire 2 (PHQ-2) in identifying major depres-sion in older people. J Am Geriatr Soc. 2007;55(4):596-602. 32. Blazer DG, Wu LT. The epidemiology of at-risk and binge drinking among middle-aged and older adult community adults: National Survey on Drug Use and Health. Am J Psychiatry. 2009;166(10):1162-1169. 33. Nath B, Li Y, Carroll JE, Szabo G, Tseng JF, Shah SA. Alcohol exposure as a risk factor for adverse outcomes in elective sur-gery. J Gastrointest Surg. 2010;14(11):1732-1741. 34. Tonnesen H, Kehlet H. Preoperative alcoholism and postopera-tive morbidity. Br J Surg. 1999;86(7):869-874. 35. National Institute on Alcohol Abuse and Alcoholism. CAGE Questionnaire. 2002. Available at: https://pubs.niaaa.nih.gov/publications/aa65/aa65.htm. Accessed August 21, 2018. 36. Gal J, Bogar L, Acsady G, Kertai MD. Cardiac risk reduction in non-cardiac surgery: the role of


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Surgery_Schwartz. with the American College of Surgeons, American Society of Anesthesiologists, American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Rhythm Society, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Anesthesiologists, and Society of Vascular Medicine Endorsed by the Society of Hospital Medicine. J Nucl Cardiol. 2015;22(1):162-215. 39. Ansaloni L, Catena F, Chattat R, et al. Risk factors and inci-dence of postoperative delirium in older adult patients after elective and emergency surgery. Br J Surg. 2010;97(2):273-280. 40. Landesberg G, Beattie WS, Mosseri M, Jaffe AS, Alpert JS. Perioperative myocardial infarction. Circulation. 2009;119(22):2936-2944. 41. Smetana GW, Macpherson DS. The case against routine preop-erative laboratory testing. Med Clin North Am. 2003;87(1):7-40. 42. Smetana GW, Cohn SL, Lawrence VA. Update in perioperative medicine. Ann Intern Med. 2004;140(6):452-461. 43. Johnson RG, Arozullah AM, Neumayer


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Surgery_Schwartz. testing. Med Clin North Am. 2003;87(1):7-40. 42. Smetana GW, Cohn SL, Lawrence VA. Update in perioperative medicine. Ann Intern Med. 2004;140(6):452-461. 43. Johnson RG, Arozullah AM, Neumayer L, Henderson WG, Hosokawa P, Khuri SF. Multivariable predictors of postop-erative respiratory failure after general and vascular surgery: results from the patient safety in surgery study. J Am Coll Surg. 2007;204(6):1188-1198. 44. White JV, Guenter P, Jensen G, et al. Consensus statement: Academy of Nutrition and Dietetics and American Society for Parenteral and Enteral Nutrition: characteristics recom-mended for the identification and documentation of adult malnutrition (undernutrition). JPEN J Parenter Enteral Nutr. 2012;36(3):275-283. 45. Barnett SR. Polypharmacy and perioperative medications in the older adult. Anesthesiol Clin. 2009;27(3):377-389. 46. Qato DM, Alexander GC, Conti RM, Johnson M, Schumm P, Lindau ST. Use of prescription and over-the-counter medications and dietary supplements


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Surgery_Schwartz. older adult. Anesthesiol Clin. 2009;27(3):377-389. 46. Qato DM, Alexander GC, Conti RM, Johnson M, Schumm P, Lindau ST. Use of prescription and over-the-counter medications and dietary supplements among older adults in the United States. JAMA. 2008;300(24):2867-2878. 47. Hajjar ER, Cafiero AC, Hanlon JT. Polypharmacy in older adult patients. Am J Geriatr Pharmacother. 2007;5(4):345-351. 48. Seckler AB, Meier DE, Mulvihill M, Paris BE. Substituted judgment: how accurate are proxy predictions? Ann Intern Med. 1991;115(2):92-98. 49. Fried TR, Bradley EH, Towle VR, Allore H. Understanding the treatment preferences of seriously ill patients. N Engl J Med. 2002;346(14):1061-1066. 50. American Society of Anesthesiologists C. Practice guidelines for preoperative fasting and the use of pharmacologic agents to reduce the risk of pulmonary aspiration: application to healthy patients undergoing elective procedures: an updated report by the American Society of Anesthesiologists Com-mittee on


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Surgery_Schwartz. agents to reduce the risk of pulmonary aspiration: application to healthy patients undergoing elective procedures: an updated report by the American Society of Anesthesiologists Com-mittee on Standards and Practice Parameters. Anesthesiology. 2011;114(3):495-511. 51. Classen DC, Evans RS, Pestotnik SL, Horn SD, Menlove RL, Burke JP. The timing of prophylactic administration of antibi-otics and the risk of surgical-wound infection. N Engl J Med. 1992;326(5):281-286. 52. Silber JH, Rosenbaum PR, Trudeau ME, et al. Preopera-tive antibiotics and mortality in the older adult. Ann Surg. 2005;242(1):107-114. 53. Harari D, Hopper A, Dhesi J, Babic-Illman G, Lockwood L, Martin F. Proactive care of older people undergoing surgery (‘POPS’): designing, embedding, evaluating, and funding a comprehensive geriatric assessment service for older elective surgical patients. Age Ageing. 2007;36(2):190-196. 54. Englesbe MJ, Grenda DR, Sullivan JA, et al. The Michigan Surgical Home and Optimization


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Surgery_Schwartz. geriatric assessment service for older elective surgical patients. Age Ageing. 2007;36(2):190-196. 54. Englesbe MJ, Grenda DR, Sullivan JA, et al. The Michigan Surgical Home and Optimization Program is a scalable model to improve care and reduce costs. Surgery. 2017;161(6): 1659-1666. 55. Temel JS, Greer JA, Muzikansky A, et al. Early palliative care for patients with metastatic non-small-cell lung cancer. N Eng J Med. 2010;363(8):733-742.Brunicardi_Ch47_p2045-p2060.indd 205828/02/19 2:08 PM 2059SURGICAL CONSIDERATIONS IN OLDER ADULTSCHAPTER 47 56. Kavialieratos D, Corbelli J, Zhang D, et al. Association between palliative care and patient and caregiver outcomes. A systematic review and meta-analysis. JAMA. 2016;316(20):2104-2114. 57. Zimmermann C, Swami N, Krzyzanowska M, et al. Early palliative care for patients with advanced cancer: a clusterrandomised controlled trial. Lancet. 2014;383(9930): 1721-1730. 58. Olmsted CL, Johnson AM, Kaboli P, et al. Use of pal-liative care and


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Surgery_Schwartz. palliative care for patients with advanced cancer: a clusterrandomised controlled trial. Lancet. 2014;383(9930): 1721-1730. 58. Olmsted CL, Johnson AM, Kaboli P, et al. Use of pal-liative care and hospice among surgical and medical spe-cialties in the Veterans Health Administration. JAMA Surg. 2014;149(11):1169-1175. 59. Surgeons Palliative Care Workgroup. Office of Promoting Excellence in End-of-Life Care: Surgeon’s Palliative Care Work-group report from the field. J Am Coll Surg. 2003;197(4):661-686. 60. Moorhouse P, Mallery LH. Palliative and therapeutic harmoni-zation: a model for appropriate decision-making in frail older adults. J Am Geriatr Soc. 2012;60(12):2326-2332. 61. Ernst KF, Hall DE, Schmid KK, et al. Surgical palliative care consultations over time in relationship to systemwide frailty screening. JAMA Surg. 2014;149(11):1121-1126. 62. McCorkle R, Dowd M, Ercolano E, et al. Effects of a nursing intervention on quality of life outcomes in post-surgical women with


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Surgery_Schwartz. systemwide frailty screening. JAMA Surg. 2014;149(11):1121-1126. 62. McCorkle R, Dowd M, Ercolano E, et al. Effects of a nursing intervention on quality of life outcomes in post-surgical women with gynecological cancers. Psychooncology. 2009;18(1):62-70. 63. McCorkle R, Strumpf NE, Nuamah IF, et al. A specialized home care intervention improves survival among older post-surgical cancer patients. J Am Geriatr Soc. 2000;48(12):1707-1713. 64. Englesbe MJ, Grenda DR, Sullivan JA, et al. The Michigan Sur-gical Home and Optimization Program is a scalable model to improve care and reduce costs. Surgery. 2017;161(6):1659-1666. 65. Lawrence VA, Hazuda HP, Cornell JE, et al. Functional inde-pendence after major abdominal surgery in the older adult. J Am Coll Surg. 2004;199(5):762-772. 66. Balentine CJ, Naik AD, Berger DH, et al. Postacute care after major abdominal surgery in older adult patients: intersection of age, functional status, and postoperative complications. JAMA Surg.


