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Surgery_Schwartz_13502 | Surgery_Schwartz | structured system for delivering care.Palliative care includes the entire spectrum of intervention for the relief of symptoms and the promotion of quality of life. No specific therapy, including surgical intervention, is excluded from consideration. Therefore, surgeons have valuable contri-butions to make to palliative care. In fact, the term palliative care was coined in 1975 by Canadian surgeon, Balfour Mount. Furthermore, surgical palliative care can be defined as the treat-ment of suffering and the promotion of quality of life for seri-ously or terminally ill patients under the care of surgeons.36 The standard of palliative treatment lies in the agreement between patient and physician that the expected outcome is relief from distressing symptoms, lessening of pain, and improvement of quality of life. The decision to intervene is based on the treat-ment’s ability to meet the stated goals, rather than its impact on the underlying disease.The fundamental elements of palliative care | Surgery_Schwartz. structured system for delivering care.Palliative care includes the entire spectrum of intervention for the relief of symptoms and the promotion of quality of life. No specific therapy, including surgical intervention, is excluded from consideration. Therefore, surgeons have valuable contri-butions to make to palliative care. In fact, the term palliative care was coined in 1975 by Canadian surgeon, Balfour Mount. Furthermore, surgical palliative care can be defined as the treat-ment of suffering and the promotion of quality of life for seri-ously or terminally ill patients under the care of surgeons.36 The standard of palliative treatment lies in the agreement between patient and physician that the expected outcome is relief from distressing symptoms, lessening of pain, and improvement of quality of life. The decision to intervene is based on the treat-ment’s ability to meet the stated goals, rather than its impact on the underlying disease.The fundamental elements of palliative care | [
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Surgery_Schwartz_13503 | Surgery_Schwartz | quality of life. The decision to intervene is based on the treat-ment’s ability to meet the stated goals, rather than its impact on the underlying disease.The fundamental elements of palliative care consist of pain and nonpain symptom management, communication among patients, their families, and care providers, and conti-nuity of care across health systems and through the trajectory Brunicardi_Ch48_p2061-p2076.indd 206619/02/19 1:49 PM 2067ETHICS, PALLIATIVE CARE, AND CARE AT THE END OF LIFECHAPTER 48of illness. Additional features of system-based palliative care are team-based planning that includes patient and family; close attention to spiritual matters; and psychosocial support for patients, their families, and care providers, including bereave-ment support.Indications for palliative care consultation in surgical practice include: (a) patients with conditions that are progres-sive and life-limiting, especially if characterized by burdensome symptoms, functional decline, and | Surgery_Schwartz. quality of life. The decision to intervene is based on the treat-ment’s ability to meet the stated goals, rather than its impact on the underlying disease.The fundamental elements of palliative care consist of pain and nonpain symptom management, communication among patients, their families, and care providers, and conti-nuity of care across health systems and through the trajectory Brunicardi_Ch48_p2061-p2076.indd 206619/02/19 1:49 PM 2067ETHICS, PALLIATIVE CARE, AND CARE AT THE END OF LIFECHAPTER 48of illness. Additional features of system-based palliative care are team-based planning that includes patient and family; close attention to spiritual matters; and psychosocial support for patients, their families, and care providers, including bereave-ment support.Indications for palliative care consultation in surgical practice include: (a) patients with conditions that are progres-sive and life-limiting, especially if characterized by burdensome symptoms, functional decline, and | [
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Surgery_Schwartz_13504 | Surgery_Schwartz | care consultation in surgical practice include: (a) patients with conditions that are progres-sive and life-limiting, especially if characterized by burdensome symptoms, functional decline, and progressive cognitive defi-cits; (b) assistance in clarification or reorientation of patient/family goals of care; (c) assistance in resolution of ethical dilemmas; (d) situations in which a patient/surrogate declines further invasive or curative treatments with stated preference for comfort measures only; (e) patients who are expected to die imminently or shortly after hospital discharge; and (f) provision of bereavement support for patient care staff, particularly after loss of a colleague under care36 (Table 48-1). Although all patients, regardless of prognosis, may benefit from the services of a palliative care physician, hospice care is a specific form of palliative care intended for patients who have an estimated prognosis of 6 months or less to live. Hospice care is covered under | Surgery_Schwartz. care consultation in surgical practice include: (a) patients with conditions that are progres-sive and life-limiting, especially if characterized by burdensome symptoms, functional decline, and progressive cognitive defi-cits; (b) assistance in clarification or reorientation of patient/family goals of care; (c) assistance in resolution of ethical dilemmas; (d) situations in which a patient/surrogate declines further invasive or curative treatments with stated preference for comfort measures only; (e) patients who are expected to die imminently or shortly after hospital discharge; and (f) provision of bereavement support for patient care staff, particularly after loss of a colleague under care36 (Table 48-1). Although all patients, regardless of prognosis, may benefit from the services of a palliative care physician, hospice care is a specific form of palliative care intended for patients who have an estimated prognosis of 6 months or less to live. Hospice care is covered under | [
