Geoffrey P. Dunn

Understanding and managing cancer cachexia

Mrs MJ is a 56-year-old architect with a husband and two children. You performed a mastectomy and axillary dissection on her after neoadjuvant chemotherapy for locally advanced breast cancer 2 years ago. Unfortunately, she developed widespread disease with metastases to liver, lung, and bone. After several more rounds of chemotherapy, she is currently on antiestrogen therapy. Her disease appears stable. You have continued to follow her and she comes to see you for her routine visit. You notice that she is much thinner than you remember, but otherwise looks well. You ask her about her weight loss. She says: “I don’t really know what it is! I can eat, my bowels are working, but I simply don’t want to. I force myself to swallow food, but I keep losing weight anyway.” On clinical examination, you notice her muscle wasting and recognize the signs of cancer cachexia. You want to know more about how to manage this phenomenon.

When the Sun Can Set on an Unoperated Bowel Obstruction: Management of Malignant Bowel Obstruction

Mr XY is a 75-year-old man with known recurrent rectosigmoid adenocarcinoma in the pelvis. He had an emergency Hartmann’s procedure 2 years earlier for a bowel perforation caused by tumor. The patient had been offered a surgical intervention 3 months earlier for the recurrent pelvic mass visualized on CT, but he declined any additional surgical intervention. No metastatic disease was noted at that time. He had no symptoms of bowel obstruction at the time, although there were signs of minimal proximal bowel dilatation. He presented to the Emergency Department on three separate occasions in a 3-week period with nausea, vomiting, abdominal cramping, and no colostomy output. A partial small bowel obstruction was confirmed on plain film x-rays. Clinically, the patient was in good condition and had no physical inhibitions. He was treated with nasogastric decompression on each occasion and the symptoms quickly resolved and bowel function resumed. On the first two occasions, he was able to eat a regular diet and return home within 3 to 5 days of being admitted to the hospital. He had a small bowel follow-through after the second obstruction episode, which was nondiagnostic. After the third episode, a lengthy conversation was undertaken with the patient about his goals and concerns related to an operation. This revealed fears of the pain related to surgery. After discussion about the likelihood of continued episodes of bowel obstruction and the assurance that diligent perioperative pain management would be practiced, including the possible use of an epidural catheter, he agreed to have an operation. The goals of restoring his capacity to eat, and the hope of allowing him to remain home without multiple readmissions to the hospital, were clearly delineated. We believed that the obstruction was most likely from a single site at his pelvic recurrence, and we were likely to achieve these goals. It was made clear to the patient that he could have more disease or adhesions than expected, making a definitive surgical approach difficult or impossible, and necessitating alternative therapies. He was told that even with surgery, bowel obstruction and wound complications could occur in the future. At operation, there were extremely dense adhesions throughout his entire peritoneal cavity, especially in the pelvis. He did not have peritoneal carcinomatosis, although he did have tumor nodules throughout his liver. The source of the bowel obstruction was difficult to locate because no area of decompressed bowel was found, and extensive adhesiolysis was required. The colostomy site was closely inspected to ensure that it was not the site of obstruction. Ultimately, a loop of very distal small bowel was adherent to a pelvic tumor mass overlaying the iliac vessels and ureter. The small bowel was folded on itself, creating a small blind loop. The decision was made to do a small resection instead of a bypass.This was accomplished with a primary anastamosis without complication. Postoperatively, the patient’s bowel function was slow to resume. Otherwise, he recovered uneventfully and went home 8 days after the operation. One month after operation he remains at home without symptoms or signs of recurrent bowel obstruction.