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Surgery_Schwartz. CJ, Naik AD, Berger DH, et al. Postacute care after major abdominal surgery in older adult patients: intersection of age, functional status, and postoperative complications. JAMA Surg. 2016;151(8):759-766. 67. Oresanya L, Zhao S, Gan S, et al. Functional outcomes after lower extremity revascularization in nursing home residents: a national cohort study. JAMA Intern Med. 2015;175(6):951-957. 68. Finlayson E, Zhaao S, Boscardin WJ, et al. Functional status after colon cancer surgery in older adult nursing home residents. J Am Geriatr Soc. 2012;60(5):967-673. 69. Pasetto LM, Lise M, Monfardini S. Preoperative assessment of older adult cancer patient. Crit Rev Oncol Hematol. 2007;64:10. 70. Yeo HL, O’Mahoney PR, Lachs M, et al. Surgical oncol-ogy outcomes in the aging US population. J Surg Res. 2016;205(1):11-18. 71. Sudlow A, Tuffaha H, Strearns AT, et al. Outcomes of surgery in patients aged >=90 years in the general surgical setting. Ann R Coll Surg Engl. 2018;24:1-6. 72. Scali ST,


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Surgery_Schwartz. Res. 2016;205(1):11-18. 71. Sudlow A, Tuffaha H, Strearns AT, et al. Outcomes of surgery in patients aged >=90 years in the general surgical setting. Ann R Coll Surg Engl. 2018;24:1-6. 72. Scali ST, Runge SJ, Feezor RJ, et al. Outcomes after endovas-cular aneurysm repair conversion and primary aortic repair for urgent and emergency indications in the Society for Vascular Surgery Quality Initiative. J Vasc Surg. 2016;64(2):338-347. 73. Finlayson E, Wang L, Landefeld CS, et al. Major abdominal surgery in nursing home residents: a national study. Ann Surg. 2011;254(6):921-926. 74. Zenilman ME. Surgery in the older adult. Curr Probl Surg. 1998;35:99-179. 75. Cerillo AG, Kodami AA, Solinas M, et al. Aortic valve surgery in the older adult patient: a retrospective review. Interact Car-diovasc Thorac Surg. 2007;6:308-313. 76. Srinivasan AK, Oo AY, Grayson AD, et al. Mid-term survival after cardiac surgery in older adult patients: analysis of predic-tors for increased mortality. Interact


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Surgery_Schwartz. Thorac Surg. 2007;6:308-313. 76. Srinivasan AK, Oo AY, Grayson AD, et al. Mid-term survival after cardiac surgery in older adult patients: analysis of predic-tors for increased mortality. Interact Cardiovasc Thorac Surg. 2004;3:289-293. 77. Davis EA, Gardner TJ, Gillinov AM, et al. Valvular disease in the older adult: influence on surgical results. Ann Thorac Surg. 1993;55:333-337. 78. Richmond TS, Kaunder D, Strumpf N, et al. Characteristics and outcomes of serious traumatic injury in older adults. J Am Geri-atr Soc. 2002;50:215-222. 79. Aziz S, Grover FL. Cardiovascular surgery in the older adult. Cardiol Clin. 1999;17:213-231. 80. Garguilo G, Sannino A, Capodanno D, et al. Transcatheter aortic valve implantation versus surgical aortic valve replace-ment: a systematic review and meta-analysis. Ann Intern Med. 2016;165(50):334-344. 81. Chakos A, Wilson-Smith A, Arora S, et al. Long term outcomes of transcatheter aortic valve implantation (TAVI): a systematic review of 5-year survival


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Surgery_Schwartz. Ann Intern Med. 2016;165(50):334-344. 81. Chakos A, Wilson-Smith A, Arora S, et al. Long term outcomes of transcatheter aortic valve implantation (TAVI): a systematic review of 5-year survival and beyond. Ann Cardiothorac Surg. 2017;6(5):432-443. 82. D’Onofrio A, Facchin M, Besola L, et al. Intermediate clini-cal and hemodynamic outcomes after transcatheter aortic valve implantation. Ann Thorac Surg. 2016;101:881-8; discussion 888. 83. Biebl M, Lau LL, Hakaim AG, et al. Midterm outcomes of endo-vascular abdominal aortic aneurysm repair in octogenarians: a single institution’s experience. J Vasc Surg. 2004;40:435-442. 84. Olson P, Pinkerton C, Brasel KJ, et al. Palliative surgery for malignant bowel obstruction from carcinomatosis: a system-atic review. JAMA Surg. 2014;149(4):383-392.Brunicardi_Ch47_p2045-p2060.indd 205928/02/19 2:08 PM


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Surgery_Schwartz. Ethics, Palliative Care, and Care at the End of LifeDaniel E. Hall, Eliza W. Beal, Peter A. Angelos, Geoffrey P. Dunn, Daniel B. Hinshaw, and Timothy M. Pawlik48chapterDedicated to the advancement of surgery along its scientific and moral side. June 10, 1926, dedication on the Murphy Auditorium, the first home of the American College of SurgeonsWHY ETHICS MATTEREthical concerns involve not only the interests of patients but also the interests of surgeons and society. Surgeons choose among the options available to them because they have particu-lar opinions regarding what would be good (or bad) for their patients. Aristotle described practical wisdom (Greek: phronesis) as the capacity to choose the best option from among several imperfect alternatives (Fig. 48-1).1 Frequently, surgeons are confronted with clinical or interpersonal situations in which there is incomplete information, uncertain outcomes, and/or complex personal and familial relationships. The capacity to choose


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Surgery_Schwartz. are confronted with clinical or interpersonal situations in which there is incomplete information, uncertain outcomes, and/or complex personal and familial relationships. The capacity to choose wisely in such circumstances is the challenge of surgi-cal practice.DEFINITIONS AND OVERVIEWBiomedical ethics is the system of analysis and deliberation dedicated to guiding surgeons toward the “good” in the prac-tice of surgery. One of the most influential ethical “systems” in the field of biomedical ethics is the principalist approach as articulated by Beauchamp and Childress.2 In this approach to ethical issues, moral dilemmas are deliberated using four guiding principles: autonomy, beneficence, nonmaleficence, and justice.2The principle of autonomy respects the capacity of indi-viduals to choose their own destiny, and it implies that indi-viduals have a right to make those choices. It also implies an obligation for physicians to permit patients to make autonomous choices about their medical


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Surgery_Schwartz. their own destiny, and it implies that indi-viduals have a right to make those choices. It also implies an obligation for physicians to permit patients to make autonomous choices about their medical care. Beneficence requires that proposed actions aim at and achieve something good whereas nonmaleficence aims at avoiding concrete harm: primum non nocere.* Justice requires fairness where both the benefits and burdens of a particular action are distributed equitably.The history of medical ethics has its origins in antiquity. The Hippocratic Oath along with other professional codes has guided the actions of physicians for thousands of years. However, the growing technical powers of modern medicine raise new questions that were inconceivable in previous gen-erations. Life support, dialysis, and modern drugs, as well as organ and cellular transplantation, have engendered new moral and ethical questions. As such, the ethical challenges faced by the surgeon have become more complex and


Surgery_Schwartz

Surgery_Schwartz. and modern drugs, as well as organ and cellular transplantation, have engendered new moral and ethical questions. As such, the ethical challenges faced by the surgeon have become more complex and require greater attention.The case-based paradigm for bioethics is used when the clinical team encounters a situation in which two or more val-ues or principles come into apparent conflict. The first step is to clarify the relevant principles (e.g., autonomy, beneficence, nonmaleficence, and justice) and values at stake (e.g., self-determination, quality of life). After identifying the principles and values that are affecting the situation, a proposed course of action is considered given the circumstances.Much of the discourse in bioethics adopts this “principal-ist” approach in which the relevant principles are identified, weighed, and balanced, and then applied to formulate a course of action. This approach to bioethics is a powerful technique for thinking through moral problems because the