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Surgery_Schwartz_13505 | Surgery_Schwartz | of a palliative care physician, hospice care is a specific form of palliative care intended for patients who have an estimated prognosis of 6 months or less to live. Hospice care is covered under Medicare Part A, and benefits may be continued beyond the original 6 months of estimated survival if physicians certify that life expectancy remains limited to 6 months or less. Although most Americans indicate a preference to die at home, nearly 75% die in an institutional setting. Earlier referral and wider use of the hospice benefit may help more patients achieve their goal of dying at home.Concepts of Suffering, Pain, Health, and HealingPalliative care specifically addresses the individual patient’s experience of suffering due to illness. Indeed, the philosophi-cal origins of palliative care began with attention to suffering and the existential questions suffering engenders. More than mere technologic evolution in the management of symptoms, the early proponents of palliative care sought | Surgery_Schwartz. of a palliative care physician, hospice care is a specific form of palliative care intended for patients who have an estimated prognosis of 6 months or less to live. Hospice care is covered under Medicare Part A, and benefits may be continued beyond the original 6 months of estimated survival if physicians certify that life expectancy remains limited to 6 months or less. Although most Americans indicate a preference to die at home, nearly 75% die in an institutional setting. Earlier referral and wider use of the hospice benefit may help more patients achieve their goal of dying at home.Concepts of Suffering, Pain, Health, and HealingPalliative care specifically addresses the individual patient’s experience of suffering due to illness. Indeed, the philosophi-cal origins of palliative care began with attention to suffering and the existential questions suffering engenders. More than mere technologic evolution in the management of symptoms, the early proponents of palliative care sought | [
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Surgery_Schwartz_13506 | Surgery_Schwartz | began with attention to suffering and the existential questions suffering engenders. More than mere technologic evolution in the management of symptoms, the early proponents of palliative care sought a revolution in the moral foundations of medicine that challenged the assumptions that so often seemed to result in futile invasive intervention, and identified many of the problems that were subsequently taken up by medical ethicists. This reorientation of the goals of medical care from a focus on disease and its management to the patient’s experience of illness focuses attention on the purpose of medicine and the meaning of health and healing.Over the past half century, several concepts and theo-ries about the nature of pain, suffering, and health have been proposed in service of the evolving conceptual framework of palliative care. For example, while considering the differences between disease-oriented and illness-oriented approaches to the care of seriously ill patients, psychiatrist | Surgery_Schwartz. began with attention to suffering and the existential questions suffering engenders. More than mere technologic evolution in the management of symptoms, the early proponents of palliative care sought a revolution in the moral foundations of medicine that challenged the assumptions that so often seemed to result in futile invasive intervention, and identified many of the problems that were subsequently taken up by medical ethicists. This reorientation of the goals of medical care from a focus on disease and its management to the patient’s experience of illness focuses attention on the purpose of medicine and the meaning of health and healing.Over the past half century, several concepts and theo-ries about the nature of pain, suffering, and health have been proposed in service of the evolving conceptual framework of palliative care. For example, while considering the differences between disease-oriented and illness-oriented approaches to the care of seriously ill patients, psychiatrist | [
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Surgery_Schwartz_13507 | Surgery_Schwartz | conceptual framework of palliative care. For example, while considering the differences between disease-oriented and illness-oriented approaches to the care of seriously ill patients, psychiatrist Arthur Kleinman wrote, “There is a moral core to healing in all societies. [Healing] is the central purpose of medicine . . . the purpose of medicine is both control of disease processes and care for the illness experience. Nowhere is this clearer than in the relationship of the chronically ill to their medical system: For them, the control of disease is by definition limited; care for the life problems created by the disorder is the chief issue.”33The relief of pain has been the clinical foundation for hospice and palliative care. Pain is defined by the International Association for the Study of Pain as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.”38 For purposes of interdisciplinary palliative care, | Surgery_Schwartz. conceptual framework of palliative care. For example, while considering the differences between disease-oriented and illness-oriented approaches to the care of seriously ill patients, psychiatrist Arthur Kleinman wrote, “There is a moral core to healing in all societies. [Healing] is the central purpose of medicine . . . the purpose of medicine is both control of disease processes and care for the illness experience. Nowhere is this clearer than in the relationship of the chronically ill to their medical system: For them, the control of disease is by definition limited; care for the life problems created by the disorder is the chief issue.”33The relief of pain has been the clinical foundation for hospice and palliative care. Pain is defined by the International Association for the Study of Pain as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.”38 For purposes of interdisciplinary palliative care, | [
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Surgery_Schwartz_13508 | Surgery_Schwartz | Pain as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.”38 For purposes of interdisciplinary palliative care, Saunders’s concept of “total pain”37 is a more useful definition and is frequently used as the basis for palliative assessments. Total pain is the sum total of four principal domains of pain: physical, psychologic, social or socioeconomic, and spiritual. Each of these contributes to, but is not synonymous with, suffering.Effective Communication and Negotiating the Goals of CareChanging the goals of care from cure to palliation near the end of life can be both emotionally and clinically challenging. It depends on determination of a clear prognosis and can be aided by effective communication. Unfortunately, prognostication can be notoriously difficult and inaccurate in advanced illness, and Christakis has argued that, to a large degree, physicians have abdicated their traditional | Surgery_Schwartz. Pain as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.”38 For purposes of interdisciplinary palliative care, Saunders’s concept of “total pain”37 is a more useful definition and is frequently used as the basis for palliative assessments. Total pain is the sum total of four principal domains of pain: physical, psychologic, social or socioeconomic, and spiritual. Each of these contributes to, but is not synonymous with, suffering.Effective Communication and Negotiating the Goals of CareChanging the goals of care from cure to palliation near the end of life can be both emotionally and clinically challenging. It depends on determination of a clear prognosis and can be aided by effective communication. Unfortunately, prognostication can be notoriously difficult and inaccurate in advanced illness, and Christakis has argued that, to a large degree, physicians have abdicated their traditional | [
