Palliative and end-of-life care communication has been a continuous topic of discussion. It is now believed that palliative care is not just for those patients who are likely to die after trauma, but for all critical, severely injured, or terminally ill patients and their families. Surgery and trauma patients are a large group of individuals who would benefit from an early discussion on palliative and/or end-of-life care. The American College of Surgeons (ACS) has, therefore, always advocated palliative care discussions for patients undergoing surgical care. The ACS has recognized the importance of the patient-centered aspect of palliative care in the field of surgery and disseminated it primarily through educational efforts directed at practicing surgeons and surgical residents. Despite efforts, recent studies show that physicians including surgeons delay their discussion on palliative care with their patients as they find it difficult. Many people have written about providing this training earlier in their career during residency, but still we find this topic difficult and uncomfortable. The benefits of palliative care are clear: prolonged survival in patients with certain malignancies, less high resource utilization at the end of life and improved quality of life. All elements of a patient experience that we aspire our patients to have.
So the question is:
- Why is it so difficult for surgeons to talk about end-of-life care issues?
- Are we not providing this essential training to our current and future surgeons?
As I mentioned earlier, many studies have shown that residents feel that the end-of-life care communication is indeed difficult and the training certainly helped them during residency. However, based on my experiences, when we try to provide such training to our residents, they show less interest in participation. One of the reasons could be their 80 hour work week restrictions. Residents likely want to focus more on the surgical aspects of training during this time. They ideally want to perform more procedures and gain more exposure in operating room (OR) than spend time on learning palliative care and communication; issues that they think could be handled by others. Surgical education and training has, traditionally, been more focused on problem solving and curing the disease. That is probably why surgeons may show a little detachment to their patients and that could be interpreted as less empathetic or rude to patients.
Education in medical school and residency should stress the importance of being empathetic and learning the core competencies of being a great surgeon that are interpersonal and communication skills. Studies show that practiced interpersonal and communication skills improve patient and family satisfaction, strengthen the doctor-patient relationship, and can reduce the stress experienced by physicians when dealing with end-of-life care. Furthermore, according to changes brought forth by the Affordable Care Act (ACA), patient/family satisfaction will be one of the criteria for reimbursement. Similar to operative skills, effective communication is not a natural skillset for most people. It is, of course, difficult to tell someone that their loved one is dying or died in surgery! So we need appropriate education and a lot of practice to acquire these skills.
I think it’s time for all surgeons to embrace the fact that sometimes patient’s death is not their defeat, but an inevitable event. The impact of such traumatic events on patients or family could certainly be alleviated by appropriate skills that are not merely some communication skills, but are crucial elements for their overall practice and patient satisfaction! After all, people may forget what you did or said, but they will never forget how you made them feel!