Surgery_Schwartz

Surgery_Schwartz. principles are identified, weighed, and balanced, and then applied to formulate a course of action. This approach to bioethics is a powerful technique for thinking through moral problems because the four princi-ples help identify what is at stake in any proposed course of action. However, the principles themselves do not resolve ethi-cal dilemmas. Working together, patients and surgeons must use wise judgment to choose the best course of action for the specific case.Why Ethics Matter 2061Definitions and Overview 2061Specific Issues in Surgical Ethics 2062Informed Consent / 2062The Boundaries of Autonomy: Advance Directives and Powers of Attorney / 2064Withdrawing and Withholding Life-Sustaining Therapies / 2065Living Donor Liver Transplantation / 2066Palliative Care 2066General Principles of Palliative Care / 2066Concepts of Suffering, Pain, Health, and Healing / 2067Effective Communication and Negotiating the Goals of Care / 2067Care at the End of Life 2068The Syndrome of Imminent


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Surgery_Schwartz. of Palliative Care / 2066Concepts of Suffering, Pain, Health, and Healing / 2067Effective Communication and Negotiating the Goals of Care / 2067Care at the End of Life 2068The Syndrome of Imminent Demise / 2068Common Symptoms at the End of Life and Their Management / 2068Pronouncing Death / 2072Aid in Dying / 2072Professional Ethics: Conflict of Interest, Research, and Clinical Ethics 2072Conflict of Interest / 2072Research Ethics / 2072Special Concerns in Surgical Research / 2072Surgical Innovation / 2073The Ethics of Authorship / 2073Clinical Ethics: Disclosure of Errors / 2074*“First do no harm.”Brunicardi_Ch48_p2061-p2076.indd 206119/02/19 1:49 PM 2062Figure 48-1. Bust of Aristotle. Marble, Roman copy after a Greek bronze original by Lysippos from 330 b.c. (From http://en.wikipedia.org/wiki/File:Aristotle_Altemps_Inv8575.jpg: Ludovisi Collection, Accession number Inv. 8575, Palazzo Altemps, Location Ground Floor, Branch of the National Roman Museum. Photographer/-source


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Surgery_Schwartz. Ludovisi Collection, Accession number Inv. 8575, Palazzo Altemps, Location Ground Floor, Branch of the National Roman Museum. Photographer/-source Jastrow [2006] from Wikipedia.)Choosing wisely requires the virtue of practical wisdom first described by Aristotle (see Fig. 48-1). Along with the other cardinal virtues of courage, justice and temperance, practical wisdom is a central component of virtue ethics which comple-ment principalist ethics by guiding choices toward the best options for treatment. Practical wisdom cannot be learned from books and is developed only through experience. The appren-ticeship model of surgical residency fosters the development of practical wisdom through experience. More than teaching merely technical mastery, surgical residency is also moral training. In fact, the sociologist Charles Bosk argues that the “postgraduate training of surgeons is above all things an ethical training.”3SPECIFIC ISSUES IN SURGICAL ETHICSInformed ConsentAlthough a relatively


Surgery_Schwartz

Surgery_Schwartz. fact, the sociologist Charles Bosk argues that the “postgraduate training of surgeons is above all things an ethical training.”3SPECIFIC ISSUES IN SURGICAL ETHICSInformed ConsentAlthough a relatively recent development, the doctrine of informed consent is one of the most widely established tenets of modern biomedical ethics. During the nineteenth and early twentieth centuries, most physicians practiced a form of benign paternalism whereby patients were rarely involved in the deci-sion-making process regarding their medical care, relying instead on the beneficence of the physician. Consensus among the wider public eventually changed such that surgeons are now expected to have an open discussion about diagnosis and treatment with the patient to obtain informed consent. In the United States, the legal doctrine of simple consent dates from the 1914 decision in Schloendorff vs. The Society of New York Hospital regarding a case in which a surgeon removed a diseased uterus after the patient


Surgery_Schwartz

Surgery_Schwartz. the legal doctrine of simple consent dates from the 1914 decision in Schloendorff vs. The Society of New York Hospital regarding a case in which a surgeon removed a diseased uterus after the patient had consented to an examination under anesthesia, but with the express stipulation that no operative excision should be performed. The physician argued that his decision was justified by the beneficent obligation to avoid the risks of a second anes-thetic. However, Justice Benjamin Cardozo stated:Every human being of adult years and sound mind has a right to determine what shall be done with his body; and a surgeon who performs an operation without his patient’s consent commits an assault, for which he is liable in damages . . . except in cases of emergency, where the patient is unconscious, and where it is neces-sary to operate before consent can be obtained.4Having established that patients have the right to deter-mine what happens to their bodies, it took some time for the modern


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Surgery_Schwartz. and where it is neces-sary to operate before consent can be obtained.4Having established that patients have the right to deter-mine what happens to their bodies, it took some time for the modern concept of informed consent to emerge from the ini-tial doctrine of simple consent. The initial approach appealed to a professional practice standard whereby physicians were obligated to disclose to patients the kind of information that experienced surgeons customarily disclosed.5 However, this dis-closure was not always adequate for patient needs. In the 1972 Key Points1 The physician should document that the patient or surrogate has the capacity to make a medical decision.2 Sufficient details regarding diagnosis and treatment options should be disclosed to the patient so that the patient can pro-vide informed consent.3 Living wills are written to anticipate treatment options and choices in the event that a patient is rendered incompetent by a terminal illness.4 The durable power of attorney


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Surgery_Schwartz. informed consent.3 Living wills are written to anticipate treatment options and choices in the event that a patient is rendered incompetent by a terminal illness.4 The durable power of attorney for healthcare identifies sur-rogate decision makers and invests them with the authority to make healthcare decisions on behalf of patients in the event that they are unable to speak for themselves.5 Surgeons should encourage their patients to complete a liv-ing will and clearly identify their surrogates early in the course of treatment.6 Earlier referrals and wider use of palliative and hospice care may help more patients achieve their goals at the end of life.7 Seven requirements for the ethical conduct of clinical research studies have been articulated: value, scientific validity, fair subject selection, favorable risk-benefit ratio, independent review, informed consent, and respect for enrolled subjects.8 Individuals working together on research endeavors should have clear discussions early


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Surgery_Schwartz. favorable risk-benefit ratio, independent review, informed consent, and respect for enrolled subjects.8 Individuals working together on research endeavors should have clear discussions early in the planning process about authorship, and those discussions should be continued throughout the project or study.9 Disclosure of error is consistent with recent ethical advances in medicine toward more transparency, openness with patients, and the involvement of patients in their care.Brunicardi_Ch48_p2061-p2076.indd 206219/02/19 1:49 PM 2063ETHICS, PALLIATIVE CARE, AND CARE AT THE END OF LIFECHAPTER 48Patient establishes selfas decision-makerNoYesEngage patientdirectly in informedconsent process andin all aspects of careIdentify patient’s culturalidentity and, if possible,explicit preferences formaking decisions,including degree of familyinvolvementMaintain heightenedawareness of patient-family or patient-surrogate interactionsMake sure family orother surrogate is willingparticipant in


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Surgery_Schwartz. formaking decisions,including degree of familyinvolvementMaintain heightenedawareness of patient-family or patient-surrogate interactionsMake sure family orother surrogate is willingparticipant in informedconsent processContinuously reassessfor signs that patient isunhappy with current role ininformed consent processSecure private discussionwith patient and remindpatient of right toinformed consent processMake sure patient hasnot deferred decision-making involuntarilyFigure 48-2. Algorithm for navigating the process of informed consent. (Modified with permission from Childers R, Lipsett A, Pawlik T. Informed consent and the surgeon, J Am Coll Surg. 2009 Apr;208(4):627-634.)landmark case, Canterbury vs. Spence, the court rejected the professional practice standard in favor of the reasonable person standard whereby physicians are obliged to disclose to patients all information regarding diagnosis, treatment options, and risks that a “reasonable patient” would want to know in a similar


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Surgery_Schwartz. person standard whereby physicians are obliged to disclose to patients all information regarding diagnosis, treatment options, and risks that a “reasonable patient” would want to know in a similar situation. Rather than relying on the practices or consensus of the medical community, the reasonable person standard empow-ers the public (reasonable persons) to determine how much information should be disclosed by physicians to ensure that consent is truly informed. The court did recognize, however, that there are practical limits on the amount of information that can be communicated or assimilated.5 Subsequent litigation has revolved around what reasonable people expect to be disclosed in the consent process to include the nature and frequency of potential complications, the prognostic life expectancy,6 and the surgeon-specific success rates.4 Despite the litigious environ-ment of medical practice, it is difficult to prosecute a case of inadequate informed consent so long as the