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Surgery_Schwartz_13509 | Surgery_Schwartz | Unfortunately, prognostication can be notoriously difficult and inaccurate in advanced illness, and Christakis has argued that, to a large degree, physicians have abdicated their traditional responsibility to provide clear prognosis regarding incurable disease and approaching death.40 However, there are validated tools for prognosis in critical ill-ness (APACHE, MODS, etc.), and with most advanced diseases, functional status is the most powerful predictor of survival. For example, patients with advanced metastatic cancer who are rest-ing or sleeping for 50% or more of normal waking hours and require some assistance with activities of daily living (ADL) have a projected survival of weeks, and patients who are essen-tially bedfast and dependent for ADL have a projected survival of days to a week or two at best. Table 48-2 shows a simple prognostic tool to aid clinicians in recognizing patients nearing the end of life.Alternatively, the Karnofsky Performance Scale is a scale of | Surgery_Schwartz. Unfortunately, prognostication can be notoriously difficult and inaccurate in advanced illness, and Christakis has argued that, to a large degree, physicians have abdicated their traditional responsibility to provide clear prognosis regarding incurable disease and approaching death.40 However, there are validated tools for prognosis in critical ill-ness (APACHE, MODS, etc.), and with most advanced diseases, functional status is the most powerful predictor of survival. For example, patients with advanced metastatic cancer who are rest-ing or sleeping for 50% or more of normal waking hours and require some assistance with activities of daily living (ADL) have a projected survival of weeks, and patients who are essen-tially bedfast and dependent for ADL have a projected survival of days to a week or two at best. Table 48-2 shows a simple prognostic tool to aid clinicians in recognizing patients nearing the end of life.Alternatively, the Karnofsky Performance Scale is a scale of | [
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] |
Surgery_Schwartz_13510 | Surgery_Schwartz | days to a week or two at best. Table 48-2 shows a simple prognostic tool to aid clinicians in recognizing patients nearing the end of life.Alternatively, the Karnofsky Performance Scale is a scale of functional status ranging from 100 (high level of function) to 0 (death). It is commonly used in palliative care to roughly assess a patient’s anticipated needs as well as prognosis. The Palliative Performance Scale41 is a validated42 expansion of the Karnofsky Performance Scale that includes five palliative-focused domains, including ambulation, activity level, self-care, intake, and level of consciousness, in addition to evidence of disease. The Missoula-Vitas Quality of Life Index is a 25-question scale specifically for palliative care and hospice patients that scores symptoms, function, interpersonal relationships, well-being, and spirituality. Updates and Spanish versions are available.39Regardless of the prognostic tool used, the prognosis should be conveyed to the patient and | Surgery_Schwartz. days to a week or two at best. Table 48-2 shows a simple prognostic tool to aid clinicians in recognizing patients nearing the end of life.Alternatively, the Karnofsky Performance Scale is a scale of functional status ranging from 100 (high level of function) to 0 (death). It is commonly used in palliative care to roughly assess a patient’s anticipated needs as well as prognosis. The Palliative Performance Scale41 is a validated42 expansion of the Karnofsky Performance Scale that includes five palliative-focused domains, including ambulation, activity level, self-care, intake, and level of consciousness, in addition to evidence of disease. The Missoula-Vitas Quality of Life Index is a 25-question scale specifically for palliative care and hospice patients that scores symptoms, function, interpersonal relationships, well-being, and spirituality. Updates and Spanish versions are available.39Regardless of the prognostic tool used, the prognosis should be conveyed to the patient and | [
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Surgery_Schwartz_13511 | Surgery_Schwartz | interpersonal relationships, well-being, and spirituality. Updates and Spanish versions are available.39Regardless of the prognostic tool used, the prognosis should be conveyed to the patient and family. If done well, communication and negotiation with patients and families about advanced terminal illnesses can potentially avoid great 66Table 48-1Indications for palliative care consultationPatients with conditions that are progressive and life-limiting, especially if characterized by burdensome symptoms, functional decline, and progressive cognitive deficitsAssistance in clarification or reorientation of patient/family goals of careAssistance in resolution of ethical dilemmasSituations in which patient/surrogate declines further invasive or curative treatments with stated preference for comfort measures onlyPatients who are expected to die imminently or shortly after hospital dischargeProvision of bereavement support for patient care staff, particularly after loss of a colleague under | Surgery_Schwartz. interpersonal relationships, well-being, and spirituality. Updates and Spanish versions are available.39Regardless of the prognostic tool used, the prognosis should be conveyed to the patient and family. If done well, communication and negotiation with patients and families about advanced terminal illnesses can potentially avoid great 66Table 48-1Indications for palliative care consultationPatients with conditions that are progressive and life-limiting, especially if characterized by burdensome symptoms, functional decline, and progressive cognitive deficitsAssistance in clarification or reorientation of patient/family goals of careAssistance in resolution of ethical dilemmasSituations in which patient/surrogate declines further invasive or curative treatments with stated preference for comfort measures onlyPatients who are expected to die imminently or shortly after hospital dischargeProvision of bereavement support for patient care staff, particularly after loss of a colleague under | [
