As the call to employ patient-centered care in medicine has grown, in surgery and beyond, so too has the recognition that addressing a patient’s needs may take more than an operation, especially when a physical ailment may be incurable. In such cases, where a patient and the family are dealing with a life-threatening illness, or profound suffering of any kind, surgical palliative care may be exactly what is needed. To help spread knowledge of the growing field, three surgeons also board certified in hospice and palliative medicine—Melissa Red Hoffman, MD, ND, FACS; Buddy Marterre, MD, MDiv, FACS; and Pringl Miller, MD, FACS—in 2020 co-founded the Surgical Palliative Care Society (SPCS) (see Figure 1).
FIGURE 1. FOUNDERS OF THE SPCS
Formally launched in July, the SPCS promotes a holistic vision of surgical practice that focuses on the well-being of patients, families, caregivers, and the health care team by addressing all types of suffering associated with surgical disease.* “We’re trying to broaden the scope of surgical care to address all aspects of what makes a person well,” said Dr. Miller, general surgeon, hospice and palliative medicine specialist, and clinical medical ethicist. “This has always been important in surgery, but now we have a better understanding of whole-person care and how this approach to clinical care should be integrated into surgical care.”
Though the philosophical and technical concepts behind surgical palliative care have existed for decades, it is within the last 25 years that they have gained footing with the broader surgeon population, in part through the strong support of the American College of Surgeons (ACS). This article summarizes some of the tenets of surgical palliative care and the need for the SPCS, the role of the ACS in promulgating principles of surgical palliative care, and the function and form of the SPCS in its early days and goals for the future.
What is surgical palliative care?
Many surgeons may not have been formally exposed to the principles of surgical palliative care or understand why it would benefit patients and families and their practice. Understanding these tenets can explain the need for expanding surgeons’ knowledge of the field and for the SPCS itself.
Surgical palliative care principles
Dr. Hoffman, an acute care surgeon and associate hospice medical director, Mission Health, Asheville, NC, defined surgical palliative care as “the attention to suffering in all of its manifestations of the patient and the family under surgical care.” There are several core concepts built in to that framework, according to Dr. Hoffman. Performing surgical procedures, such as relieving gastric outlet obstruction or implanting an esophageal stent to aid a patient with esophageal cancer, are important tools of symptom relief, at which surgeons are innately skilled. But surgical palliative care extends far beyond palliative surgical procedures.
“This is care delivered in parallel with high-tech surgical procedures and medical treatments and focuses on identification and relief of patient suffering in all aspects of humanity,” said Dr. Marterre, assistant professor, surgery and internal medicine, Wake Forest School of Medicine, Winston-Salem, NC. “Not only does surgical palliative care address physical suffering, but it also aims to treat psychological suffering, social suffering, and spiritual suffering, as well.” As Dr. Miller added, it is “patient-centered, whole-person care.”
“It is a common misconception that palliative surgery is what we’re talking about when we talk about surgical palliative care,” said Geoffrey Dunn, MD, FACS, retired chair, department of surgery, and retired medical director, palliative care consultation service, University of Pittsburgh Medical Center Hamot, Erie, PA, who is referred to as the “father of surgical palliative care.” “However, that’s only a tool within surgical palliative care—an arrow in our quiver.”
Holistic surgical palliative care also involves the recognition of palliative care needs, which may be the most foundational element. “Sometimes I rotate into the intensive care unit (ICU) and wonder, ‘Why haven’t we been having goals of care discussions? Why aren’t we talking to the family about what we think is the likely prognosis? Why haven’t we consulted with the palliative care team?’” Dr. Hoffman said, noting that palliative care often is not adequately addressed in patients who could use it most. She also spoke of the foundational work of Anne Mosenthal, MD, FACS, chief academic officer, Lahey Hospital & Medical Center, Burlington, MA, and a renowned figure in this specialty, who has suggested that seriously ill or injured patients should have a palliative care assessment within 24 hours of entering a hospital.
Other important aspects of surgical palliative care include the following:
- Psychological, social, and spiritual support, including providing access to trained mental health experts, social workers, chaplains, and so on
- Guiding patients through decision-making, with a framing discussion of prognosis and helping to focus treatment pathways on realistic value-congruent goals in a way that makes sense to them and their families
- Appropriate and timely referral to hospice, when needed
These responsibilities are well within the scope of any surgeon, especially when palliative care is fully integrated into practice patterns. “This care can become part of your daily practice caring for patients, particularly if you care for people who are seriously ill,” Dr. Mosenthal said, explaining that like any other quality check in surgery, integrative palliative care is a series of time-based processes that can be formatted like a checklist. These skills are mostly focused on communication. “Asking patients if they have a health care proxy, asking about their advance directive, and discussing their prognosis in a compassionate way. Many of us do these things already, but integrative palliative care formalizes it as a skill. None of us want more requirements for what we need to do and document, but we can all get excited if we think these skills will help our patients to do better,” Dr. Mosenthal said.