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Surgery_Schwartz. life expectancy,6 and the surgeon-specific success rates.4 Despite the litigious environ-ment of medical practice, it is difficult to prosecute a case of inadequate informed consent so long as the clinician has made a concerted and documented effort to involve the patient in the decision-making process.Adequate informed consent entails at least four basic ele-ments: (a) the physician documents that the patient or surrogate has the capacity to make a medical decision; (b) the sur-geon discloses to the patient details regarding the diagno-sis and treatment options sufficiently for the patient to make an informed choice; (c) the patient demonstrates understanding of the disclosed information before (d) authoriz-ing freely a specific treatment plan without undue influence (Fig. 48-2). These goals are aimed at respecting each patient’s prerogative for autonomous self-determination. To accomplish these goals, the surgeon needs to engage in a discussion about the causes and nature of the


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Surgery_Schwartz. goals are aimed at respecting each patient’s prerogative for autonomous self-determination. To accomplish these goals, the surgeon needs to engage in a discussion about the causes and nature of the patient’s disease, the risks and ben-efits of available treatment options, as well as details regarding what patients can expect after an operative intervention includ-ing possible outcomes and complications.7-14Certain clinical settings make obtaining informed consent challenging. For example, obtaining consent for emergency surgery can be difficult, as the clinical team is forced to make decisions with incomplete information. Emergency consent requires the surgeon to consider if and how possible interven-tions might save a patient’s life, and if successful, what kind of disability might be anticipated. Surgical emergencies are one of the few instances where the limits of patient autonomy are freely acknowledged, and surgeons are empowered by law and ethics to act promptly in the best


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Surgery_Schwartz. anticipated. Surgical emergencies are one of the few instances where the limits of patient autonomy are freely acknowledged, and surgeons are empowered by law and ethics to act promptly in the best interests of their patients according to the surgeon’s judgment. Most applicable medi-cal laws require physicians to provide the standard of care to incapacitated patients, even if it entails invasive procedures without the explicit consent of the patient or surrogate. If at all possible, surgeons should seek the permission of their patients to provide treatment, but when emergency medical conditions render patients unable to grant that permission, and when delay is likely to have grave consequences, surgeons are legally and ethically justified in providing whatever surgical treatment the surgeon judges necessary to preserve life and restore health.4 This justification is based on the social consensus that most people would want their lives and health protected in this way, and this


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Surgery_Schwartz. surgeon judges necessary to preserve life and restore health.4 This justification is based on the social consensus that most people would want their lives and health protected in this way, and this consensus is manifest in the medical profession’s gen-eral orientation to preserve life. It may be that subsequent care may be withdrawn or withheld when the clinical prognosis is clearer, but in the context of initial resuscitation of injured patients, incomplete information makes clear judgments about the patient’s ultimate prognosis or outcome impossible.The pediatric population also presents unique challenges for the process of consent. For many reasons, children and ado-lescents cannot participate in the process of giving informed 1122Brunicardi_Ch48_p2061-p2076.indd 206319/02/19 1:49 PM 2064SPECIFIC CONSIDERATIONSPART IIconsent in the same way as adults. Depending on their age, children may lack the cognitive and emotional maturity to participate fully in the process. In addition,


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Surgery_Schwartz. 2064SPECIFIC CONSIDERATIONSPART IIconsent in the same way as adults. Depending on their age, children may lack the cognitive and emotional maturity to participate fully in the process. In addition, depending on the child’s age, their specific circumstances, as well as the local jurisdiction, children may not have legal standing to fully par-ticipate on their own independent of their parents. The use of parents or guardians as surrogate decision makers only partially addresses the ethical responsibility of the surgeon to involve the child in the informed consent process. The surgeon should strive to augment the role of the decision makers by involving the child in the process. Specifically, children should receive age-appropriate information about their clinical situation and therapeutic options delivered in an appropriate setting and tone so that the surgeon can solicit the child’s “assent” for treatment. In this manner, while the parents or surrogate decision makers formally give the


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Surgery_Schwartz. delivered in an appropriate setting and tone so that the surgeon can solicit the child’s “assent” for treatment. In this manner, while the parents or surrogate decision makers formally give the informed consent, the child remains an inte-gral part of the process.Certain religious practices can present additional chal-lenges when treating minor children whose parents disallow medically indicated blood transfusions; however, case law has made clear the precedent that parents, regardless of their held beliefs, may not place their minor children at mortal risk. In such a circumstance, the physician should seek counsel from the hospital medicolegal team, as well as from the institutional ethics team. Legal precedent has, in general, established that the hospital or physician can proceed with providing all necessary care for the child.Obtaining “consent” for organ donation deserves spe-cific mention.15 Historically, discussion of organ donation with families of potential donors was


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Surgery_Schwartz. with providing all necessary care for the child.Obtaining “consent” for organ donation deserves spe-cific mention.15 Historically, discussion of organ donation with families of potential donors was performed by transplant professionals, who were introduced to families by intensivists after brain death had been confirmed and the family had been informed of the fact of death. In other instances, consent might be obtained by intensivists caring for the donor, as they were assumed to know the patient’s family and could facilitate the process. However, issues of moral “neutrality” as part of end-of-life care in the intensive care unit have caused a shift in how obtaining “consent” for organ donation is handled. Responsibility for obtaining consent from the donor family is now vested in trained “designated requestors” (or “organ procurement coordinators”)16 or by “independent” intensivists who do not have a therapeutic clinical relationship with the potential donor.17 In this way, the


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Surgery_Schwartz. “designated requestors” (or “organ procurement coordinators”)16 or by “independent” intensivists who do not have a therapeutic clinical relationship with the potential donor.17 In this way, the donor family can be allowed to make the decision regarding donation in a “neutral” environment without erosion of the therapeutic relationship with the treating physician or perceived undue pressure from the transplant team.The process of informed consent also can be limited by the capacity of patients to assimilate information in the context of their illness. For example, despite the best efforts of surgeons, evidence suggests that patients rarely retain much of what is dis-closed in the consent conversation, and they may not remember discussing details of the procedure that become relevant when postoperative complications arise.18 It is important to recognize that the doctrine of informed consent places the most emphasis on the principle of autonomy precisely in those clinical situa-tions


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Surgery_Schwartz. postoperative complications arise.18 It is important to recognize that the doctrine of informed consent places the most emphasis on the principle of autonomy precisely in those clinical situa-tions when, because of their severe illness or impending death, patients are often divested of their autonomy.The Boundaries of Autonomy: Advance Directives and Powers of AttorneySevere illness and impending death can often render patients incapable of exercising their autonomy regarding medical decisions. One approach to these difficult situations is to make decisions in the “best interests” of patients, but because such decisions require value judgments about which thoughtful peo-ple frequently disagree, ethicists, lawyers, and legislators have sought a more reliable solution. Advance directives of various forms have been developed to carry forward into the future the autonomous choices of competent adults regarding healthcare decisions. Furthermore, the courts often accept “informal” advance


Surgery_Schwartz

Surgery_Schwartz. various forms have been developed to carry forward into the future the autonomous choices of competent adults regarding healthcare decisions. Furthermore, the courts often accept “informal” advance directives in the form of sworn testimony about state-ments the patient made at some time previous to their illness. When a formal document expressing the patient’s advance directives fails to exist, surgeons should consider the comments patients and families make when asked about their wishes in the setting of debilitating illness.Living wills are written to anticipate treatment options and choices in the event that a patient is incapacitated by a terminal illness. In the living will, the patient indicates which treatments she wishes to permit or prohibit in the setting of terminal illness. The possible treatments addressed often include mechanical ventilation, cardiopulmonary resuscitation, artificial nutri-tion, dialysis, antibiotics, or transfusion of blood products. Unfor-tunately,


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Surgery_Schwartz. The possible treatments addressed often include mechanical ventilation, cardiopulmonary resuscitation, artificial nutri-tion, dialysis, antibiotics, or transfusion of blood products. Unfor-tunately, living wills are often too vague to offer concrete guidance in complex clinical situations, and the language (“termi-nal illness,” “artificial nutrition”) can be interpreted in many ways. Furthermore, by limiting the directive only to “terminal” conditions, it does not provide guidance for common clinical sce-narios like advanced dementia, delirium, or persistent vegetative states where the patient is unable to make decisions, but is not “terminally” ill. Perhaps even more problematic is the evidence that demonstrates that healthy patients cannot reliably predict their preferences when they are actually sick. This phenomenon is called “affective forecasting” and applies to many situations. For example, the general public estimates the health-related qual-ity of life (HRQoL) score of


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Surgery_Schwartz. are actually sick. This phenomenon is called “affective forecasting” and applies to many situations. For example, the general public estimates the health-related qual-ity of life (HRQoL) score of patients on dialysis at 0.39, although dialysis patients themselves rate their HRQoL at 0.56.19 Similarly, patients with colostomies rated their HRQoL at 0.92, compared to a score of 0.80 given by the general public for patients with colostomies.19 For these and other reasons, living wills are often unable to provide the extent of assistance they promise.20An alternative to living wills is the durable power of attor-ney for healthcare in which patients identify surrogate decision makers and invest them with the authority to make healthcare decisions on their behalf in the event that they are unable to speak for themselves. Proponents of this approach hope that the surrogate will be able to make decisions that reflect the choices that the patients themselves would make if they were able.