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Surgery_Schwartz_13512 | Surgery_Schwartz | measures onlyPatients who are expected to die imminently or shortly after hospital dischargeProvision of bereavement support for patient care staff, particularly after loss of a colleague under careBrunicardi_Ch48_p2061-p2076.indd 206719/02/19 1:49 PM 2068SPECIFIC CONSIDERATIONSPART IITable 48-2Simple prognostication tool in advanced illness (especially cancer)FUNCTIONAL LEVELPERFORMANCE STATUS (ECOG)PROGNOSISAble to perform all basic ADLs independently and some IADLs2MonthsResting/sleeping up to 50% or more of waking hours and requiring some assistance with basic ADLs3Weeks to a few monthsDependent for basic ADLs and bed-to-chair existence4Days to a few weeks at mostThese observations apply to patients with advanced, progressive, incurable illnesses (e.g., metastatic cancer refractory to treatment).Basic ADL = activities of daily living (e.g., transferring, toileting, bathing, dressing, and feeding oneself); IADL = instrumental activities of daily living (e.g., more complex | Surgery_Schwartz. measures onlyPatients who are expected to die imminently or shortly after hospital dischargeProvision of bereavement support for patient care staff, particularly after loss of a colleague under careBrunicardi_Ch48_p2061-p2076.indd 206719/02/19 1:49 PM 2068SPECIFIC CONSIDERATIONSPART IITable 48-2Simple prognostication tool in advanced illness (especially cancer)FUNCTIONAL LEVELPERFORMANCE STATUS (ECOG)PROGNOSISAble to perform all basic ADLs independently and some IADLs2MonthsResting/sleeping up to 50% or more of waking hours and requiring some assistance with basic ADLs3Weeks to a few monthsDependent for basic ADLs and bed-to-chair existence4Days to a few weeks at mostThese observations apply to patients with advanced, progressive, incurable illnesses (e.g., metastatic cancer refractory to treatment).Basic ADL = activities of daily living (e.g., transferring, toileting, bathing, dressing, and feeding oneself); IADL = instrumental activities of daily living (e.g., more complex | [
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Surgery_Schwartz_13513 | Surgery_Schwartz | to treatment).Basic ADL = activities of daily living (e.g., transferring, toileting, bathing, dressing, and feeding oneself); IADL = instrumental activities of daily living (e.g., more complex activities such as meal preparation, performing household chores, balancing a checkbook, shopping, etc.); ECOG = Eastern Cooperative Oncology Group functional (performance) status.Table 48-3Communicating unfavorable news: important principles• Setting: Find a quiet, private place to meet. Sit down close to the patient.• Listen: Clarify the patient’s and/or the family’s understanding of the situation.• “Warning shot”: Prepare patient and family and obtain their permission to communicate bad news (e.g., “I’m afraid I have bad news.”).• Silence: Pause after giving bad news. Allow patient/family to absorb/react to the news.• Encourage: Convey hope that is realistic and appropriate to the circumstances (e.g., patient will not be abandoned; symptoms will be controlled).psychologic harm and help make a | Surgery_Schwartz. to treatment).Basic ADL = activities of daily living (e.g., transferring, toileting, bathing, dressing, and feeding oneself); IADL = instrumental activities of daily living (e.g., more complex activities such as meal preparation, performing household chores, balancing a checkbook, shopping, etc.); ECOG = Eastern Cooperative Oncology Group functional (performance) status.Table 48-3Communicating unfavorable news: important principles• Setting: Find a quiet, private place to meet. Sit down close to the patient.• Listen: Clarify the patient’s and/or the family’s understanding of the situation.• “Warning shot”: Prepare patient and family and obtain their permission to communicate bad news (e.g., “I’m afraid I have bad news.”).• Silence: Pause after giving bad news. Allow patient/family to absorb/react to the news.• Encourage: Convey hope that is realistic and appropriate to the circumstances (e.g., patient will not be abandoned; symptoms will be controlled).psychologic harm and help make a | [
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Surgery_Schwartz_13514 | Surgery_Schwartz | to the news.• Encourage: Convey hope that is realistic and appropriate to the circumstances (e.g., patient will not be abandoned; symptoms will be controlled).psychologic harm and help make a difficult transition easier. To communicate effectively and compassionately, it is helpful to pursue an organized process similar to the structured history and physical central to the evaluation of any patient. One such structured approach to delivering unfavorable news proposes six steps that can be easily learned by clinicians: (a) getting started by selection of the appropriate setting, introductions, and seating; (b) determining what the patient or family knows; (c) determining what the patient or family wants to know; (d) giving the information; (e) expressing empathy; and (f) establishing expectations, planning, and aftercare (Table 48-3).43 Success with this approach to breaking bad news is critically depen-dent upon the clinician’s ability to empathically respond to the patient’s (and | Surgery_Schwartz. to the news.• Encourage: Convey hope that is realistic and appropriate to the circumstances (e.g., patient will not be abandoned; symptoms will be controlled).psychologic harm and help make a difficult transition easier. To communicate effectively and compassionately, it is helpful to pursue an organized process similar to the structured history and physical central to the evaluation of any patient. One such structured approach to delivering unfavorable news proposes six steps that can be easily learned by clinicians: (a) getting started by selection of the appropriate setting, introductions, and seating; (b) determining what the patient or family knows; (c) determining what the patient or family wants to know; (d) giving the information; (e) expressing empathy; and (f) establishing expectations, planning, and aftercare (Table 48-3).43 Success with this approach to breaking bad news is critically depen-dent upon the clinician’s ability to empathically respond to the patient’s (and | [