It is important to remember that this additional set of skills aimed at alleviating suffering is not at odds with technical proficiency or achievement. “Some of the people that laid the foundation for the philosophical framework [of surgical palliative care] were innovators in surgery and highly skilled technical surgeons,” Dr. Dunn said. “The impetus for what they did was relief of suffering, and not even necessarily a cure. The original impulse was to provide relief and dignity to their patients.”
Working against misconceptions
With easing patient suffering as the goal, the principles of surgical palliative care are nothing if not beneficial to patients, and yet, part of the challenge in the field, and for the SPCS, is fighting against some surgeons’ misconceptions that palliative care is only needed for older patients and those for whom death seems imminent, or that introducing palliative care to a patient constitutes failure.
“Surgeons may think that palliative care is synonymous with hospice and that it is only appropriate for people who are elderly and/or dying, and we’re trying to help change that mindset through the society.”
According to Dr. Miller, changing surgeons’ minds about these misconceptions is one of the goals of the SPCS. “Surgeons may think that palliative care is synonymous with hospice and that it is only appropriate for people who are elderly and/or dying, and we’re trying to help change that mindset through the society,” she said.
Perhaps even more pernicious is the belief that palliative care is meant to be employed only as a last resort after a disappointing end to treatment. “There are a lot of corollaries to the basic misconception that successful surgery and palliative care are mutually exclusive, such as that palliative care principles only get applied when there’s ‘nothing more we can do,’ for the patient,” Dr. Marterre said. However, surgeons and care teams are not limited to only curative surgical intervention, as previously noted. To address the physical, emotional, and spiritual sides of a patient’s suffering, which will not solve their physical ailments but will improve their quality of life, is not “giving up.”
“One of the beautiful character traits of surgeons is that we take our jobs so seriously, and we’re so intimately involved with our patients. So, when there is a complication, foreseen or not, or the end result of care is not total health, a lot of surgeons see any of these episodes as a failure. But as long as we keep our patient at the center of our view in a holistic, whole-person way, there is no such thing as a failure,” Dr. Marterre said.
In some ways, surgeons have become victims of the technical, lifesaving successes that have defined the field. “We can be so blinded by the successes and developments in surgery that we forget how to handle things that couldn’t be fixed, or shouldn’t be fixed,” Dr. Dunn said. “There is only one place where death is the enemy—that’s the operating room. If it happens somewhere else, then it might be exactly what was supposed to happen; it might be natural, and it might not be something to fix.” Learning the tenets of surgical palliative care provides surgeons and care teams the skills needed to attend to a patient’s wants and needs, even when the ultimate outcome of treatment may be death, Dr. Dunn suggested.
And while it is critically important to ensure that young surgeons have a clear idea of the importance of surgical palliative care so that they incorporate it into their future practice, it may be more challenging to persuade mid-career or senior surgeons to formally take up this set of skills. However, according to Dr. Mosenthal, framing that conversation in a positive light can help. “If you are talking to a mid-career and senior surgeon who already has a full plate, you could say, ‘You might be using some of these skills already, but here’s some education and training that will help you do it better, and your patients will have better outcomes,’” she said, noting that the SPCS will be important in this space in offering standardized training courses in communication skills, having a difficult conversation, guiding preoperative goals of care discussions, and so on.
Addressing provider well-being
The focus of surgical palliative care is on addressing the suffering of the patients, families, and caregivers in times of great stress and angst. However, one of the unique elements of the practice is the support that it provides to the care team, and the SPCS aims to nurture that element within its members and the field, as well.
As a trauma surgeon, Dr. Hoffman explained that she and her team often find themselves in the position of interacting with patients and families who have a difficult communication dynamic or of delivering a devastating diagnosis to a young patient. In these moments, the whole ICU team can experience mental trauma, and the team-based nature of the practice can help its members cope. “Surgical palliative care provides an extra layer of support for the care team so we can continue to provide necessary care to everyone else,” Dr. Hoffman said. “The magic of the practice is that it’s a team sport, and we can support one another at the same time we are supporting our patients.”
