It should be noted, though, that physicians are subject to a
“condition” of their own. Surgeons, in particular, are apt to
focus primarily on a “cure” from the technical standpoint,
rather than taking a step back and looking at the big picture.
patient’s definition of a successful outcome. However,
assessing potential harm and interpreting the likelihood
of a successful outcome should be performed by the skilled
physician and not the untrained patient or proxy. A definition of mutual decision making should be just that—mutual.
Patients often appreciate appropriate guidance from the
It should be noted, however, that physicians are subject
to a “condition” of their own. Surgeons, in particular, are
apt to focus primarily on a “cure” from the technical standpoint, rather than taking a step back and looking at the big
picture. As such, a shift in training and practice for many
surgeons is necessary. More specifically, surgeons should
be educated about the goals and ideals of palliative care
medicine and encouraged to use these services more often.
Physician and surgeon incentives, financial and otherwise, also must change. In a case such as the one described
at the beginning of this article—a 93-year-old woman with
Alzheimer’s dementia and a medical history that includes
congestive heart failure—the surgeon is less apt to provide
nonoperative treatment. Although he or she will spend the
same amount of time on the operation as it would to take
to meet and discuss care planning with the family, the latter
activity would only pay a fraction of the potential procedural fee.
Nonoperative planning also requires skilled communication with a humanistic approach. Many surgeons lack
adequate training in how to discuss this form of patient
care. Thus, surgeons will need to develop a new skill set so
that discomfort does not prevent them from participating
in appropriate palliative care conversations. These conversations should be patient-centered but not patient-driven. They
should be time-sensitive, but not rushed—particularly since
research suggests increased communication leads to greater
patient satisfaction and a decrease in futile treatments. 10, 11
In the words of Hippocrates, the physician is sometimes
mandated to “refuse to treat those who are overmastered by
their disease, realizing that in such cases medicine is powerless.” 12 In these cases, we hope that surgeons will resist
offering futile options and focus more on compassionately
guiding patients and their families through the difficult process of end-of-life care. ♦
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