Palliative care by the surgeon: how to do it

Geoffrey P Dunn, MD, FACS: This is a symposium, Palliative Care by the Surgeon: How To Do It. This symposium is actually the continuation of an idea that has been evolving in the course of several consecutive symposia held by the American College of Surgeons. The shot across the bow for this ongoing discussion and for this symposium came back in 1997 when the College held a general symposium on the subject of physicianassisted suicide. Many of us took this as a huge red flag or a sign of great distress that surgeons were wrestling with this question. There was controversy within the surgical community with people taking positions pro and con. One thing that was agreed on by everybody at that symposium was the utility, the lasting value, and the moral imperative of good palliative care. Everybody also agreed that in many ways, although we may be temperamentally very committed to the idea, and might have had personal experiences in our practices and also in our families that drove home the point of the value of good compassionate care for people with advanced illness, many of us felt very unprepared to do the basic work, the day-to-day activity at the bedside, to know which kinds of medication to order or how to engage in difficult discussion. That led to a series of initiatives with ongoing and increasing cooperation, interest, and support by the American College of Surgeons. Last year we had a symposium on the subject where we got more at the level of the surgeon identifying and finding a place in palliative care. At the very heart of that discussion was this almost palpable struggle: Is a surgeon really temperamentally suited to do this kind of thing or would it be best left to be done by others? At that point we believed that was a choice that every surgeon would make personally. What we can do is offer the tools, the nuts and bolts, and from that point carry forward; that is the purpose of the symposium today: to provide some basic practical concepts that would be helpful at the bedside. The panelists are members of a newly formed Workgroup for Surgical Palliative Care. This is a Robert Wood Johnsonfunded initiative. The group members were selected because of their demonstrated and proactive interest in these areas. The Workgroup recognizes that many important areas of surgery are not yet represented in this work. The purpose of the Workgroup is to facilitate introduction of the precepts and techniques of palliative care to surgical practice and education in the United States and Canada. The Workgroup will do this by bringing together surgeons with demonstrated interest in palliative care to share resources, strategies, and expertise, and in so doing act as a catalyst for a change. There are a number of definitions of palliative care and that term will be used frequently. This is the very orthodox teaching in any current textbook or article about palliative care. You will see that the World Health Organization definition goes back to 1990 (Table 1). This was specifically applied to oncology but was rapidly accepted as applicable to all areas of palliative care. I find it a very cumbersome and dry definition, and when people ask Presented at the American College of Surgeons 87th Annual Clinical Congress, New Orleans, LA, October 2001. Moderator: Geoffrey P Dunn, MD, FACS, Department of Surgery, Hamot Medical Center, Erie, PA. Panelists: Robert A Milch, MD, FACS, The Center for Hospice and Palliative Care, Buffalo, NY; Anne C Mosenthal, MD, FACS, New Jersey Medical School, Department of Surgery, Newark, NJ; K Francis Lee, MD, FACS, Baystate Medical Center, Springfield, MA; Alexandra M Easson, MD, Princess Margaret Hospital, Toronto, ON; Joan L Huffman, MD, FACS, Crozer-Chester Medical Center, Upland, PA.

Introduction and historical background of palliative care: where does the surgeon fit in?1

• Respect the dignity of both patient and caregivers. • Be sensitive to and respectful of the patient’s and family’s wishes. • Use the most appropriate measures that are consistent with the choices of the patient or the patient’s legal surrogate. • Ensure alleviation of pain and management of other physical symptoms. • Recognize, assess, and address psychological, social, and spiritual problems. • Ensure appropriate continuity of care by the patient’s primary and/or specialist physician. • Provide access to therapies that may realistically be expected to improve the patient’s quality of life. • Provide access to appropriate palliative care and hospice care. • Respect the patient’s right to refuse treatment. • Recognize the physician’s responsibility to forego treatments that are futile.