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Surgery_Schwartz. unable to speak for themselves. Proponents of this approach hope that the surrogate will be able to make decisions that reflect the choices that the patients themselves would make if they were able. Unfortunately, several studies demonstrate that surrogates are not much better than chance at predicting the choices patients make when the patient is able to state a preference. For example, a recent meta-analysis found that surrogates predicted patients’ treatment preferences with only 68% accuracy.21 These data reveal a flaw in the guiding principle of surrogate decision making: Surrogates do not necessarily have privileged insight into the autonomous preferences of patients. However, the dura-ble power of attorney at least allows patients to choose the person who will eventually make prudential decisions on their behalf and in their best interests; therefore, respecting the judgment of the surrogate is a way of respecting the self-determination of the incapacitated patient.22There is


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Surgery_Schwartz. decisions on their behalf and in their best interests; therefore, respecting the judgment of the surrogate is a way of respecting the self-determination of the incapacitated patient.22There is continuing enthusiasm for a wider use of advance directives. In fact, the 1991 Patient Self Determination Act requires all U.S. healthcare facilities to (a) inform patients of 334Brunicardi_Ch48_p2061-p2076.indd 206419/02/19 1:49 PM 2065ETHICS, PALLIATIVE CARE, AND CARE AT THE END OF LIFECHAPTER 48their rights to have advance directives, and (b) to document those advance directives in the chart at the time any patient is admitted to the healthcare facility.4 However, only a minority of patients in U.S. hospitals have advance directives despite concerted efforts to teach the public of their benefits and pro-vide resources to help patients prepare and maintain them. For example, the ambitious SUPPORT trial used specially trained nurses to promote communication between physicians, patients, and


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Surgery_Schwartz. and pro-vide resources to help patients prepare and maintain them. For example, the ambitious SUPPORT trial used specially trained nurses to promote communication between physicians, patients, and their surrogates to improve the care and decision making of critically ill patients. Despite this concerted effort, the interven-tion demonstrated “no significant change in the timing of do not resuscitate (DNR) orders, in physician-patient agreement about DNR orders, in the number of undesirable days (patients’ experiences), in the prevalence of pain, or in the resources consumed.”23Some of the reluctance around physician–patient agree-ment about DNR orders may reflect patient and family anxiety that DNR orders equate to “do not treat.” Patients and families should be assured, when appropriate, that declarations of DNR/do not intubate will not necessarily result in a change in ongoing routine clinical care. The issue of temporarily rescinding DNR/do not intubate orders around the time of an


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Surgery_Schwartz. that declarations of DNR/do not intubate will not necessarily result in a change in ongoing routine clinical care. The issue of temporarily rescinding DNR/do not intubate orders around the time of an operative procedure may also need to be addressed with the family.Patients should be encouraged to clearly identify their sur-rogates, both formally and informally, early in the course of treatment and before any major elective operation. Often, around the time of surgery or at the end of life, there are limits to patient autonomy in medical decision-making. Seeking an advance directive or surrogate decision maker requires time that is not always available when the clinical situation deterio-rates. As such, these issues should be clarified as early as pos-sible in the patient–physician relationship.Withdrawing and Withholding Life-Sustaining TherapiesThe implementation of various forms of life support technol-ogy raise a number of legal and ethical concerns about when it is permissible to


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Surgery_Schwartz. and Withholding Life-Sustaining TherapiesThe implementation of various forms of life support technol-ogy raise a number of legal and ethical concerns about when it is permissible to withdraw or withhold available therapeu-tic technology. There is general consensus among ethicists that there are no philosophic differences between withdrawing (stopping) or withholding (not starting) treatments that are no longer beneficial.24 However, the right to refuse, withdraw, and withhold beneficial treatments was not established before the landmark case of Karen Ann Quinlan. In 1975, Quinlan lapsed into a persistent vegetative state requiring ventilator support. After several months without clinical improvement, Quinlan’s parents asked the hospital to withdraw ventilator support. The hospital refused, fearing prosecution for euthanasia. The case was appealed to the New Jersey Supreme Court where the justices ruled that it was permissible to withdraw ventilator support.25 This case established a


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Surgery_Schwartz. fearing prosecution for euthanasia. The case was appealed to the New Jersey Supreme Court where the justices ruled that it was permissible to withdraw ventilator support.25 This case established a now commonly recognized right to with-draw “extraordinary” life-saving technology if it is no longer desired by the patient or the patient’s surrogate.The difference between “ordinary” and “extraordinary” care, and whether there is an ethical difference in withhold-ing or withdrawing “ordinary” vs. “extraordinary” care, has been an area of much contention. The 1983 Nancy Cruzan case highlighted this issue. In this case, Cruzan had suffered severe injuries in an automobile crash that rendered her in a persistent vegetative state. Cruzan’s family asked that her tube feeds be withheld, but the hospital refused. The case was appealed to the U.S. Supreme Court, which ruled that the tube feeding could be withheld if her parents demonstrated “clear and convincing evidence” that the incapacitated


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Surgery_Schwartz. refused. The case was appealed to the U.S. Supreme Court, which ruled that the tube feeding could be withheld if her parents demonstrated “clear and convincing evidence” that the incapacitated patient would have rejected the treatment.26 In this ruling, the court essentially ruled that there was no legal distinction between “ordinary” vs. “extraor-dinary” life-sustaining therapies.27 In allowing the feeding tube to be removed, the court accepted the principle that a competent person (even through a surrogate decision maker) has the right to decline treatment under the Fourteenth Amendment of the U.S. Constitution. The court noted, however, that there has to be clear and convincing evidence of the patient’s wishes (con-sistent with the principle of autonomy) and that the burdens of the medical intervention should outweigh its benefits (consistent with the principles of beneficence and nonmaleficence).In deliberating the issue of withdrawing vs. withholding life-sustaining therapies,


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Surgery_Schwartz. intervention should outweigh its benefits (consistent with the principles of beneficence and nonmaleficence).In deliberating the issue of withdrawing vs. withholding life-sustaining therapies, the principle of “double effect” is often mentioned. According to the principle of “double effect,” a treatment (e.g., opioid administration in the terminally ill) that is intended to help and not harm the patient (i.e., relieve pain) is ethically acceptable even if an unintended consequence (side effect) of its administration is to shorten the life of the patient (e.g., by respiratory depression). Under the principle of double effect, a physician may withhold or withdraw a life-sustaining therapy if the surgeon’s intent is to relieve suffering, not to has-ten death. The classic formulation of double effect has four ele-ments (Fig. 48-3).Withholding or withdrawing of life-sustaining therapy is ethically justified under the principle of double effect if the phy-sician’s intent is to relieve


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Surgery_Schwartz. double effect has four ele-ments (Fig. 48-3).Withholding or withdrawing of life-sustaining therapy is ethically justified under the principle of double effect if the phy-sician’s intent is to relieve suffering, not to kill the patient. Thus, in managing the distress of the dying, there is a fundamental eth-ical difference between titrating medications rapidly to achieve relief of distress and administering a very large bolus with the 55Double effectConditionsActionGood effectBad effectGood effectBad effectActIntrinsic moral wrongAgentIntendsGood effectBad effect1234ActBad effectGood effectFigure 48-3. The four elements of the double effect principle: (1) The good effect is produced directly by the action and not by the bad effect. (2) The person must intend only the good effect, even though the bad effect may be foreseen. (3) The act itself must not be intrinsically wrong, or needs to be at least neutral. (4) The good effect is sufficiently desirable to compensate for allowing the bad


