(Don’t Fear) The Reaper

I’ve been thinking a lot about death. No, I’m no more depressed than usual, and I’d tell you if I were. I’m thinking about death in the Atul Gawande Being Mortal way, the way Shoshana Berger writes so eloquently about in an outstanding essay. Palliative medicine, I’m hoping beyond hope, is finally starting to make some inroads into the land of surgery, though surgeons still have plenty of difficulty with end of life conversations.

I’m an acute care surgeon. While that term continues to have some flexibility, some misunderstanding, and some vagaries surrounding it, the specifics are not terribly important in this context. I take care of ill and injured patients. Some of those patients have extraordinarily difficult, complex, and even devastating illnesses and injuries. Some of them die. Some of them have bad outcomes. The two are not necessarily synonymous. The awesome Anne Mosenthal has written extensively on the intersection between trauma and palliative care, especially on opportunities to improve our delivery of the latter while continuing our dedication to the former.

There are arguments supporting the integration of palliative care into surgery that focus on quality of life, patient and family satisfaction, and symptom relief, but also on resource allocation, healthcare economics, and even improved “traditional” medical outcomes. They’ve all been made, and I won’t repeat them here or revisit all the data. (One tip to the budding researcher: if you just search for the works of the good Dr. Mosenthal and Dr. Karen Brasel, you’ll find a great deal of it.) Instead, I’ll point out another benefit that’s likely recognized by anyone who’s ever worked in an ICU: the difference palliative care for a patient makes to everyone treating them.

Our own (and our colleagues’) mental wellbeing isn’t our highest priority, and it’s not entirely clear that it should be. We don’t make important patient care decisions in surgery based on the amount of stress the decision will result in for us. However, stress and PTSD is real among caregivers, and how we experience the events of patient deaths matters. Palliative medicine, whether delivered by a specialist team or by the primary surgeon, can have an immense impact on this experience, for both a patient’s family and their medical providers. This occurs (to varying degrees) whenever implemented in a patient’s hospitalization. It can be a change to symptom-directed management with discharge to hospice weeks before the patient’s expected death, and it can be a decision not to push any more vasopressors on the patient that’s crashing. We must all recognize that “doing everything” is not always consistent with the best medical care, and that palliative care is conversely not “doing nothing”.

It’s not unusual, unfortunately, for two patients I’m caring for to die on the same day. On one such day, the first was a critically ill man who’d had multiple surgeries, had failure of most of his organ systems, and that day began a rapid decline. Our outstanding palliative care team had been consulted, but we continued our disease-directed management until his family was at his bedside and said “no more”. I held a grieving hand as the man died, and his family members thanked me. The second was a man with unsurvivable injuries who arrested not long after arrival in our ICU. He underwent aggressive attempts at resuscitation to no avail.

A patient’s death is never easy, and shouldn’t be. They needn’t, however, be traumatic. Our ICU team had a communal debriefing after our second death that day. It was filled with frustration, sadness, and fatigue. Nobody mentioned the first patient who’d died. There were vast differences between the two, yet I could only compare their last minutes. This is why palliative care matters.