Given that palliative care is appropriate for any patient facing a serious or life-threatening illness, many patients presenting with acute surgical illness will benefit from palliative care. Furthermore, virtually all patients with acute surgical disease are symptomatic. Symptoms commonly seen in the acute care surgical patient include: right upper quadrant pain from acute cholecystitis, right lower quadrant abdominal pain from appendicitis, left lower quadrant pain from diverticulitis, nausea and vomiting due to a small bowel obstruction, anorectal pain caused by a perirectal abscess. While many of these diseases will not be life-threatening or produce long-term debility, a significant percentage of patients with these common acute surgical problems are at risk for disease and/or treatment-related morbidity and mortality which may result in long-lasting symptoms or debility. A recent study by Moore et al. [6] found that emergency colon operations were associated with a 28% mortality rate even in the hands of experienced acute care surgeons. Ingraham et al. [7] examined the morbidity and mortality associated with emergency appendectomy, cholecystectomy, or colon resection in the National Surgical Quality Improvement Program database and reported a 15% complication rate across these three procedures. The morbidity rate was highest for colorectal resection (47%), followed by cholecystectomy (9%) and appendectomy (6%).

The first challenge facing the acute care surgeon is the identification of a patient who will benefit from a palliative procedure. In other words, “what are the characteristics of a prospective palliative care patient?” An acute care surgical patient appropriate for palliative care will typically meet the following criteria:

Taken together, these criteria reflect the basic tenets of surgical decision-making. As Winchester noted [8], “It is judgment that matters in this profession. Otherwise the surgeon is no more than a man (or woman) with a knife, and a license to mutilate.”

While it may be argued that any surgical disease, no matter how limited or seemingly uncomplicated, may become serious or life-threatening under certain circumstances (e.g., incarcerated ventral hernia in a patient 3 months following an acute myocardial infarction). The more obvious cases involve either patients with common surgical problems in the setting of advanced underlying disease such as cancer or end stage organ dysfunction or advanced surgical disease in an otherwise healthy patient. In the case of the former, it is imperative that the acute care surgeon consider the status of the underlying disease and its associated prognosis before considering the disease-related complications or procedure-specific risks. To illustrate this point, consider the following case of Ms. O.

Ms. O is a 57-year-old woman with Stage IIIC ovarian cancer whose disease has progressed on second-line chemotherapy. She presents to the emergency department with severe anorectal pain. On physical examination, you determine that she has a perirectal abscess.

A surgical palliative care approach to Ms. O will include the following steps:

A second criterion of an acute care surgical patient appropriate for a palliative surgical approach is the presence of disease potentially responsive to surgical therapy. This criterion highlights the importance of accurate prognostication in the acute care surgical patient. Although prognostication has traditionally been listed as the third of the three great clinical skills-behind diagnosis and treatment, it may be considered second behind diagnosis when caring for the acute care surgical patient in need of palliative care. Prognosis is generally used to describe the prediction of any health outcome. When performed accurately, prognostication allows patients and their families to participate in their healthcare decision-making in a way that ensures their autonomy through a process of informed consent.

Although issues related to informed consent are addressed elsewhere in this book, it is instructive to briefly consider the informed consent process here since informed consent is a direct extension of accurate prognostication. As Robert Veatch [9] notes in his remarks regarding informed consent: “Telling the patient everything about a procedure is an impossible task. All that is being called for is adequate information.” The standards used to determine adequate information include the professional standard, the reasonable person standard, and the subjective standard. According to the subjective standard, the surgeon gives the patient the information he or she would personally find meaningful. The information shared should fit with the life plan and interests of the individual patient. In the setting of palliative acute care surgery, it is the subjective standard that seems most relevant when considering prognostication and informed consent given the emphasis placed on providing treatments that may realistically be expected to improve the patient’s quality of life and reflect sensitivity to, and respect for, the patient’s and family’s wishes.

Unlike prognostication in other medical specialties, surgical palliative care is unique in that surgeons are called upon to incorporate knowledge of the surgical disease, any relevant underlying diseases (e.g., end stage organ dysfunction), as well as the anticipated surgical outcome, when providing prognostic information to a patient and their family. Various factors have been used to formulate estimates of prognosis: clinician estimate of survival, performance status scales (e.g., Karnofsky performance status), biological parameters (e.g., preoperative albumin levels, Acute Physiology and Chronic Health Evaluation II score). The Palliative Prognostic (PaP) Score [10] was created by a group of Italian investigators who combined laboratory values, symptoms, clinician estimates, and performance status into a survival prognostication tool that can be readily calculable at the bedside. In their study of 451 terminally ill cancer patients, the PaP score was able to subdivide patients into three distinct risk groups with median survival of 14, 32, and 76 days in three groups.

The Palliative Performance Scale (PPS) is another validated prognostic tool used to estimate the survival of patients with life-threatening illness [11, 12]. The PPS provides a functional assessment of ambulation, activity level, evidence of disease, self-care, oral intake, and level of consciousness. The scale consists of 11 categories yielding a score from 0% (death) to 100% (ambulatory and healthy). A PPS score of 50% is associated with a patient who is non-ambulatory (mainly sits or lies), requires a significant amount of assistance, and has normal to reduced oral intake. At a score of 50%, extensive disease is evident, and the estimated life expectancy ranges from 2 to 4 weeks. The PPS was recently used to assess survival in an inpatient population at a university teaching [13]. A total of 310 adult inpatients with advanced cancer (60%) and other advanced (life-limiting) diseases were included in the study cohort. Three distinct survival groups were identified based upon PPS: 10–20, 30–40, and ≥50. The median survival for patients with PPS 10–20 was approximately 10 days, while that for 30–40 was approximately 40 days, and for patients with PPS of ≥50 it was not reached by 150 days. A 10% decrement in PPS was associated with a 1.65-fold increased risk of death [13].