Is this a bad day, or one of the last days?: How to recognize and respond to approaching demise

At the end of a long afternoon case you find a stickynote on the operating room window informing you of a consultation request: “Consult from Staff GI. Room 527. Blair, Robt. Dx: Metastatic ca. of pancreas. Request central line for TPN.” During the walk up you wonder if this is going to be necessary. The chart of this individual yields little history except a scribbled note; “Unfortunate 58 y.o. white male with history of metastatic ca. of pancreas admitted with dehydration and malnutrition. Plan: Hydration/? TPN. Discuss chemorx. options.” The “yes” or “no” box indicating presence of advance directives on the front sheet of the chart is unmarked. On entering Mr. Blair’s room you are greeted from the bed by an alert, sallow-complected, cachectic man who speaks in a whisper and grasps your hand with a surprisingly strong handshake. “I hope you can do something to make me stronger.” His wife, sitting at the bedside, appearing overwhelmed, adds, “I can’t stand to see him like this. He just doesn’t seem to want to eat. He is sleeping all the time and he’s been having nightmares. We both know there’s no cure for this, but at least he shouldn’t starve to death in the meantime! His next chemo appointment is next week. They said they might try something new. I don’t think he can take it unless they put some meat on his bones.” While his wife is speaking you note Mr. Blair gazing in the distance through the window. During the ensuing discussion you learn he had undergone an exploratory laparotomy 2 months previously and had a “double bypass” for his tumor. Subsequently he was treated with what they were told was a fairly new chemotherapy agent with “mild” side effects. Despite the resolution of his jaundice after his operation he continued to lose weight even though he had an initial return of appetite. During the previous 2 weeks, he had shown little interest in food or drink and he seemed to be sleeping more and more of the time. He had been receiving oxycodone (slow release) for his cancer-related back pain, with satisfactory relief and no recent dosage escalations. Earlier that week he had several nightmares about his death. Privately he confided, “I think my wife is more hopeful than I am. I’m just so tired.” After this initial meeting you learn that an abdominal CT done the previous week demonstrated progression in size of his hepatic metastases.

The paradox of hydration in advanced terminal illness

Eighty-two-year-old John suffered from metastatic prostate cancer. He had developed lumbar vertebral metastasis with consequential lower extremity weakness. He lived alone and functioned independently, but recently had to depend on a walker for his new disability. Early one morning, he fell. His family discovered him several hours later, and he was taken to the Emergency Room. John was awake, alert, and hemodynamically stable, but complained of severe neck and low back pain. His upper extremity strength was normal, but his lower extremity power was 3/5. He had poor rectal tone and was unable to void. A urinary catheter was placed. Workup revealed an unstable C-2 fracture, and lumbar vertebral metastasis compressing the spinal canal. Neurosurgery placed him in a halo for C-spine stabilization. Metastatic involvement of C-2 was confirmed by bone scan. Shortly after admission, John developed neck edema, aspirated, and required intubation and mechanical ventilation. Nutritional support was initiated with enteral feedings through a nasoduodenal feeding tube. John frequently indicated that he had severe neck and back pain. Palliative radiation therapy was recommended, but could not be logistically accomplished because of his ventilatory support and halo devices. He required sedating doses of narcotics and anxiolytics to control his persistent pain. Finally, John was made comfortable on a regimen of transdermal narcotics and anxiolytics administered through his feeding tube. With aggressive pulmonary care and IV antibiotics, John improved sufficiently to be weaned from the ventilator and extubated. He was again alert and communicated appropriately and quite clearly that he wished no further aggressive measures. He removed his feeding tube, was restrained, yet “escaped,” and vigorously resisted the resident’s attempts to insert another. He was unable to take an oral diet because of ongoing dysphagia from his halo positioning. IV fluids were continued until his cachectic arms precluded peripheral access. He refused to consent to central IV access. His frustrated doctors and fearful family pleaded with him to no avail. John persisted in his refusal of food and water. An ethics consult confirmed John’s legal right to forgo both nutrition and hydration. A hospice consult was obtained. His pain regimen was adjusted, and comfort care was instituted. The family was instructed in alternative measures to ease his discomfort. John gradually became oliguric; a week later he slipped into a coma; 2 days later he died peacefully with his family at his side.

Patient assessment in palliative care: how to see the "big picture" and what to do when "there is no more we can do".