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Surgery_Schwartz_13515 | Surgery_Schwartz | planning, and aftercare (Table 48-3).43 Success with this approach to breaking bad news is critically depen-dent upon the clinician’s ability to empathically respond to the patient’s (and family’s) reaction to the news.44 The empathic response does not require the surgeon to share the same emo-tions of the patient, but it does require the surgeon to identify the patient’s emotion and accurately reflect that awareness back to the patient. Such effective communication may be facilitated by involving other members of the healthcare team who have developed relationships with the patient and their family. Patient assessment in these conversations should give the highest prior-ity to identifying and responding to the most immediate source of distress. Relieving a pressing symptom is prerequisite for a more thorough search for other potential sources of suffering, and the assessment process itself can be therapeutic if conducted in a respectful and gentle manner.CARE AT THE END OF LIFEThe | Surgery_Schwartz. planning, and aftercare (Table 48-3).43 Success with this approach to breaking bad news is critically depen-dent upon the clinician’s ability to empathically respond to the patient’s (and family’s) reaction to the news.44 The empathic response does not require the surgeon to share the same emo-tions of the patient, but it does require the surgeon to identify the patient’s emotion and accurately reflect that awareness back to the patient. Such effective communication may be facilitated by involving other members of the healthcare team who have developed relationships with the patient and their family. Patient assessment in these conversations should give the highest prior-ity to identifying and responding to the most immediate source of distress. Relieving a pressing symptom is prerequisite for a more thorough search for other potential sources of suffering, and the assessment process itself can be therapeutic if conducted in a respectful and gentle manner.CARE AT THE END OF LIFEThe | [
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Surgery_Schwartz_13516 | Surgery_Schwartz | for a more thorough search for other potential sources of suffering, and the assessment process itself can be therapeutic if conducted in a respectful and gentle manner.CARE AT THE END OF LIFEThe process of dying and the care of a patient at the time of death is a distinct clinical entity that demands specific skills from physicians. The issues specific to dying and the available tools for compassionate care at the end of life are addressed in this section.The Syndrome of Imminent Demise34,45In a patient who has progressed to the terminal stage of an advanced illness (e.g., cancer), a number of signs provide evi-dence of imminent death. As terminally ill patients progress toward death, they become increasingly bedbound, requiring assistance for all basic ADL. There is a steady decrease in desire and requests for food and fluids. More distressing to the dying patient is a progressively dry mouth that may be confused by the treating team as thirst. It is often exacerbated by | Surgery_Schwartz. for a more thorough search for other potential sources of suffering, and the assessment process itself can be therapeutic if conducted in a respectful and gentle manner.CARE AT THE END OF LIFEThe process of dying and the care of a patient at the time of death is a distinct clinical entity that demands specific skills from physicians. The issues specific to dying and the available tools for compassionate care at the end of life are addressed in this section.The Syndrome of Imminent Demise34,45In a patient who has progressed to the terminal stage of an advanced illness (e.g., cancer), a number of signs provide evi-dence of imminent death. As terminally ill patients progress toward death, they become increasingly bedbound, requiring assistance for all basic ADL. There is a steady decrease in desire and requests for food and fluids. More distressing to the dying patient is a progressively dry mouth that may be confused by the treating team as thirst. It is often exacerbated by | [
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Surgery_Schwartz_13517 | Surgery_Schwartz | decrease in desire and requests for food and fluids. More distressing to the dying patient is a progressively dry mouth that may be confused by the treating team as thirst. It is often exacerbated by anticholinergic medications, mouth breathing, and supplemental oxygen (O2) administered without humidification.With progressive debility, fatigue, and weight loss, it is common for terminally ill patients to experience increasing dif-ficulty swallowing. This may result in aspiration episodes and an inability to swallow tablets, requiring alternative routes for medication administration (e.g., IV, SC, PR, sublingual, buccal, or transdermal). In addition to the increased risk of aspiration, patients near death develop great difficulty clearing oropharyn-geal and upper airway secretions, leading to noisy breathing or the so-called “death rattle.” As death approaches, the respiratory pattern may change to increasingly frequent periods of apnea often following a Cheyne-Stokes pattern of rapid, | Surgery_Schwartz. decrease in desire and requests for food and fluids. More distressing to the dying patient is a progressively dry mouth that may be confused by the treating team as thirst. It is often exacerbated by anticholinergic medications, mouth breathing, and supplemental oxygen (O2) administered without humidification.With progressive debility, fatigue, and weight loss, it is common for terminally ill patients to experience increasing dif-ficulty swallowing. This may result in aspiration episodes and an inability to swallow tablets, requiring alternative routes for medication administration (e.g., IV, SC, PR, sublingual, buccal, or transdermal). In addition to the increased risk of aspiration, patients near death develop great difficulty clearing oropharyn-geal and upper airway secretions, leading to noisy breathing or the so-called “death rattle.” As death approaches, the respiratory pattern may change to increasingly frequent periods of apnea often following a Cheyne-Stokes pattern of rapid, | [
