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Surgeons Palliative Care Workgroup

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Mission Statement: To facilitate introduction of the precepts and techniques of palliative care to surgical practice and education in the United States and Canada 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 change.

The Surgeons Palliative Care Workgroup began its work in September 2001 and completed its Recommendations to the Field summary in November 2002. Co-chaired by Geoffrey P. Dunn, MD, FACS (Medical Director of the Great Lakes Hospice, Erie, Pennsylvania), and Robert A. Milch, MD, FACS (Medical Director of the Center for Hospice and Palliative Care, Cheektowaga, New York), the 25-person workgroup's primary focus has been to raise awareness of practicing surgeons about roles and responsibilities that surgeons can assume in assisting patients with serious, life-threatening conditions. This mandate is consistent with the Principles Guiding Care at the End of Life developed by the American College of Surgeons Committee on Ethics and approved by the College's Board of Regents in February 1998.

Although the Surgeons Workgroup did not solely rely on work by subcommittee to accomplish its goals, six subcommittees were formed. To wit:

Needs Assessment subcommittee has worked to determine what surgeons already know and what they want to know about palliative care. The assessment will include a national on-line and mail survey of Fellows of the American College of Surgeons (minimum of 5000) regarding their attitudes concerning end-of-life issues and palliative care. Findings are to be published in the Palliative Care Series in the Journal of the American College of Surgeons in 2003.

Symposia Planning subcommittee has developed palliative care education and interactive programs that are held at the semi-annual meetings of the American College of Surgeons, which are attended by 5,000 to 10,000 surgeons. This subcommittee built upon the success of its first offerings "Palliative Care by the Surgeon: How To Do It", presented to an audience of nearly 300 surgeons at the October 2001 Clinical Congress and "Palliative Care in Surgery", presented to an audience of approximately 250 attendees at the Spring 2002 Clinical Congress. Topics have included Overview of Surgical Palliative Care; Medical Futility and Ethics; Withdrawal of Life Support: When to Do It; Withdrawal of Life Support: How to Do It; The Challenge of Educating House Staff about Medical Futility and Withdrawal of Life Support. The entire symposium was transcribed and published in the April 2003 edition of JACS.

The Symposia Planning Committee's symposium for the ACS Spring 2003 meeting (April 15, 2003, New York City) was entitled, "Palliative Care in the Trenches". The symposium covered topics suggested by attendees of the highly successful Spring 2002 Spring symposium, to include: Introduction: Clinical Palliative Care; Assessing and Discussing Patient Preferences; Withdrawal of Support in Critically Ill Surgical Patients; Palliative Care for Oncologic Patients; Legal Foundation and Protection for Palliative Care.

The Symposia Planning Committee's symposium for the ACS 2003 Clinical Congress will be held in Chicago on Wednesday, October 22, 2003. Entitled "Palliation as Core Surgical Principle", topics will include: Reclaiming Palliative Care as a Surgical Tradition; Legal and Ethical Considerations in Surgical Palliative Care; Evidence-based Outcomes in Surgical Palliative Care; Palliative Care in Surgical Education; Palliative Surgical Procedures: Present and Future. This symposium will be transcribed for future publication in JACS.

Residency Education subcommittee has worked to incorporate concepts of palliative care into the educational experience of surgical residents, an initiative spurred by the recent requirement of the American Board of Surgery that residents be knowledgeable about geriatrics and palliative care. In May, 2002, ten Surgery Workgroup members participated in the fifth year of a Residency End-of-Life Curriculum Project funded by The Robert Wood Johnson Foundation, which was designed to introduce and enhance an end-of-life curriculum that meets Accreditation Council for Graduate Medical (ACGME) training requirements, including the new ACGME core competencies.

Journal of the American College of Surgeons subcommittee continues to work with the Journal of the American College of Surgeons on a 15-plus article series concerning palliative care, published monthly in JACS. More than 12 articles have been published and an indefinite number of additional articles has been commissioned. (See below)

Liaison subcommittee has developed collaborative relationships with other organizations and constituencies (with such organizations as Society of Surgical Oncology, Society of Thoracic Surgeons, Association of Academic Surgeons, Society of University Surgeons, American Urological Association, American Society of Transplant Surgeons, American Association for the Surgery of Trauma, Eastern Association for the Surgery of Trauma, John Hopkins University Surgery Department).

