A good surgical death�
Jane M Blazeby
Professor of Surgery, University of Bristol
A commissioner for the Lancet Commission on the Value of Death
�
Surgery (unlike medicine)��Usually, irreversible��Evidence limited��Unrealistic expectations���
2
Cannot discontinue treatment
Uncertainty (surgery often not evidence based)
Unrealistic expectations of what surgery can achieve
A surgical death differs from a medical death
What is a good surgical death?
A good surgical death: a shared decision about undergoing surgery at the end of life
Patients are supported to make decisions about surgery at the end of life
Some may undergo surgery, others may decline
Advance discussion/decision about ‘how far to go’
Invasive procedures common at the end of life
US: 30% of elderly Medicare beneficiaries have surgery in final year of life. Kwok Lancet 2011;378:1408-13
US: 25% of patients undergoing high risk surgery die within 90 days. Yefimova JAMA Surg 2020;155:138-146
UK: 20% of surgical in-patients are within the last year of life. J Pain Symp Manage 2016;52:e2-4
Surgical activity near the end of life – �may not benefit patients, has costs to the NHS & a carbon footprint
Spend and carbon consumption are closely related.��About 10% of NHS carbon footprint is on care in the last year of life.
Surgeons like operating
‘a good surgeon knows how to operate, a better one knows when to operative and the best one knows when not to operative’
‘a good surgeon knows how to operate, a better one knows when to operate and the best one knows how to support a patient to reach a decision about surgery’
Reimagining death & dying: a realistic utopia for surgeons?
The Lancet Commission on the Value of Death���Recommendations ��
The social determinants of death, dying, and grieving are tackled
Dying is understood to be a relational and spiritual process rather than a physiological/medical event
Networks of care lead support for people dying, caring, and grieving
Conversations and stories about everyday death, dying, and grieving become common
Death is recognised as having value
Surgeons need training��
Difficult/essential conversations��5 questions -
What is your understanding of your illness & where you are?
What are your fears or worries for the future?
What are your goals and priorities?
What outcomes are acceptable to you?
What are you willing to sacrifice and not?
And later, what would a good day look like?
Core sets developed for,
Oesophageal cancer surgery
CoIorectal cancer surgery
Anal cancer
Head & Neck surgery
Innovative procedures
Identify and prioritize what requires discussion
Data sources
The literature
Patients’ views
Health professional views
Professional guidance
Create long list
Consensus methods to establish
‘core information’
Need a core information set for end-of-life surgery/conservative treatment discussions
What now?
Develop, pilot and evaluate a SDM intervention (core information set) for surgeons to use about end-of-life options
Do research to compare end-of-live surgery with conservative treatment powered on measures that matter to patients and that assess carbon footprint
Change surgical culture (multiple tactics needed), important establish training for surgeons in end-of-life shared decision-making and monitor quality
Take home message
Acknowledgements: ��C Chamberlain, J Donovan, A McNair, B Main, B Zucker��j.m.blazeby@bris.ac.uk