Palliative Surgery

Dr. Mohamed Alasmar M.S. MRCS

Objectives

• What is “Palliative” Surgery?• How to manage terminally ill patients?– How to communicate?– How to relieve symptoms?– What surgery required?

Definitions

• What is meant by “Terminally ill” patient?• A terminally ill patient is – one with a confident diagnosis that cure is impossible.– Prognosis is usually months or less.– Treatment is aimed at relief of symptoms. – Most such patients have advanced cancer, but non-

malignant disease also falls within this definition, – such as the end stage of renal failure, chronic

obstructive airways disease, multiples clerosis,(AIDS)and motorneuron disease.

Definitions

What is Palliative Surgery?• Palliative Surgery

– (Latin palliare - to disguise, extenuate)– A surgical procedure used with the primary intention of

improving QOF or relieving symptoms caused by an advanced disease.

– the effectiveness of palliative surgery is judged by the presence and durability of patient-acknowledged symptom resolution.

• Noncurative Surgery– operations with curative intent in asymptomatic patient that

result in residual disease or positive margins.

Communication• Communication is difficult with patients who have advanced incurable

illness.• COMMON EMOTIONAL REACTIONS

– Anxiety, Depression, Denial and Anger

• What to do?• These fears lead to the use of certain tactics in order to keep patients at

a safe emotional distance:– Premature reassurance. You reassure the patient that you can control physical

symptoms when the real issue is the patient's underlying emotional fears.– Selective attention. You avoid addressing the emotional issue by selecting the

physical problem for attention.– Changing the topic when emotional issues are raised.– Closed questions.

Communication

• Give Clear Explanations of the physical and functional outcome of surgery.

• Patients handle side-effects better and gain trust in you if they understand the rationale for treatment.

• If they are given accurate facts about their diagnosis and treatment they adapt better to radical surgery.

• It gives them the opportunity to prepare psychologically for the major physical changes associated with procedures such as: radical mastectomy, colostomy and head and neck surgery.

SYMPTOM CONTROL• Diagnose the cause and treat appropriately.• Vomiting may be due to:

– Raised intracranial pressure– Drugs– Hepatomegaly– Intestinal obstruction, etc.

• Each of these requires specific management.

• Explain symptoms to the patient. Discuss the treatment options.• Set objectives that are realistic.

– It is frustrating for both patient and staff if expectations are set that will never be achieved.

• Anticipate. With advancing illness, symptoms may change rapidly.

Symptoms

Pain

• CausesPain may be due to a malignant cause but in up

to a third of patients with advanced cancer the underlying cause is non-malignant.– Bone pain– Visceral pain– Nerve pain– Myofascial pain– Superficial pain

Pain Management

• STEP1: Non opioid +/- adjuvant, such as paracetamol.

If the pain is not relieved with 2 paracetamol 6-hourly move onto:

• STEP2: Weak opioid +/- adjuvant, such as tramadol.

If the pain is not relieved move onto:• STEP3: Strong opioid +/- adjuvant, such as

morphine.

Pain

• Management– Pain can be significantly modified in nearly all patients and fully

relieved in many.– Not all pain requires analgesia; for example, the pain of constipation

is best treated with laxatives, not analgesics.– Prescribe it regularly to pre-empt pain. An "as-required" basis

results in poor pain control, increased incidence of side-effects and the use of higher doses overall.

• Prescribe “p.r.n.” (SOS) doses of analgesic for:– "Breakthrough" pain - that breaks through the background

analgesia.– "Incident" pain - that is precipitated by painful incidents such as

dressing changes.

Weakness and Immobility

• What are the possible Causes?– A patient who is immobile and confined to bed loses muscle

strength.– A normal person loses 10-15% of muscle strength when

completely rested for 1 week and it takes 60 days to restore that strength.

• What to do?– Good nursing care and regular physiotherapy– Steroids– special mattresses– wheelchair

Anorexia• What are the possible Causes?

– Tumour bulk and associated biochemical abnormalities (hypercalcaemia, uraemia, etc.)

– Oral problems(e.g. thrush, oral tumour)– Constipation– Drugs, radiotherapy– Depression or anxiety– Fear of Vomiting

• What to do?– Treat the Cause.– Presentation of food is important - it should be in small portions and well

presented.– Consider progestogens or steroids as appétit stimulants.

Dysphagia

Nausea and vomiting

Bowel Obstruction

Surgical procedures

• The three main determinants for selecting a procedure include: 1. the patient's symptoms and personal goals; 2. the expected impact of the procedure on quality

of life, function, and prognosis.3. the prognosis of the underlying disease (time

and functional decline expectations)

Surgical procedures• Drainage procedures for ascites, plural effusions or pericardial

effusions.• Laparotomy/laparoscopy and bypass or resection for relief of biliary

or bowel obstruction• Resection of tumor (debulking) for relief of pain, constitutional

symptoms, control of odor.• Endoscopic interventions for stenting an obstructed lumen, ablation

of tumor, hemostasis.• Gastrostomy (PEG) placement for relief of obstruction, hunger or

feeding.• Craniotomy for excision of symptomatic matastasis or for

hemorrhage.• Fixation of pathological fracture.

Surgical procedures

• Major amputation for painful, nonviable extremity.• Tumor embolization procedures.• Surgical procedures for metastatic spinal cord

compression.• Suprapubic cystostomy for bladder outlet obstruction.• Simple mastectomy (toilet).• Tracheostomy.• Biopsy procedure to guide palliative treatment.• Vascular access procedures for medication

administration, dialysis and parenteral nutrition.

?

• To summarize,

American College of Surgeons’ Statement of Principles of Palliative Care

1. Respect the dignity and autonomy of patients, patients’ surrogates, and caregivers.

2. Honor the right of the competent patient or surrogate to choose among treatments, including those that may or may not prolong life.

3. Communicate effectively and empathetically with patients, their families, and caregivers.

4. Identify the primary goals of care from the patient's perspective, and address how the surgeon's care can achieve the patient's objectives.

5. Strive to alleviate pain and other burdensome physical and nonphysical symptoms.

6. Recognize, assess, discuss, and offer access to services for psychological, social, and spiritual issues.

7. Provide access to therapeutic support, encompassing the spectrum from life-prolonging treatments through hospice care, when they can realistically be expected to improve the quality of life as perceived by the patient.

8. Recognize the physician's responsibility to discourage treatments that are unlikely to achieve the patient's goals, and encourage patients and families to consider hospice care when the prognosis for survival is likely to be less than a half-year.

9. Arrange for continuity of care by the patient's primary or specialist physician, thus alleviating the sense of abandonment patients may feel when “curative” therapies are no longer useful.

10. Maintain a collegial and supportive attitude toward others entrusted with care of the patient

American College of Surgeons’ Statement of Principles of Palliative Care

References

• Clinical Surgery in General (RCS Course Manual) 4E– Edited by R.M.KirkM MS FRCS, W.J.Ribbans FRCS

FRSC Ed Orth• Surgical Palliative Care: Residents Guide 2009– American College of Surgeons– Geoffrey P. Dunn MD FACS , Robert Martenson MD

PhD, David E. Weissman MD FACP

• Thank you