In modern medicine, the term “surgery” conjures images of curative interventions. A paradigm shift, however, is emerging with the rise of palliative surgery – an approach that focuses on alleviating symptoms and enhancing quality of life for patients facing serious, non-curable illnesses.
According to the National Cancer Institute, the primary aim of palliative surgery is to “reduce pain and/or other symptoms” for patients, such as by debulking tumors to relieve bowel compression in cases like ovarian cancer. This innovative field not only aims to lessen suffering but may, in certain circumstances, even prolong life.
Surgical palliation is not merely for patients at the end of life; it applies to anyone grappling with severe illness who could benefit from surgical intervention to improve their quality of life. However, as with all medical procedures, palliative surgery raises ethical questions and concerns regarding its implementation.
Various organizations, including the American Medical Association of Ethics, have scrutinized the implications of surgical palliation. One major concern is informed consent. There have been various reports of patients undergoing palliative surgeries under the mistaken belief they are receiving curative treatment. This misalignment can lead to challenging conversations about care goals and expectations. Ensuring that consent is obtained in an informed and transparent manner is crucial.
Some experts suggest adopting clearer language during the surgical consent process. Other considerations include adopting a more thorough consent process akin to that used in medical assistance in dying, where patients are made fully aware of their options and the realities of their situation. Additionally, as with any surgical intervention, discussing the risks – ranging from infection to mortality – is essential. Given the often-limited life expectancy of palliative patients, the risks can feel disproportionately heavy, and complications can be particularly devastating.
Another pressing concern is resource allocation. According to the 2023 Fraser Institute report, the median wait time from a general practitioner visit to specialist treatment across Canada is 27.7 weeks. In this context, utilizing valuable surgical time for palliative procedures can seem counterintuitive, especially when life-saving surgeries might be sidelined.
As a general surgery resident, I have witnessed the benefits and challenges of palliative surgical interventions. For example, I have been involved in the treatment of many patients with incurable malignant bowel obstructions secondary to colorectal cancer. Although the role of palliative surgery in colorectal cancer remains a subject of ongoing debate, largely due to the risk of significant complications, procedures like stoma creation can provide significant relief. While these surgeries do not cure the cancer, they can greatly improve the patient’s quality of life during their remaining time. The decision to proceed with surgery in cases of advanced cancer requires careful consideration of multiple factors, such as the extent of the disease, the availability of alternative treatments, and the patient’s overall goals of care. While some patients choose to forego these surgical options in favour of medical palliation, having the choice available is vital. It empowers patients and ensures they maintain dignity and agency in their care at the end of life.
Despite the concept of surgical palliation evolving rapidly, there has yet to be the development of a formal fellowship program dedicated to training surgeons. Instead, interested surgeons integrate palliative care principles into their training and build a foundation for their future practice by pursuing formal medical palliative care fellowships. This underscores the need for enhanced training and specialization in this critical and fast-changing area of surgery.
As the concept of surgical palliation gains traction, more individuals and their families will face the difficult question: Would you or a loved one undergo surgery knowing that it would not lead to a cure? This question invites a broader discussion about the risks and benefits of such decisions. The answer may differ for each individual, depending on their circumstances, values and priorities.
Ultimately, as we consider the notion of “cutting for comfort versus cure,” we must also explore the ethical frameworks that should guide these interventions. How can we ensure that palliative surgeries are performed with integrity and respect for patient autonomy? Should there be standardized protocols to ensure that patients are more thoroughly informed?
The answers will shape the future of palliative surgical care and its role in enhancing the quality of life for those navigating serious illnesses. By fostering open discussions and building a more robust framework for palliative interventions, we can honour the dignity and choices of patients, ensuring that comfort remains a central tenet of medical care.