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Surgery_Schwartz. the bad effect may be foreseen. (3) The act itself must not be intrinsically wrong, or needs to be at least neutral. (4) The good effect is sufficiently desirable to compensate for allowing the bad effect.Brunicardi_Ch48_p2061-p2076.indd 206519/02/19 1:49 PM 2066SPECIFIC CONSIDERATIONSPART IIintent of causing apnea. It is important to note, however, that although the use of opioids for pain relief in advanced illness is frequently cited as the classic example of the double effect rule, opioids can be used safely without significant risk. In fact, if administered appropriately, in the vast majority of instances the rule of double effect need not be invoked when administering opioids for symptom relief in advanced illness.28In accepting the ethical equivalence of withholding and withdrawing of life-sustaining therapy, surgeons can make dif-ficult treatment decisions in the face of prognostic uncertainty.24 In light of this, some important principles to consider when con-sidering


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Surgery_Schwartz. of life-sustaining therapy, surgeons can make dif-ficult treatment decisions in the face of prognostic uncertainty.24 In light of this, some important principles to consider when con-sidering withdrawal of life-sustaining therapy include: (a) Any and all treatments can be withdrawn. If circumstances justify withdrawal of one therapy (e.g., IV pressors, antibiotics), they may also justify withdrawal of others; (b) Be aware of the sym-bolic value of continuing some therapies (e.g., nutrition, hydra-tion) even though their role in palliation is questionable; (c) Before withdrawing life-sustaining therapy, ask the patient and family if a spiritual advisor (e.g., pastor, imam, rabbi, or priest) should be called; and (d) Consider requesting an ethics consult.Although the clinical setting may seem limited, a range of options usually exists with respect to withdrawing or with-holding treatment, allowing for an incremental approach, for example (a) continuing the current regimen without adding


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Surgery_Schwartz. limited, a range of options usually exists with respect to withdrawing or with-holding treatment, allowing for an incremental approach, for example (a) continuing the current regimen without adding new interventions or tests; (b) continuing the current regimen but withdrawing elements when they are no longer beneficial; and (c) withdrawing and withholding all treatments that are not tar-geted to relieve symptoms and maximize patient comfort.34The surgeon might consider discussing the clinical situ-ation with the patient or proxy decision maker, identify the various therapeutic options, and delineate the reasons why with-holding or withdrawing life-sustaining therapy would be in the patient’s best interest. If the patient (or designated proxy deci-sion maker) does not agree with withholding or withdrawing life-sustaining therapy, the surgeon should consider involving consultants who have participated in the patient’s care, experts in palliative or end-of-life care or recommend a second


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Surgery_Schwartz. or withdrawing life-sustaining therapy, the surgeon should consider involving consultants who have participated in the patient’s care, experts in palliative or end-of-life care or recommend a second medical opinion. If the second opinion corroborates that life-sustaining therapy should be withheld or withdrawn but the patient/family continues to disagree, the surgeon should consider assistance from institutional resources such as the ethics committee and hospital administration. Although the surgeon is not ethically obligated to provide treatment that he or she believes is futile, the surgeon is responsible for continued care of the patient, which may involve transferring the patient to a surgeon who is willing to provide the requested intervention.24Living Donor Liver TransplantationOne unique ethical issue that deserves special mention is that of living donor liver transplantation. Living donor kidney transplantation has been practiced for almost 50 years and has become a routine


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Surgery_Schwartz. unique ethical issue that deserves special mention is that of living donor liver transplantation. Living donor kidney transplantation has been practiced for almost 50 years and has become a routine part of clinical care, but living donor liver transplantation was first performed in the late 1980s with par-ent-to-child grafts and in the late 1990s for adult-to-adult grafts. These procedures are unique in that there are two patients, one with a diseased organ who requires intervention to be made well and one who is healthy and is being made unwell, albeit usu-ally temporarily, during the intervention. Performing an ethi-cal analysis of this situation requires considering both risks and benefits to each of the patients individually.For the recipient, the benefits of receiving a living donor organ as opposed to a deceased donor organ are many: first, there is reduced risk of death on the waitlist, and second, there is a potential for improved post-transplant outcomes due to improved


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Surgery_Schwartz. organ as opposed to a deceased donor organ are many: first, there is reduced risk of death on the waitlist, and second, there is a potential for improved post-transplant outcomes due to improved matching between relatives and the absence of hemo-dynamic instability often present before organ procurement in a deceased donor.30 Furthermore, the use of living donor organs is supported by the principal of utility, maximizing efficient use of organs.32The benefit to the organ donor is in fulfillment of an altru-istic ideal and satisfaction associated with having extended the recipient’s life, while the risks are those associated with partial hepatectomy, a procedure that is not without risks including postoperative complications and mortality, the risk of which is estimated to be 0.15%.29 The ethical concern in this case is hav-ing possibly violated the principle of nonmaleficence.This particular ethical issue emphasizes the importance of truly informed consent. The donor should be


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Surgery_Schwartz. The ethical concern in this case is hav-ing possibly violated the principle of nonmaleficence.This particular ethical issue emphasizes the importance of truly informed consent. The donor should be provided with information on local complication and mortality rates and allowed sufficient time to consider the risks and benefits with-out pressure from healthcare workers.30 Furthermore, experi-enced centers have recommended that living donors have access to sufficient resources and strong support from an institutions’ ethics committee, given substantial pressure exerted by the criti-cal illness of a family member.31PALLIATIVE CAREGeneral Principles of Palliative CarePalliative care is a coordinated, interdisciplinary effort that aims to relieve suffering and improve quality of life for patients and their families in the context of serious illness.33 It is offered simultaneously with all other appropriate medical treatment, and its indication is not limited to situations associated with a


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Surgery_Schwartz. and their families in the context of serious illness.33 It is offered simultaneously with all other appropriate medical treatment, and its indication is not limited to situations associated with a poor prognosis for survival. Palliative care strives to achieve more than symptom control, but it should not be confused with noncurative treatment.The World Health Organization defines palliative care as “an approach that improves the quality of life of patients and their families facing the problems associated with life-threat-ening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial, and spiritual.”34 Palliative care is both a philosophy of care and an organized, highly structured system for delivering care.Palliative care includes the entire spectrum of intervention for the relief of symptoms and the promotion of quality of life. No specific therapy, including


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Surgery_Schwartz. structured system for delivering care.Palliative care includes the entire spectrum of intervention for the relief of symptoms and the promotion of quality of life. No specific therapy, including surgical intervention, is excluded from consideration. Therefore, surgeons have valuable contri-butions to make to palliative care. In fact, the term palliative care was coined in 1975 by Canadian surgeon, Balfour Mount. Furthermore, surgical palliative care can be defined as the treat-ment of suffering and the promotion of quality of life for seri-ously or terminally ill patients under the care of surgeons.36 The standard of palliative treatment lies in the agreement between patient and physician that the expected outcome is relief from distressing symptoms, lessening of pain, and improvement of quality of life. The decision to intervene is based on the treat-ment’s ability to meet the stated goals, rather than its impact on the underlying disease.The fundamental elements of palliative care


Surgery_Schwartz

Surgery_Schwartz. quality of life. The decision to intervene is based on the treat-ment’s ability to meet the stated goals, rather than its impact on the underlying disease.The fundamental elements of palliative care consist of pain and nonpain symptom management, communication among patients, their families, and care providers, and conti-nuity of care across health systems and through the trajectory Brunicardi_Ch48_p2061-p2076.indd 206619/02/19 1:49 PM 2067ETHICS, PALLIATIVE CARE, AND CARE AT THE END OF LIFECHAPTER 48of illness. Additional features of system-based palliative care are team-based planning that includes patient and family; close attention to spiritual matters; and psychosocial support for patients, their families, and care providers, including bereave-ment support.Indications for palliative care consultation in surgical practice include: (a) patients with conditions that are progres-sive and life-limiting, especially if characterized by burdensome symptoms, functional decline, and


Surgery_Schwartz

Surgery_Schwartz. care consultation in surgical practice include: (a) patients with conditions that are progres-sive and life-limiting, especially if characterized by burdensome symptoms, functional decline, and progressive cognitive defi-cits; (b) assistance in clarification or reorientation of patient/family goals of care; (c) assistance in resolution of ethical dilemmas; (d) situations in which a patient/surrogate declines further invasive or curative treatments with stated preference for comfort measures only; (e) patients who are expected to die imminently or shortly after hospital discharge; and (f) provision of bereavement support for patient care staff, particularly after loss of a colleague under care36 (Table 48-1). Although all patients, regardless of prognosis, may benefit from the services of a palliative care physician, hospice care is a specific form of palliative care intended for patients who have an estimated prognosis of 6 months or less to live. Hospice care is covered under