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Surgery_Schwartz_13518 | Surgery_Schwartz | to noisy breathing or the so-called “death rattle.” As death approaches, the respiratory pattern may change to increasingly frequent periods of apnea often following a Cheyne-Stokes pattern of rapid, progressively longer breaths leading up to an apneic period. As circulatory instability develops near death, patients may exhibit cool and mottled extremities. Periods of confusion are often accompanied by decreasing urine output and episodes of fecal and urinary incontinence.A number of cognitive changes occur as death approaches. Patients who are in the last days of life may demonstrate some signs of confusion or delirium. Agitated delirium is a promi-nent feature of a difficult death. Other cognitive changes that may be seen include a decreased interest in social interactions, increased somnolence, reduced attention span, disorientation to time (often with altered sleep-wake cycles), and an altered dream life, including vivid “waking dreams” or visual halluci-nations. Reduced hearing | Surgery_Schwartz. to noisy breathing or the so-called “death rattle.” As death approaches, the respiratory pattern may change to increasingly frequent periods of apnea often following a Cheyne-Stokes pattern of rapid, progressively longer breaths leading up to an apneic period. As circulatory instability develops near death, patients may exhibit cool and mottled extremities. Periods of confusion are often accompanied by decreasing urine output and episodes of fecal and urinary incontinence.A number of cognitive changes occur as death approaches. Patients who are in the last days of life may demonstrate some signs of confusion or delirium. Agitated delirium is a promi-nent feature of a difficult death. Other cognitive changes that may be seen include a decreased interest in social interactions, increased somnolence, reduced attention span, disorientation to time (often with altered sleep-wake cycles), and an altered dream life, including vivid “waking dreams” or visual halluci-nations. Reduced hearing | [
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Surgery_Schwartz_13519 | Surgery_Schwartz | reduced attention span, disorientation to time (often with altered sleep-wake cycles), and an altered dream life, including vivid “waking dreams” or visual halluci-nations. Reduced hearing and visual acuity may be an issue for some patients; however, patients who appear comatose may still be aware of their surroundings. Severely cachectic patients may lose the ability to keep their eyes closed during sleep because of loss of the retro-orbital fat pad.Common Symptoms at the End of Life and Their Management34,45,46The three most common, major symptoms that threaten the comfort of dying patients in their last days are respiratory Brunicardi_Ch48_p2061-p2076.indd 206819/02/19 1:49 PM 2069ETHICS, PALLIATIVE CARE, AND CARE AT THE END OF LIFECHAPTER 48Table 48-4Principles of pharmacotherapy in palliative care• Believe patient report of symptoms.• Modify pathologic process when possible and appropriate.• In terminally ill patients, avoid medications not directly linked to symptom | Surgery_Schwartz. reduced attention span, disorientation to time (often with altered sleep-wake cycles), and an altered dream life, including vivid “waking dreams” or visual halluci-nations. Reduced hearing and visual acuity may be an issue for some patients; however, patients who appear comatose may still be aware of their surroundings. Severely cachectic patients may lose the ability to keep their eyes closed during sleep because of loss of the retro-orbital fat pad.Common Symptoms at the End of Life and Their Management34,45,46The three most common, major symptoms that threaten the comfort of dying patients in their last days are respiratory Brunicardi_Ch48_p2061-p2076.indd 206819/02/19 1:49 PM 2069ETHICS, PALLIATIVE CARE, AND CARE AT THE END OF LIFECHAPTER 48Table 48-4Principles of pharmacotherapy in palliative care• Believe patient report of symptoms.• Modify pathologic process when possible and appropriate.• In terminally ill patients, avoid medications not directly linked to symptom | [
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Surgery_Schwartz_13520 | Surgery_Schwartz | in palliative care• Believe patient report of symptoms.• Modify pathologic process when possible and appropriate.• In terminally ill patients, avoid medications not directly linked to symptom control.• Use a multidisciplinary approach.• Consider nonpharmacologic approaches whenever possible.• Engage participation of clinical pharmacist in treatment plan.• Select drugs that can multitask (i.e., use haloperidol for agitated delirium and nausea).• For pain, use adjuvant medications when possible (see Table 48-7).• When using opioids, spare when possible (adjuvant medication, local or regional anesthetics, surgical interventions, etc.).• Avoid fixed combination drugs.• Avoid excessive cost.• Select agents with minimum side effects.• Anticipate and prophylax against side effects.• For older adult patients, the hypoproteinemic, the azotemic: “Start low and go slow.”• Oral route whenever possible and practical.• No intramuscular injections.• Scheduled dosing, not as needed, for persistent | Surgery_Schwartz. in palliative care• Believe patient report of symptoms.• Modify pathologic process when possible and appropriate.• In terminally ill patients, avoid medications not directly linked to symptom control.• Use a multidisciplinary approach.• Consider nonpharmacologic approaches whenever possible.• Engage participation of clinical pharmacist in treatment plan.• Select drugs that can multitask (i.e., use haloperidol for agitated delirium and nausea).• For pain, use adjuvant medications when possible (see Table 48-7).• When using opioids, spare when possible (adjuvant medication, local or regional anesthetics, surgical interventions, etc.).• Avoid fixed combination drugs.• Avoid excessive cost.• Select agents with minimum side effects.• Anticipate and prophylax against side effects.• For older adult patients, the hypoproteinemic, the azotemic: “Start low and go slow.”• Oral route whenever possible and practical.• No intramuscular injections.• Scheduled dosing, not as needed, for persistent | [