Palliative Care Interest Group has developed a dedicated Web site to share ideas and information and to extend the concept of palliative care to all surgical subspecialties. Drs. Dunn and Milch met with ACS's Director of Information Services and Manager of Public Information and Electronic Publishing (June 2002) and subsequently launched a Surgeons Palliative Care Web site that is supported by ACS (www.facs.org/palliativecare).

Finally, the Surgeons Palliative Care Workgroup was invited to become an established taskforce within the ACS Department of Education and will continue to function as an ongoing group. Future plans include:
- Ongoing development of a needs assessment;
- Development of a national conference on surgical palliative care (the first conference focused on this concept), to be co-sponsored by Johns Hopkins University;
- Establishment of a Speakers' Bureau to introduce leaders in palliative care practice and research to the mainstream of surgery.

The workgroup's final meeting was held in Chicago from November 3-4, 2002. Recommendations to the Field will be posted on the Promoting Excellence and Surgeons Palliative Care Web sites after publication. The Executive Summary was published in the May 2003 issue of the Journal of the American College of Surgeons and the entire report will be published in the October 2003 edition of JACS.

Workgroup Products

Recommendations to the Field Summary
Office of Promoting Excellence in End-of-Life Care: Surgeons' Palliative Care Workgroup Report to the Field. Journal of the American College of Surgeons. October 2003. Vol. 197, No. 4: 661-686.
PDF 211 KB / 26 pages

Journal of American College of Surgeons (JACS) (circulation: 65,000 surgeons) has featured a 20-plus article series on palliative care in surgery, the editor of which is workgroup co-chair Geoffrey Dunn, MD. You may view these articles by clicking on the download links below. JACS has compiled these articles into a publication titled Palliative Care By The Surgeon: A Compendium. For more information visit www.journalacs.org and www.sciencedirect.com. Reprinted with permission from the American College of Surgeons (Journal of American College of Surgeons).

Palliative Care By The Surgeon
Journal of the American College of Surgeons
(Monthly Series addressing End-of-Life Issues written for and by Surgeons.)

*Viewing PDF files requires downloading and installation of the free Adobe Acrobat Reader.

Piotrowski MM, Paterson C, Mitchinson A, Kim HM, Kirsh M, Hinshaw DB. Massage as adjuvant therapy in the management of acute postoperative pain: A preliminary study in men. Journal of the American College of Surgeons. December 2003. Vol. 197, No. 6: 1037-1046.
PDF 151 KB / 10 pages

Eachempati SR, Miller FG, Fins JJ. The surgical intensivist as mediator of end-of-life issues in the care of critically ill patients. Journal of the American College of Surgeons. November 2003. Vol. 197, No. 5: 847-853.
PDF 92 KB / 7 pages

Buchman TG. Invited commentary. Journal of the American College of Surgeons. November 2003. Vol. 197, No. 5: 853-854.
PDF 55 KB / 2 pages

Mosenthal AC, Murphy PA. Trauma care and palliative care: Time to integrate the two? Journal of the American College of Surgeons. September 2003. Vol. 197, No. 3: 509-516.
PDF 108 KB / 8 pages

Baluss ME, Lee KF. Legal considerations for palliative care in surgical practice. Journal of the American College of Surgeons. August 2003. Vol. 197, No. 2: 323-330.
PDF 106 KB / 8 pages

MacDonald N, Easson A, Mazurak V, Dunn G, Baracos V. Understanding and managing cancer cachexia. Journal of the American College of Surgeons. July 2003. Vol. 197, No. 1: 143-161.
PDF 214 KB / 19 pages

Buchman T, Ray S, Wax M, Cassell J, Rich D, Niemczycki MA. Families' perceptions of surgical intensive care. Journal of the American College of Surgeons. June 2003. Vol. 196, No. 6: 977-983.
PDF 96 KB / 7 pages

Surgeons Palliative Care Workgroup. Robert Wood Johnson Foundation Office of Promoting Excellence in End-of-Life Care: executive summary of the report from the field. Journal of the American College of Surgeons. May 2003. Vol. 196, No. 5: 807- 815.
PDF 102 KB / 9 pages

Hinshaw, D, Pawlik T, Mosenthal A, Civetta J, Hallenbeck J. When do we stop, and how do we do it? Medical futility and withdrawal of care. Journal of the American College of Surgeons. Apr. 2003. Vol. 196, No. 4: 621-651.
PDF 263 KB / 31 pages

Krouse R, Easson A, Angelos P. Ethical considerations and barriers to research in surgical palliative care. Journal of the American College of Surgeons. Mar. 2003. Vol. 196, No. 3: 469-474.
PDF 95 KB / 6 pages