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Surgery_Schwartz. of a palliative care physician, hospice care is a specific form of palliative care intended for patients who have an estimated prognosis of 6 months or less to live. Hospice care is covered under Medicare Part A, and benefits may be continued beyond the original 6 months of estimated survival if physicians certify that life expectancy remains limited to 6 months or less. Although most Americans indicate a preference to die at home, nearly 75% die in an institutional setting. Earlier referral and wider use of the hospice benefit may help more patients achieve their goal of dying at home.Concepts of Suffering, Pain, Health, and HealingPalliative care specifically addresses the individual patient’s experience of suffering due to illness. Indeed, the philosophi-cal origins of palliative care began with attention to suffering and the existential questions suffering engenders. More than mere technologic evolution in the management of symptoms, the early proponents of palliative care sought


Surgery_Schwartz

Surgery_Schwartz. began with attention to suffering and the existential questions suffering engenders. More than mere technologic evolution in the management of symptoms, the early proponents of palliative care sought a revolution in the moral foundations of medicine that challenged the assumptions that so often seemed to result in futile invasive intervention, and identified many of the problems that were subsequently taken up by medical ethicists. This reorientation of the goals of medical care from a focus on disease and its management to the patient’s experience of illness focuses attention on the purpose of medicine and the meaning of health and healing.Over the past half century, several concepts and theo-ries about the nature of pain, suffering, and health have been proposed in service of the evolving conceptual framework of palliative care. For example, while considering the differences between disease-oriented and illness-oriented approaches to the care of seriously ill patients, psychiatrist


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Surgery_Schwartz. conceptual framework of palliative care. For example, while considering the differences between disease-oriented and illness-oriented approaches to the care of seriously ill patients, psychiatrist Arthur Kleinman wrote, “There is a moral core to healing in all societies. [Healing] is the central purpose of medicine . . . the purpose of medicine is both control of disease processes and care for the illness experience. Nowhere is this clearer than in the relationship of the chronically ill to their medical system: For them, the control of disease is by definition limited; care for the life problems created by the disorder is the chief issue.”33The relief of pain has been the clinical foundation for hospice and palliative care. Pain is defined by the International Association for the Study of Pain as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.”38 For purposes of interdisciplinary palliative care,


Surgery_Schwartz

Surgery_Schwartz. Pain as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.”38 For purposes of interdisciplinary palliative care, Saunders’s concept of “total pain”37 is a more useful definition and is frequently used as the basis for palliative assessments. Total pain is the sum total of four principal domains of pain: physical, psychologic, social or socioeconomic, and spiritual. Each of these contributes to, but is not synonymous with, suffering.Effective Communication and Negotiating the Goals of CareChanging the goals of care from cure to palliation near the end of life can be both emotionally and clinically challenging. It depends on determination of a clear prognosis and can be aided by effective communication. Unfortunately, prognostication can be notoriously difficult and inaccurate in advanced illness, and Christakis has argued that, to a large degree, physicians have abdicated their traditional


Surgery_Schwartz

Surgery_Schwartz. Unfortunately, prognostication can be notoriously difficult and inaccurate in advanced illness, and Christakis has argued that, to a large degree, physicians have abdicated their traditional responsibility to provide clear prognosis regarding incurable disease and approaching death.40 However, there are validated tools for prognosis in critical ill-ness (APACHE, MODS, etc.), and with most advanced diseases, functional status is the most powerful predictor of survival. For example, patients with advanced metastatic cancer who are rest-ing or sleeping for 50% or more of normal waking hours and require some assistance with activities of daily living (ADL) have a projected survival of weeks, and patients who are essen-tially bedfast and dependent for ADL have a projected survival of days to a week or two at best. Table 48-2 shows a simple prognostic tool to aid clinicians in recognizing patients nearing the end of life.Alternatively, the Karnofsky Performance Scale is a scale of


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Surgery_Schwartz. days to a week or two at best. Table 48-2 shows a simple prognostic tool to aid clinicians in recognizing patients nearing the end of life.Alternatively, the Karnofsky Performance Scale is a scale of functional status ranging from 100 (high level of function) to 0 (death). It is commonly used in palliative care to roughly assess a patient’s anticipated needs as well as prognosis. The Palliative Performance Scale41 is a validated42 expansion of the Karnofsky Performance Scale that includes five palliative-focused domains, including ambulation, activity level, self-care, intake, and level of consciousness, in addition to evidence of disease. The Missoula-Vitas Quality of Life Index is a 25-question scale specifically for palliative care and hospice patients that scores symptoms, function, interpersonal relationships, well-being, and spirituality. Updates and Spanish versions are available.39Regardless of the prognostic tool used, the prognosis should be conveyed to the patient and


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Surgery_Schwartz. interpersonal relationships, well-being, and spirituality. Updates and Spanish versions are available.39Regardless of the prognostic tool used, the prognosis should be conveyed to the patient and family. If done well, communication and negotiation with patients and families about advanced terminal illnesses can potentially avoid great 66Table 48-1Indications for palliative care consultationPatients with conditions that are progressive and life-limiting, especially if characterized by burdensome symptoms, functional decline, and progressive cognitive deficitsAssistance in clarification or reorientation of patient/family goals of careAssistance in resolution of ethical dilemmasSituations in which patient/surrogate declines further invasive or curative treatments with stated preference for comfort measures onlyPatients who are expected to die imminently or shortly after hospital dischargeProvision of bereavement support for patient care staff, particularly after loss of a colleague under


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Surgery_Schwartz. measures onlyPatients who are expected to die imminently or shortly after hospital dischargeProvision of bereavement support for patient care staff, particularly after loss of a colleague under careBrunicardi_Ch48_p2061-p2076.indd 206719/02/19 1:49 PM 2068SPECIFIC CONSIDERATIONSPART IITable 48-2Simple prognostication tool in advanced illness (especially cancer)FUNCTIONAL LEVELPERFORMANCE STATUS (ECOG)PROGNOSISAble to perform all basic ADLs independently and some IADLs2MonthsResting/sleeping up to 50% or more of waking hours and requiring some assistance with basic ADLs3Weeks to a few monthsDependent for basic ADLs and bed-to-chair existence4Days to a few weeks at mostThese observations apply to patients with advanced, progressive, incurable illnesses (e.g., metastatic cancer refractory to treatment).Basic ADL = activities of daily living (e.g., transferring, toileting, bathing, dressing, and feeding oneself); IADL = instrumental activities of daily living (e.g., more complex


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Surgery_Schwartz. to treatment).Basic ADL = activities of daily living (e.g., transferring, toileting, bathing, dressing, and feeding oneself); IADL = instrumental activities of daily living (e.g., more complex activities such as meal preparation, performing household chores, balancing a checkbook, shopping, etc.); ECOG = Eastern Cooperative Oncology Group functional (performance) status.Table 48-3Communicating unfavorable news: important principles• Setting: Find a quiet, private place to meet. Sit down close to the patient.• Listen: Clarify the patient’s and/or the family’s understanding of the situation.• “Warning shot”: Prepare patient and family and obtain their permission to communicate bad news (e.g., “I’m afraid I have bad news.”).• Silence: Pause after giving bad news. Allow patient/family to absorb/react to the news.• Encourage: Convey hope that is realistic and appropriate to the circumstances (e.g., patient will not be abandoned; symptoms will be controlled).psychologic harm and help make a


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Surgery_Schwartz. to the news.• Encourage: Convey hope that is realistic and appropriate to the circumstances (e.g., patient will not be abandoned; symptoms will be controlled).psychologic harm and help make a difficult transition easier. To communicate effectively and compassionately, it is helpful to pursue an organized process similar to the structured history and physical central to the evaluation of any patient. One such structured approach to delivering unfavorable news proposes six steps that can be easily learned by clinicians: (a) getting started by selection of the appropriate setting, introductions, and seating; (b) determining what the patient or family knows; (c) determining what the patient or family wants to know; (d) giving the information; (e) expressing empathy; and (f) establishing expectations, planning, and aftercare (Table 48-3).43 Success with this approach to breaking bad news is critically depen-dent upon the clinician’s ability to empathically respond to the patient’s (and


