Residency · Residency · General Surgery
Surgical Palliative Care
Introduction
Surgical palliative care is the integration of palliative medicine principles into surgical practice for patients with life-limiting illness. It encompasses the use of surgical procedures to relieve suffering, management of complex symptoms in surgical patients, and facilitation of goals-of-care discussions. Approximately 10 to 15% of surgical procedures in the United States are palliative in intent. The general surgeon must be skilled in recognizing when cure is no longer achievable, communicating effectively with patients and families, and selecting interventions that maximize quality of life while minimizing treatment burden.
Defining Palliative Surgery
Palliative surgery is any operative procedure performed with the primary intent of relieving symptoms or improving quality of life, without the expectation of cure. Clear documentation and communication of palliative intent is critical, as patients often overestimate the curative potential of palliative procedures. Palliative care is not synonymous with end-of-life care; palliative interventions can occur alongside disease-directed therapy at any stage of illness. The "double effect" principle acknowledges that a procedure may have both palliative and life-prolonging effects, with the primary intent determining its classification.
Common Palliative Surgical Procedures
Malignant Bowel Obstruction (MBO)
Malignant bowel obstruction occurs in 5 to 43% of patients with advanced abdominal and pelvic malignancies, most commonly in ovarian and colorectal cancer. Assessment must differentiate complete from partial obstruction, single versus multiple levels of obstruction, and functional obstruction from carcinomatosis without a discrete obstruction point versus mechanical obstruction.
Surgical options include resection with anastomosis when a single point of obstruction exists and the patient has reasonable functional status; bypass of proximal bowel to distal bowel when resection is not feasible; diverting stoma with loop ileostomy or colostomy for distal obstruction, which can often be performed with local anesthesia; and enteral stenting with self-expanding metallic stents for colonic obstruction, particularly left-sided, which avoids surgery in poor surgical candidates but carries complication rates including perforation of 4 to 12%, migration, and re-obstruction.
Non-surgical management is appropriate when diffuse carcinomatosis causes multifocal obstruction. Options include nasogastric tube decompression, venting gastrostomy, octreotide to reduce secretions by approximately 50%, dexamethasone to reduce edema, hyoscine butylbromide to reduce colic, and IV fluids. Decision-making should consider functional status (ECOG/KPS), extent of disease, number of obstruction points, nutritional status, patient goals, and expected survival.
Malignant Gastric Outlet Obstruction
Endoscopic duodenal stenting is preferred for patients with expected survival under 3 to 6 months because of faster recovery and fewer complications. Surgical gastrojejunostomy is preferred for patients with expected survival exceeding 3 to 6 months because of more durable relief. Prophylactic gastrojejunostomy may be considered during palliative bypass for pancreatic cancer, as it reduces future gastric outlet obstruction from 19% to 2%.
Malignant Biliary Obstruction
Endoscopic retrograde cholangiopancreatography (ERCP) with stenting is the first-line approach for distal biliary obstruction, with metal stents preferred over plastic for longer patency (median 6 to 9 months versus 3 to 4 months). Percutaneous transhepatic biliary drainage is used for proximal (hilar) obstruction or when ERCP fails. Surgical bypass with hepaticojejunostomy or choledochojejunostomy is reserved for cases where endoscopic and percutaneous approaches fail or when open exploration for planned resection reveals unresectable disease.
<image>Decision algorithm for management of malignant bowel obstruction showing the assessment of obstruction type (single vs. multiple levels, complete vs. partial), patient functional status, and treatment options ranging from surgical intervention (resection, bypass, stoma) to non-surgical palliation (venting gastrostomy, octreotide, corticosteroids), with expected outcomes and survival considerations at each decision point</image>
Malignant Ascites
Repeated paracentesis provides symptomatic relief but may require weekly procedures. Indwelling peritoneal catheters such as PleurX catheters allow home drainage, reducing the need for hospital visits, with an infection rate of 5 to 10%. Peritoneovenous shunts (Denver shunts) are less commonly used and connect the peritoneal cavity to the superior vena cava, with complications including DIC, shunt occlusion, and infection. HIPEC may be considered in select patients with low-volume malignant ascites from peritoneal carcinomatosis.
Other Palliative Procedures
Pathologic fracture fixation through intramedullary nailing or arthroplasty allows mobilization and pain relief. Tumor debulking addresses fungating, bleeding, or infected tumors causing refractory symptoms. Palliative gastrectomy may occasionally be indicated for refractory bleeding or obstruction. Nerve blocks, including celiac plexus block for pancreatic cancer pain and superior hypogastric plexus block for pelvic pain, provide targeted analgesia.