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Surgery_Schwartz_13521 | Surgery_Schwartz | adult patients, the hypoproteinemic, the azotemic: “Start low and go slow.”• Oral route whenever possible and practical.• No intramuscular injections.• Scheduled dosing, not as needed, for persistent symptoms.• Stepwise approach. (See the World Health Organization Analgesic Ladder for pain, Table 48-5.)• Reassess continuously and titrate to effect.• Use equianalgesic doses when changing opioids (see Table 48-5).• Assess the patient’s and family’s comprehension of management plan.Table 48-5The World Health Organization’s three-step ladder for control of cancer pain30Step 1: mild pain (visual analogue scale, 1–3) Nonopioid ± adjuvant medicationStep 2: moderate pain (visual analogue scale, 4–6) Opioid for mild to moderate pain and nonopioid ± an adjuvantStep 3: severe pain (visual analogue scale, 7–10) Opioid for moderate to severe pain ± nonopioid ± an adjuvantThe primary treatment of dyspnea (air hunger) in the dying is opioids, which should be cautiously titrated to increase com-fort | Surgery_Schwartz. adult patients, the hypoproteinemic, the azotemic: “Start low and go slow.”• Oral route whenever possible and practical.• No intramuscular injections.• Scheduled dosing, not as needed, for persistent symptoms.• Stepwise approach. (See the World Health Organization Analgesic Ladder for pain, Table 48-5.)• Reassess continuously and titrate to effect.• Use equianalgesic doses when changing opioids (see Table 48-5).• Assess the patient’s and family’s comprehension of management plan.Table 48-5The World Health Organization’s three-step ladder for control of cancer pain30Step 1: mild pain (visual analogue scale, 1–3) Nonopioid ± adjuvant medicationStep 2: moderate pain (visual analogue scale, 4–6) Opioid for mild to moderate pain and nonopioid ± an adjuvantStep 3: severe pain (visual analogue scale, 7–10) Opioid for moderate to severe pain ± nonopioid ± an adjuvantThe primary treatment of dyspnea (air hunger) in the dying is opioids, which should be cautiously titrated to increase com-fort | [
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Surgery_Schwartz_13522 | Surgery_Schwartz | 7–10) Opioid for moderate to severe pain ± nonopioid ± an adjuvantThe primary treatment of dyspnea (air hunger) in the dying is opioids, which should be cautiously titrated to increase com-fort and reduce tachypnea to a range of 15 to 20 breaths per minute. Air movement across the face generated by a fan can sometimes be quite helpful. If this is not effective, empirical use of supplemental O2 by nasal cannula (2–3 L/min) may bring some subjective relief, independent of observable changes in pulse oximetry. Supplemental O2 should be humidified to avoid exacerbation of dry mouth. Typical starting doses of an immedi-ate release opioid for breathlessness should be one-half to two-thirds of a starting dose of the same agent for cancer pain. For patients already on opioids for pain, a 25% to 50% increment in the dose of the current immediate release agent for breakthrough pain often will be effective in relieving breathlessness in addi-tion to breakthrough pain.The availability and variety | Surgery_Schwartz. 7–10) Opioid for moderate to severe pain ± nonopioid ± an adjuvantThe primary treatment of dyspnea (air hunger) in the dying is opioids, which should be cautiously titrated to increase com-fort and reduce tachypnea to a range of 15 to 20 breaths per minute. Air movement across the face generated by a fan can sometimes be quite helpful. If this is not effective, empirical use of supplemental O2 by nasal cannula (2–3 L/min) may bring some subjective relief, independent of observable changes in pulse oximetry. Supplemental O2 should be humidified to avoid exacerbation of dry mouth. Typical starting doses of an immedi-ate release opioid for breathlessness should be one-half to two-thirds of a starting dose of the same agent for cancer pain. For patients already on opioids for pain, a 25% to 50% increment in the dose of the current immediate release agent for breakthrough pain often will be effective in relieving breathlessness in addi-tion to breakthrough pain.The availability and variety | [
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Surgery_Schwartz_13523 | Surgery_Schwartz | increment in the dose of the current immediate release agent for breakthrough pain often will be effective in relieving breathlessness in addi-tion to breakthrough pain.The availability and variety of drugs should not prevent consideration of nonpharmacologic therapy. Massage therapy, music therapy, art therapy, guided imagery, hypnosis, physi-cal therapy, pet therapy, and others play a constructive role not only for the relief of symptoms but also for promoting a sense of hope through improving function, aesthetic pleasure, and social connectedness. Talents and capacities neglected during the treatment and progression of disease can be recovered even in the most advanced stages of illness.Pain is often less of a problem in the last days of life because the reduced activity level is associated with lower inci-dent pain. This, combined with lower renal clearance of opioids, may result in greater potency of the prescribed agents. Severe pain crises are fortunately rare, but when they | Surgery_Schwartz. increment in the dose of the current immediate release agent for breakthrough pain often will be effective in relieving breathlessness in addi-tion to breakthrough pain.The availability and variety of drugs should not prevent consideration of nonpharmacologic therapy. Massage therapy, music therapy, art therapy, guided imagery, hypnosis, physi-cal therapy, pet therapy, and others play a constructive role not only for the relief of symptoms but also for promoting a sense of hope through improving function, aesthetic pleasure, and social connectedness. Talents and capacities neglected during the treatment and progression of disease can be recovered even in the most advanced stages of illness.Pain is often less of a problem in the last days of life because the reduced activity level is associated with lower inci-dent pain. This, combined with lower renal clearance of opioids, may result in greater potency of the prescribed agents. Severe pain crises are fortunately rare, but when they | [
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Surgery_Schwartz_13524 | Surgery_Schwartz | with lower inci-dent pain. This, combined with lower renal clearance of opioids, may result in greater potency of the prescribed agents. Severe pain crises are fortunately rare, but when they are inadequately addressed, can cause great and lasting distress (complicated grief) for loved ones who witness the final hours or days of agony. Such situations may require continuous administration of parenteral opioids. As death approaches and patients become less verbal, it is important to assess pain frequently, including the use of close observation for nonverbal signs of distress (e.g., grimacing, increased respiratory rate). Adequate dosing of opi-oid analgesics may require alternate route(s) of administration other than oral as patients become more somnolent or develop swallowing difficulties. Opioids should not be stopped abruptly, even if the patient becomes nonresponsive, because sudden withdrawal can cause severe distress.49,50Cognitive failure at the end of life is manifested in | Surgery_Schwartz. with lower inci-dent pain. This, combined with lower renal clearance of opioids, may result in greater potency of the prescribed agents. Severe pain crises are fortunately rare, but when they are inadequately addressed, can cause great and lasting distress (complicated grief) for loved ones who witness the final hours or days of agony. Such situations may require continuous administration of parenteral opioids. As death approaches and patients become less verbal, it is important to assess pain frequently, including the use of close observation for nonverbal signs of distress (e.g., grimacing, increased respiratory rate). Adequate dosing of opi-oid analgesics may require alternate route(s) of administration other than oral as patients become more somnolent or develop swallowing difficulties. Opioids should not be stopped abruptly, even if the patient becomes nonresponsive, because sudden withdrawal can cause severe distress.49,50Cognitive failure at the end of life is manifested in | [