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Surgery_Schwartz. planning, and aftercare (Table 48-3).43 Success with this approach to breaking bad news is critically depen-dent upon the clinician’s ability to empathically respond to the patient’s (and family’s) reaction to the news.44 The empathic response does not require the surgeon to share the same emo-tions of the patient, but it does require the surgeon to identify the patient’s emotion and accurately reflect that awareness back to the patient. Such effective communication may be facilitated by involving other members of the healthcare team who have developed relationships with the patient and their family. Patient assessment in these conversations should give the highest prior-ity to identifying and responding to the most immediate source of distress. Relieving a pressing symptom is prerequisite for a more thorough search for other potential sources of suffering, and the assessment process itself can be therapeutic if conducted in a respectful and gentle manner.CARE AT THE END OF LIFEThe


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Surgery_Schwartz. for a more thorough search for other potential sources of suffering, and the assessment process itself can be therapeutic if conducted in a respectful and gentle manner.CARE AT THE END OF LIFEThe process of dying and the care of a patient at the time of death is a distinct clinical entity that demands specific skills from physicians. The issues specific to dying and the available tools for compassionate care at the end of life are addressed in this section.The Syndrome of Imminent Demise34,45In a patient who has progressed to the terminal stage of an advanced illness (e.g., cancer), a number of signs provide evi-dence of imminent death. As terminally ill patients progress toward death, they become increasingly bedbound, requiring assistance for all basic ADL. There is a steady decrease in desire and requests for food and fluids. More distressing to the dying patient is a progressively dry mouth that may be confused by the treating team as thirst. It is often exacerbated by


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Surgery_Schwartz. decrease in desire and requests for food and fluids. More distressing to the dying patient is a progressively dry mouth that may be confused by the treating team as thirst. It is often exacerbated by anticholinergic medications, mouth breathing, and supplemental oxygen (O2) administered without humidification.With progressive debility, fatigue, and weight loss, it is common for terminally ill patients to experience increasing dif-ficulty swallowing. This may result in aspiration episodes and an inability to swallow tablets, requiring alternative routes for medication administration (e.g., IV, SC, PR, sublingual, buccal, or transdermal). In addition to the increased risk of aspiration, patients near death develop great difficulty clearing oropharyn-geal and upper airway secretions, leading to noisy breathing or the so-called “death rattle.” As death approaches, the respiratory pattern may change to increasingly frequent periods of apnea often following a Cheyne-Stokes pattern of rapid,


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Surgery_Schwartz. to noisy breathing or the so-called “death rattle.” As death approaches, the respiratory pattern may change to increasingly frequent periods of apnea often following a Cheyne-Stokes pattern of rapid, progressively longer breaths leading up to an apneic period. As circulatory instability develops near death, patients may exhibit cool and mottled extremities. Periods of confusion are often accompanied by decreasing urine output and episodes of fecal and urinary incontinence.A number of cognitive changes occur as death approaches. Patients who are in the last days of life may demonstrate some signs of confusion or delirium. Agitated delirium is a promi-nent feature of a difficult death. Other cognitive changes that may be seen include a decreased interest in social interactions, increased somnolence, reduced attention span, disorientation to time (often with altered sleep-wake cycles), and an altered dream life, including vivid “waking dreams” or visual halluci-nations. Reduced hearing


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Surgery_Schwartz. reduced attention span, disorientation to time (often with altered sleep-wake cycles), and an altered dream life, including vivid “waking dreams” or visual halluci-nations. Reduced hearing and visual acuity may be an issue for some patients; however, patients who appear comatose may still be aware of their surroundings. Severely cachectic patients may lose the ability to keep their eyes closed during sleep because of loss of the retro-orbital fat pad.Common Symptoms at the End of Life and Their Management34,45,46The three most common, major symptoms that threaten the comfort of dying patients in their last days are respiratory Brunicardi_Ch48_p2061-p2076.indd 206819/02/19 1:49 PM 2069ETHICS, PALLIATIVE CARE, AND CARE AT THE END OF LIFECHAPTER 48Table 48-4Principles of pharmacotherapy in palliative care• Believe patient report of symptoms.• Modify pathologic process when possible and appropriate.• In terminally ill patients, avoid medications not directly linked to symptom


Surgery_Schwartz

Surgery_Schwartz. in palliative care• Believe patient report of symptoms.• Modify pathologic process when possible and appropriate.• In terminally ill patients, avoid medications not directly linked to symptom control.• Use a multidisciplinary approach.• Consider nonpharmacologic approaches whenever possible.• Engage participation of clinical pharmacist in treatment plan.• Select drugs that can multitask (i.e., use haloperidol for agitated delirium and nausea).• For pain, use adjuvant medications when possible (see Table 48-7).• When using opioids, spare when possible (adjuvant medication, local or regional anesthetics, surgical interventions, etc.).• Avoid fixed combination drugs.• Avoid excessive cost.• Select agents with minimum side effects.• Anticipate and prophylax against side effects.• For older adult patients, the hypoproteinemic, the azotemic: “Start low and go slow.”• Oral route whenever possible and practical.• No intramuscular injections.• Scheduled dosing, not as needed, for persistent


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Surgery_Schwartz. adult patients, the hypoproteinemic, the azotemic: “Start low and go slow.”• Oral route whenever possible and practical.• No intramuscular injections.• Scheduled dosing, not as needed, for persistent symptoms.• Stepwise approach. (See the World Health Organization Analgesic Ladder for pain, Table 48-5.)• Reassess continuously and titrate to effect.• Use equianalgesic doses when changing opioids (see Table 48-5).• Assess the patient’s and family’s comprehension of management plan.Table 48-5The World Health Organization’s three-step ladder for control of cancer pain30Step 1: mild pain (visual analogue scale, 1–3) Nonopioid ± adjuvant medicationStep 2: moderate pain (visual analogue scale, 4–6) Opioid for mild to moderate pain and nonopioid ± an adjuvantStep 3: severe pain (visual analogue scale, 7–10) Opioid for moderate to severe pain ± nonopioid ± an adjuvantThe primary treatment of dyspnea (air hunger) in the dying is opioids, which should be cautiously titrated to increase com-fort


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Surgery_Schwartz. 7–10) Opioid for moderate to severe pain ± nonopioid ± an adjuvantThe primary treatment of dyspnea (air hunger) in the dying is opioids, which should be cautiously titrated to increase com-fort and reduce tachypnea to a range of 15 to 20 breaths per minute. Air movement across the face generated by a fan can sometimes be quite helpful. If this is not effective, empirical use of supplemental O2 by nasal cannula (2–3 L/min) may bring some subjective relief, independent of observable changes in pulse oximetry. Supplemental O2 should be humidified to avoid exacerbation of dry mouth. Typical starting doses of an immedi-ate release opioid for breathlessness should be one-half to two-thirds of a starting dose of the same agent for cancer pain. For patients already on opioids for pain, a 25% to 50% increment in the dose of the current immediate release agent for breakthrough pain often will be effective in relieving breathlessness in addi-tion to breakthrough pain.The availability and variety


Surgery_Schwartz

Surgery_Schwartz. increment in the dose of the current immediate release agent for breakthrough pain often will be effective in relieving breathlessness in addi-tion to breakthrough pain.The availability and variety of drugs should not prevent consideration of nonpharmacologic therapy. Massage therapy, music therapy, art therapy, guided imagery, hypnosis, physi-cal therapy, pet therapy, and others play a constructive role not only for the relief of symptoms but also for promoting a sense of hope through improving function, aesthetic pleasure, and social connectedness. Talents and capacities neglected during the treatment and progression of disease can be recovered even in the most advanced stages of illness.Pain is often less of a problem in the last days of life because the reduced activity level is associated with lower inci-dent pain. This, combined with lower renal clearance of opioids, may result in greater potency of the prescribed agents. Severe pain crises are fortunately rare, but when they


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Surgery_Schwartz. with lower inci-dent pain. This, combined with lower renal clearance of opioids, may result in greater potency of the prescribed agents. Severe pain crises are fortunately rare, but when they are inadequately addressed, can cause great and lasting distress (complicated grief) for loved ones who witness the final hours or days of agony. Such situations may require continuous administration of parenteral opioids. As death approaches and patients become less verbal, it is important to assess pain frequently, including the use of close observation for nonverbal signs of distress (e.g., grimacing, increased respiratory rate). Adequate dosing of opi-oid analgesics may require alternate route(s) of administration other than oral as patients become more somnolent or develop swallowing difficulties. Opioids should not be stopped abruptly, even if the patient becomes nonresponsive, because sudden withdrawal can cause severe distress.49,50Cognitive failure at the end of life is manifested in