Thompson, A. The importance of opioid tolerance: a therapeutic paradox. Journal of the American College of Surgeons. Feb. 2003. Vol. 196, No. 2: 321-324.
PDF 70 KB / 4 pages

Easson A. Clinical research for surgeons in palliative care: challenges and opportunites. Journal of the American College of Surgeons. Jan. 2003. Vol. 196, No. 1: 141-151.
PDF 142 KB / 11 pages

Dunn G. Is this a bad day, or one of the last days? : How to recognize and respond to approaching demise. Journal of the American College of Surgeons. Dec. 2002. Vol. 195, No. 6: 879- 887.
PDF 111 KB / 9 pages

Wax M. Dilemmas within the surgical intensive care unit. Journal of the American College of Surgeons. Nov. 2002. Vol. 195, No. 5: 721-728.
PDF 93 KB / 8 pages

Hinshaw D. The spiritual needs of the dying patient. Journal of the American College of Surgeons. Oct. 2002; Vol. 195, No. 4: 565-568.
PDF 76 KB / 4 pages

McCahill L, Krouse R, Chu D, Juarez G, Uman G, Ferrell B, Wagman L. Decision making in palliative surgery. Journal of the American College of Surgeons. Sept. 2002; Vol. 195, No. 3: 411-422.
PDF 114 KB / 4 pages

Hinshaw D, Carnahan J, Johnson D. Depression, anxiety, and asthenia in advanced illness. Journal of the American College of Surgeons. Aug. 2002; Vol 195, No. 2: 271-277.
PDF 88 KB / 4 pages

Krouse R, Laurence M, Easson A, Dunn G. When the sun can set on an unoperated bowel obstruction: management of malignant bowel obstruction. Journal of the American College of Surgeons. July 2002; Vol. 195, No. 1: 117-128.
PDF 127 KB / 4 pages

Huffman J, Dunn G. The paradox of hydration in advanced terminal illness. Journal of the American College of Surgeons. June 2002; Vol 194, No. 6: 835-839.
PDF 82 KB / 4 pages

Buchman T. Palliative care symposium: who should manage the dying patient?: rescue, shame, and the surgical ICU dilemma. Journal of the American College of Surgeons. May 2002; Vol. 194, No. 5: 665-673.
PDF 98 KB / 4 pages

Dunn G, Milch R, Mosenthal A, Lee K, Easson A, Huffman J. Palliative care by the surgeon: how to do it. Journal of the American College of Surgeons. April 2002; Vol. 194, No. 4: 509-537.
PDF 235 KB / 29 pages

Mosenthal A. Management of dyspnea at the end of life: relief for patients and surgeons. Journal of the American College of Surgeons. March 2002; Vol. 194, No. 3: 337-386.
PDF 107 KB / 10 pages

Eason A, Hinshaw D, Johnson D. The role of tube feeding and total parenteral nutrition in advanced illness. Journal of the American College of Surgeons. Feb. 2002; Vol. 194, No. 2: 225-228.
PDF 62 KB / 4 pages

Mosenthal A, Lee K, Huffman J. Palliative care in the surgical intensive care unit. Journal of American College of Surgeons. Jan. 2002; Vol. 194, No. 1: 75-83.
PDF 106 KB / 9 pages

Lee K, Ray J, Dunn G. Chronic pain management and the surgeon: barriers and opportunities. Journal of the American College of Surgeons. Dec. 2001; Vol. 193, No. 6: 689-701.
PDF 135 KB / 13 pages

Dunn G. Patient assessment in palliative care: how to see the "big picture" and what to do when "there Is no more we can do" Journal of the American College of Surgeons. Nov. 2001; Vol. 193 No. 5: 565-573.
PDF 101 KB / 9 pages

Milch R, Dunn G. Communication: part of the surgical armamentarium. Journal of the American College of Surgeons. Oct. 2001; Vol. 193, No. 4; 449-451.
PDF 74 KB / 4 pages

Dunn G, Milch R. Introduction and historical background of palliative care: where does the surgeon fit in? Journal of the American College of Surgeons. Sept. 2001; Vol. 193, No. 3: 325-328.
PDF 105 KB / 5 pages

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Promoting Excellence in End-of-Life Care was a national program of the Robert Wood Johnson Foundation dedicated to long-term changes in health care institutions to substantially improve care for dying people and their families.