Formulating a prognosis in other serious diseases such as congestive heart failure, chronic obstructive pulmonary disease, and various forms of dementia can be more difficult than it is in the case of malignancy due to the difference in disease trajectories. Despite these challenges, guidelines do exist to assist in determining the prognosis of patients with non-cancer diagnoses [14]. A thorough review of the guidelines for each disease is beyond the scope of this chapter, but they are nicely summarized in a review article by Lynn [15].

The other group of acute care surgical patients who may benefit from a surgical palliative care approach is those with advanced surgical disease but are otherwise without significant comorbidities or serious underlying disease. The case of Mr. A illustrates the vital role of communication in the setting of acute surgical disease.

Mr. A is a healthy 73-year-old man recently diagnosed with atrial fibrillation during an annual physical examination. He was started on digoxin and is heart rate is well controlled. He presents to the emergency department with acute onset of abdominal pain which woke him from sleep. His workup in the emergency department shows that he is in atrial fibrillation with a heart rate of 125 and a blood pressure of 102/58. When you examine his abdomen, you do not hear any bowel sounds, he is soft, non-tender, and non-distended. He complains of severe abdominal pain out of proportion to his physical examination. You diagnose him with mesenteric ischemia and take him to the operating room for urgent exploration. At laparotomy, his entire small bowel is ischemic but not necrotic and he has an embolus in his superior mesenteric artery for which you perform an embolectomy. You transfer him to the surgical intensive care unit intubated with a temporary abdominal closure and plan to examine his bowel again in 24 h.

A surgical palliative care approach to Mr. A will include the following steps:

The case of Mr. A emphasizes the importance of prompt, clear, and direct communication. As noted above, the American College of Surgeons has identified communication one of the two basic elements of palliative care in which all surgeons must be competent. Essential components of communication in the acute care surgery setting include willingness on the part of the surgeon to disclose prognosis truthfully, an appreciation that communication with patients and/or their families is a process and not a singular event, and the skills to effectively communicate with all members of the care team. Despite the well-intentioned efforts of some surgeons to avoid giving bad news out of fear of robbing hope, there is little evidence to support this position. In his book entitled The Dying Patient, Simpson asserts that “Hope is based on knowledge, not ignorance” [16]. It is more likely that misguided avoidance of difficult information, or worse, blatant dishonesty about prognosis, may add to a patient or family’s distress, cause them to seek treatment which they might not otherwise pursue, and rob them of precious time better spent engaged in activities that promote peace and dignity. A recent study by Wilkinson et al. [17] studied patient preferences for information and for participation in decision-making among 152 consecutive acute medical inpatients. They found that 61% of patients favored a passive approach to decision-making (physician makes the final decision). In contrast, 66% of patients sought “very extensive” or “a lot” of information about their condition. Importantly, there was no relationship between patient preferences for involvement in decision-making and for information about their medical condition. A study by Mazur and Hickam [18] of 467 veterans studied the level of involvement the patients wanted in decision-making related to invasive medical interventions. The vast majority of patients (93%) preferred that their physician disclose risk information to them and two-thirds of patients preferred shared decision-making compared to only 21% who preferred physician-based decision-making. Taken together, these studies confirm that patients want to participate in their healthcare decisions and desire the necessary information needed to make these decisions.

Family meetings are a crucial tool for effective communication in palliative care. Optimal palliative decision-making is facilitated through effective interactions among the patient, family members, and the surgeon through a dynamic relationship described as the “palliative triangle” [19]. The “palliative triangle” is a model designed to aid in complex surgical decision-making when palliative surgical procedures are being considered. The three arms of the triangle include the patient, family and surgeon and the goals that each member of the triangle brings when palliative surgical procedures are considered. The patient’s concerns, values, and emotional support are considered against existing medical and surgical alternatives. The process of aligning the concerns and interests of the three parties involved can moderate against the unrealistic expectations that each party may bring to the decision-making process. A study by Miner et al. [20] utilized the “palliative triangle” technique in 227 patients with incurable metastatic or advanced cancer considered for a palliative procedure. A palliative procedure was performed in 47% of patients, while 53% were not selected for a palliative operation. The indications for the palliative procedures included gastrointestinal obstruction in 36%, local control of tumor-related symptoms (e.g., bleeding, pain, or malodor, 25.5%), jaundice in 10%, and other symptoms in 28%. Patient-reported symptom improvement or resolution was noted following 91% of procedures. Patients who experienced symptom relief did so within 30 days of the operation. It is noteworthy that prior to the palliative procedures being performed, one or two meetings between the patient, family, and surgeons occurred before a final treatment decision was reached [20]. While there may be cases in which time for such meetings are not possible, this opportunity does exist for a significant proportion of acute care surgical patients. In the end, the highly satisfactory results published by Miner et al. [20] reflect the essential combination of appropriate patient selection, excellent surgical technique, and effective communication among the arms of the “palliative triangle.” As Buckman noted, “Communication is often the most important component of palliative care, and effective symptom control is virtually impossible without effective communication” [21].