Goals-of-Care Communication
The SPIKES Protocol
The SPIKES protocol provides a structured framework for delivering difficult news. Setting involves choosing a private room, sitting down, ensuring adequate time, and inviting key family members. Perception involves assessing the patient's understanding of their condition by asking what they have been told about their illness. Invitation involves asking permission to share information. Knowledge involves sharing information in clear, simple language, avoiding jargon, and delivering it in small pieces. Emotions involves acknowledging and responding to emotional reactions with empathy, recognizing that silence and presence are therapeutic. Strategy and Summary involves discussing next steps, establishing goals, and summarizing the plan.
Surgical Decision-Making Framework
Several guiding questions assist in surgical decision-making for palliative patients. The "surprise question" asks whether the surgeon would be surprised if the patient died within 12 months; an answer of "no" identifies patients who would benefit from palliative care integration. Additional questions include what the best and worst outcomes of the procedure might be, what the patient's life would look like with and without the procedure, and whether the expected benefit justifies the procedural risk, recovery time, and hospital stay relative to remaining life expectancy. Shared decision-making presents options including non-surgical alternatives and the option of no intervention, aligning treatment with patient values and goals.
<image>Illustration of the shared decision-making framework for palliative surgical procedures showing a balance scale with treatment benefits (symptom relief, functional improvement, dignity) on one side and treatment burdens (operative risk, recovery time, hospitalization, complications) on the other, with patient values, goals, and prognosis as the fulcrum, surrounded by the multidisciplinary team members involved in the discussion</image>
Symptom Management in Surgical Patients
Pain Management
The WHO analgesic ladder progresses from Step 1 (non-opioid) through Step 2 (weak opioid) to Step 3 (strong opioid), with adjuvants at every step. A multimodal approach combines acetaminophen, NSAIDs when not contraindicated, gabapentinoids for neuropathic pain, corticosteroids for inflammatory pain, and regional anesthesia. Opioid management requires titration to effect with scheduled dosing and breakthrough doses, rotation for tolerance or side effects, and use of equianalgesic conversion tables. Interventional pain management options include neuraxial analgesia, nerve blocks, and intrathecal pumps for refractory pain.
Other Symptoms
Nausea and vomiting management begins with identifying and treating reversible causes, followed by ondansetron for chemoreceptor trigger zone-mediated nausea, metoclopramide for gastroparesis (avoiding its use in complete obstruction), haloperidol for refractory nausea, and dexamethasone as an adjunct. Delirium is the most common neuropsychiatric complication in surgical patients; management involves identifying and treating the underlying cause such as infection, medications, or metabolic derangement, with haloperidol for hyperactive delirium and avoidance of benzodiazepines except in alcohol withdrawal. Malignant wound care requires odor control with topical metronidazole, bleeding management with topical tranexamic acid or epinephrine-soaked gauze or radiation, and psychosocial support.
Ethical Considerations
A procedure is considered futile when it cannot achieve its physiologic goal or when the burden clearly outweighs the benefit; surgeons are not obligated to perform futile procedures. Withdrawal of life-sustaining treatment is legally and ethically equivalent to withholding treatment, and the surgeon's role includes supporting families through this process. Advance directives and POLST forms should be discussed and documented preoperatively, and "do not resuscitate" status should be addressed before any surgical procedure, with the possibility of suspension during surgery with informed consent. Moral distress occurs when surgeons and surgical teams are asked to perform procedures of questionable benefit; institutional ethics consultation and debriefing are important resources.
Clinical Pearls
Palliative surgery should be offered when the expected symptom relief outweighs the procedural risk and recovery burden relative to the patient's remaining life expectancy. Malignant bowel obstruction in the setting of diffuse carcinomatosis is often best managed non-surgically with pharmacologic decompression using octreotide, dexamethasone, and venting gastrostomy. Goals-of-care conversations are a procedural skill that improves with practice, and the SPIKES protocol provides a reliable framework. The "surprise question" is a simple screening tool to identify surgical patients who would benefit from palliative care integration. DNR status should be explicitly discussed and documented before palliative procedures, with a nuanced approach allowing suspension during the procedure and reactivation postoperatively.
References
- Krouse RS, Nelson RA, Farrell BR, et al. Surgical palliation at a cancer center: incidence and outcomes. Arch Surg. 2001;136(7):773-778.
- Lilley EJ, Khan KT, Johnston FM, et al. Palliative care interventions for surgical patients: a systematic review. JAMA Surg. 2016;151(2):172-183.
- Baile WF, Buckman R, Lenzi R, et al. SPIKES: a six-step protocol for delivering bad news. Oncologist. 2000;5(4):302-311.
- Paul Olson TJ, Pinkerton C, Brasel KJ, Schwarze ML. Palliative surgery for malignant bowel obstruction from carcinomatosis: a systematic review. JAMA Surg. 2014;149(4):383-392.