For the SPCS, that support extends beyond patient-facing interactions to fostering a sense of togetherness for the entire field. “With the society, this camaraderie and fellowship means creating a venue for being able to help share concerns, joys, and angst,” according to Dr. Marterre. “The society will be a well-being benefit to members, and it will give us a tent to meet under in different formats. There’s a common bent among those of us interested in surgical palliative care, and it’s nice to know you’re not the only kid on the block.”
Dr. Miller added, “I think that part of the formation of the society was based on building community and supporting each other in this rare hybrid of specialty interests and to promote evidence-based practice that we’re learning benefits patients and their families.” Building that sense of community, common purpose, and fellowship was one of the primary goals of the SPCS in its early days and will help to develop a shared direction to pursue as it develops.
The ACS and surgical palliative care
One of the primary goals of the SPCS is to spread awareness of the principles of and the need to incorporate palliative care into surgical practice, and yet the tenets of surgical palliative care may sound familiar to many Fellows of the ACS. The College has been a strong supporter of palliative care for surgical patients for more than 20 years, and several College leaders, including Drs. Dunn and Mosenthal; task forces; and committees have helped to develop the field to the point where an organization such as the SPCS is ready to take its place as a leading organization.
Dr. Dunn explained the impetus behind the College becoming involved in surgical palliative care, including the role he and Robert Milch, MD, FACS, played in introducing the need for the practice to Fellows at a 1997 ACS symposium on physician-assisted suicide. At the invitation of the late Thomas J. Krizek, MD, FACS, a Past-First Vice-President of the ACS and Past-Chair of the Committee on Ethics, Dr. Dunn laid out for the audience how surgeons were intimately involved in palliative care through pain management, delivering adverse news in a compassionate way, wound care, and so on.
There was a spike of interest in the field after his talk, and Dr. Dunn felt that the ACS was needed to promulgate its tenets because, he said, “Only the College had the scientific, the social, and the moral credibility to really get this message out to surgeons.” Dr. Milch—who passed away earlier this year and was a pioneer in palliative care in general and had vast experience in leading and developing hospice care in the U.S.—and Dr. Dunn were selected to Co-Chair the ACS Task Force on Surgical Palliative Care. Dr. Mosenthal, who now is Chair of the Committee on Surgical Palliative Care, recalled the early days of the College’s support, as well. “The ACS was pivotal in seeing this vision of how to integrate palliative care into surgical practice, which, prior to around the year 2000, when our group formed, was really considered an either/or decision,” she said.
These key Fellows eventually developed principles and statements that would prove formative for the field of surgical palliative care. In 1998, the Committee on Ethics, with help from members of the task force, developed and released the Statement of Principles Guiding Care at the End of Life; however, these principles evolved and were replaced by the Committee’s revised Statement of Principles of Palliative Care in 2005, which expanded palliative care as a concept useful in addressing any patient who was suffering, not only patients who were approaching death.† Asserting that “the tradition and heritage of surgery emphasize that the control of suffering is of equal importance to the cure of disease,” this statement and its constituent 10 principles, some 16 years after development, continue to serve as a bedrock of surgical palliative care and have informed continuing guidance for the founders of the SPCS.
The College’s commitment to surgical palliative care extended beyond statements to institutional support from leaders such as Olga M. Jonasson, MD, FACS, Past-Medical Director, ACS Education and Surgical Services Department, who lobbied for the American Board of Surgery to sponsor a certifying board exam in hospice and palliative medicine. Additionally, the ACS released Surgical Palliative Care: A Resident’s Guide in 2009, which continues to serve as a comprehensive resource for surgical trainees and practicing surgeons interested in the field. Dr. Dunn served as Editor-in-Chief of the guide.
Function and form of the SPCS
Building on established principles of surgical palliative care and a history of support from the ACS, the SPCS is well-positioned to grow with the stewardship of Drs. Hoffman, Marterre, and Miller, who are three among the fewer than 100 individuals dually board-certified in surgery and in hospice and palliative care in the U.S. They want to use the unique experiences of this subset of surgeons to identify how the society and the field can develop in the coming years.
The SPCS has long-term goals to provide mentorship, education, research, quality improvement, and advocacy services to its members, but it is counting on using early members to help drive the organization’s initial agenda.
The SPCS has long-term goals to provide mentorship, education, research, quality improvement, and advocacy services to its members, but it is counting on using early members to help drive the organization’s initial agenda. “We’re still trying to find out from members what they want the society to offer them,” Dr. Miller said. “We’re starting from a place of fellowship, networking, support, education, and collaboration that is singularly focused [on surgical palliative care], as opposed to being a smaller group within a large organization,” such as the ACS. In the short term, the SPCS wants to serve as a repository of information and resources on surgical palliative care that surgeons and care teams might find useful and that can help to generate interest in this distinct field of study and practice.