“It doesn’t look good on CT,” said the radiologist with a resigned look as he finished dictating the results of the films on a 47-year-old man with painless jaundice and weight loss I was asked to see in the emergency room. I thought jaundice was probably the best thing he had, given the multiple liver metastases I saw on his CT. The source of his metastases was no mystery judging from the look of the pancreas. “Does this guy have any idea about this,” asked the radiologist. “I don’t really know,” I said, trying to pull together what I really did know about the man. “He’s married with three kids, all still in school. His wife is worrying about the HMO dinging her for an unauthorized ER visit: wait till she learns about this,” I said, sliding the last of his films in the jacket. “Too bad there’s nothing more you can do,” said the radiologist as he continued with his dictations. I was annoyed with his sentiment, but partly jealous of his detachment from this situation. He was right. There was not much to do in the “usual” sense of controlling disease, but I didn’t know where to start going from here. The relationship this man had with his primary physician was not a good one by his own account, and this gave me an added sense of urgency about helping him any way I could. Later, as I looked at his needle biopsy through a microscope at the islands of tumor in the darkening sea of liver parenchyma, it occurred to me I needed a different kind of lens to see this person and his circumstances as clearly as the microscope showed me this tiny fragment of the man. This new optic would gather more information about him and make sense of all that was happening and was going to happen to him. We all have been at this point, and we all have felt the frustration of not having a satisfying operative solution for a problem that won’t go away. How do we conceptualize these encounters so we can be of service without having to withdraw or refer to someone else, someone who may not have our skills or our patient’s trust? The end of life and dying, itself, are not merely medical

Robert Wood Johnson Foundation Office of promoting excellence in end-of-life care: Executive summary of the report from the field

I. BACKGROUND AND CONVENING PROCESS In recognition of a growing interest in palliative care by clinicians, patients, and families, the Promoting Excellence in End-of-Life Care national program of The Robert Wood Johnson Foundation, in conjunction with the American College of Surgeons, created a national Peer Workgroup to facilitate introduction of the precepts and techniques of palliative care to surgical practice and education in the United States and Canada. The World Health Organization has defined palliative care as “The active total care of patients whose disease is not responsive to curative treatment.” The Surgeons Palliative Care Workgroup brought together surgeons with demonstrated interest and experience in palliative care to share resources, strategies, and expertise, and in so doing act as a catalyst for change. This is a summary of their analysis of the current state of palliative care in the surgical field and their recommendations. The full report will be released this summer by the Robert Wood Johnson Foundation. The Workgroup met during a 14-month period from September 2001 through November 2002. The initial Workgroup membership of 20 consisted of 17 surgeons representing 6 subspecialties, representatives of the executive and administrative staff of the American College of Surgeons, two recognized leaders in palliative care research and education, and a representative of the National Program Office of the Robert Wood Johnson Foundation. The Workgroup divided into seven subcommittees and conducted its business at four plenary sessions and periodic teleconferences. The Workgroup adopted the American College of Surgeons’ Statement of Principles Guiding Care at End of Life (1998) as its compass in the execution of its charge. After approval by the American College of Surgeons Board of Regents in October 2002, the Workgroup became integrated into the Division of Education of the American College of Surgeons as the Surgical Palliative Care Task Force.

Surgical Palliative Care: Recent Trends and Developments

Palliation has been an essential, if not the primary, activity of surgery during much of its history. However, it has been only during the past decade that the modern principles and practices of palliative care developed in the nonsurgical specialties in the United States and abroad have been introduced to surgical institutions, widely varied practice settings, education, and research.

Palliative care in the surgical intensive care unit: where least expected, where most needed.

Despite dramatic improvements in survival from a broad range of afflictions seen in the surgical critical care unit, the problem of suffering in its many forms and its long-term consequences will remain as long as mortality characterizes the human condition. Palliative care in the surgical intensive care unit is an extension of time-honoured surgical principles and traditions that aims to relieve suffering and improve quality of life associated with serious illness as an end in it self or as part of treatment to save and prolong life.