In addition, because the small number of hospice and palliative care-certified surgeons may have specialized knowledge within the field, the SPCS ideally will help to spread knowledge among members of the group. “My hope is that since we have so few surgeons who are board certified [in palliative surgery] that we can take advantage of those who are and use their knowledge to educate the rest of us,” Dr. Hoffman said. “Members who are more experienced with hospice, for example, could share their specialized knowledge with colleagues who might focus more on inpatient palliative care and vice versa.”
Dr. Hoffman also wants to emphasize to interested surgeons that board certification is not necessary to use the principles of surgical palliative care. “The vast majority of surgeons are not going to do a fellowship in hospice and palliative medicine, but one of the most important messages I want to spread through the society is that you don’t need to do a fellowship to integrate palliative care into your practice,” she said. “We hope to be a source of information and education for our colleagues, through webinars, through society meetings, and through our monthly newsletter about how to practice primary palliative care.”
Inclusivity in practice and leadership
Inclusivity lies at the heart of the SPCS, Dr. Dunn said. “What excites me about the society is that it’s another step forward in the integration of the idea of surgical palliative care into surgery—an autonomous, independent society that’s open not just to surgeons but to people with nonsurgical training who are necessary contributors to palliative care,” including nurses, social workers, and members of the clergy, among others. This expansive definition of who is included in a care team is reflected in the ethos of surgical palliative care itself, as it is only by addressing the spectrum of a patient’s personhood that their needs, medical and otherwise, can be met.
According to Dr. Miller, “Leaders in this space are curious and reverential to what makes a person themselves and how that translates to what treatments they want.” Above almost any other principle, “We want to be sure we’re honoring their personhood, respecting autonomy and not violating their bodily integrity for an indicated treatment that may not be important to them as a person,” said Dr. Miller, who has extensive experience in promoting equity and inclusion in health care. This whole-person care fosters autonomy and is vital to helping a surgical palliative care team identify the primary goals of care from the patient’s perspective, which is one of the ACS’s principles of palliative care.†
One of the distinguishing features of the SPCS is that not only will its content be informed by the team-based principles of palliative care, so too will its leadership. Dr. Marterre, an experienced beekeeper, explained how the unique leadership structure of the society is based on the “swarm intelligence” exhibited by bees. “Swarm intelligence is a nonhierarchical structure. There is no honeybee that is in charge, even the queen,” Dr. Marterre said. Similarly, the SPCS will have “no president, no past-president, no secretary, no treasurer—the typically hierarchical structure that works so well in surgery and is so important, particularly in the operating room. But in a society like this, we felt like it was important that we do away with hierarchy so that all voices in leadership are heard on an equal level,” he said.
He added that “swarm intelligence allows for more efficient, better decision-making than the typical hierarchical structure that almost all other surgical societies employ. The issues bubble to the surface and get dealt with in an efficient fashion. But you need to check your ego at the door, which is important in a servant-leadership model.” Multiple solutions can come from different leaders—a council, a committee—and a natural affinity toward one solution develops organically. Above all else, “We respect everyone else’s voice and provide honor and dignity and make sure that everyone is heard, which is just as important in palliative care consultation or a family meeting as it is among colleagues,” Dr. Marterre said.
Building on a legacy of alleviating suffering
The SPCS’s launch in many ways meets the needs of a modern moment, in which patient-centered care and addressing the holistic needs of a patient, the family, the caregivers, and even health care teams have been recognized as critical to achieving better value and outcomes in health care. It builds on the seminal work of key figures who nurtured and developed surgical palliative care, within the ACS and without, into an area of practice that necessitates a dedicated society to continue to grow—a legacy that Drs. Mosenthal and Dunn are proud to see continue.
“In many ways, the society is a culmination of what we didn’t know we were starting more than 20 years ago,” Dr. Mosenthal said. “It makes me feel proud that what began as a vision has come to this point. I feel assured that this legacy will continue to grow and change the field and bring more young people into it. No field is sustainable if you don’t have young people who think of it as a career pathway.”
Dr. Dunn added, “I saw a lot of rolling eyes and slammed doors when I initially began talking [about the importance of surgical palliative care]. I got a lot of pushback, and not necessarily only from surgeons,” he said. “To see the field come to this level of sophistication, to see people with fellowship training, certified in this specialty, and now starting a society, to see it come to this level, it gives me hope in the next generation and a supreme sense of satisfaction, pride, and relief. The idea is in good hands.”
*The Surgical Palliative Care Society website. Available at: https://spcsociety.org/. Accessed October 22, 2021.