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Surgery_Schwartz_13525 | Surgery_Schwartz | Opioids should not be stopped abruptly, even if the patient becomes nonresponsive, because sudden withdrawal can cause severe distress.49,50Cognitive failure at the end of life is manifested in most patients by increasing somnolence and delirium. Gradually increasing somnolence can be accompanied by periods of dis-orientation and mild confusion, and it may respond to the reas-suring presence of loved ones and caregivers with minimal need for medications. A more distressing form of delirium also can distress, pain, and cognitive failure. General principles that are applicable to symptom management in the last days of life include (a) anticipating symptoms before they develop; (b) minimizing technologic interventions (usually manage symp-toms with medications); and (c) planning alternative routes for medications in case the oral route fails. It may be possible to cautiously reduce the dose of opioids and other medications as renal clearance decreases near the end of life, but it is | Surgery_Schwartz. Opioids should not be stopped abruptly, even if the patient becomes nonresponsive, because sudden withdrawal can cause severe distress.49,50Cognitive failure at the end of life is manifested in most patients by increasing somnolence and delirium. Gradually increasing somnolence can be accompanied by periods of dis-orientation and mild confusion, and it may respond to the reas-suring presence of loved ones and caregivers with minimal need for medications. A more distressing form of delirium also can distress, pain, and cognitive failure. General principles that are applicable to symptom management in the last days of life include (a) anticipating symptoms before they develop; (b) minimizing technologic interventions (usually manage symp-toms with medications); and (c) planning alternative routes for medications in case the oral route fails. It may be possible to cautiously reduce the dose of opioids and other medications as renal clearance decreases near the end of life, but it is | [
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Surgery_Schwartz_13526 | Surgery_Schwartz | routes for medications in case the oral route fails. It may be possible to cautiously reduce the dose of opioids and other medications as renal clearance decreases near the end of life, but it is important to remember that increased somnolence and decreasing respira-tions are prominent features of the dying process independent of medication side effects. Sudden cessation of opioid analgesics near the end of life could precipitate withdrawal symptoms, and therefore medications should not be stopped for increasing som-nolence or slowed respirations.The principles of pharmacotherapy for pain and non-pain symptoms in the palliative care setting are outlined in Table 48-4. The World Health Organization,35 the United States Agency for Healthcare Policy and Research,47 the Academy of Hospice and Palliative Medicine,48 and many other agencies have endorsed a “step ladder” approach to cancer pain man-agement that can predictably result in satisfactory pain control in most patients (Table | Surgery_Schwartz. routes for medications in case the oral route fails. It may be possible to cautiously reduce the dose of opioids and other medications as renal clearance decreases near the end of life, but it is important to remember that increased somnolence and decreasing respira-tions are prominent features of the dying process independent of medication side effects. Sudden cessation of opioid analgesics near the end of life could precipitate withdrawal symptoms, and therefore medications should not be stopped for increasing som-nolence or slowed respirations.The principles of pharmacotherapy for pain and non-pain symptoms in the palliative care setting are outlined in Table 48-4. The World Health Organization,35 the United States Agency for Healthcare Policy and Research,47 the Academy of Hospice and Palliative Medicine,48 and many other agencies have endorsed a “step ladder” approach to cancer pain man-agement that can predictably result in satisfactory pain control in most patients (Table | [
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Surgery_Schwartz_13527 | Surgery_Schwartz | and Palliative Medicine,48 and many other agencies have endorsed a “step ladder” approach to cancer pain man-agement that can predictably result in satisfactory pain control in most patients (Table 48-5). More refractory pain problems require additional expertise, and occasionally, more invasive approaches (Tables 48-6 and 48-7).Brunicardi_Ch48_p2061-p2076.indd 206919/02/19 1:49 PM 2070SPECIFIC CONSIDERATIONSPART IITable 48-6Analgesics for persistent painDRUGINITIAL DOSING (ADULT, >60 kg)COMMENTSMild persistent pain, visual analogue scale (VAS) 1–3 Acetaminophen (Tylenol)325–650 mg PO four times a day Maximum = 3200 mg/24 hUse <2400 mg if other potentially hepatotoxic drugs taken. Acetaminophen contained in concurrent nonprescription medications can easily exceed maximum daily allowable dose. Aspirin600–1500 mg PO four times a dayGastric bleeding, platelet dysfunction Choline magnesium trisalicylate (Trilisate)750–1500 mg PO twice a dayUseful for avoiding platelet | Surgery_Schwartz. and Palliative Medicine,48 and many other agencies have endorsed a “step ladder” approach to cancer pain man-agement that can predictably result in satisfactory pain control in most patients (Table 48-5). More refractory pain problems require additional expertise, and occasionally, more invasive approaches (Tables 48-6 and 48-7).Brunicardi_Ch48_p2061-p2076.indd 206919/02/19 1:49 PM 2070SPECIFIC CONSIDERATIONSPART IITable 48-6Analgesics for persistent painDRUGINITIAL DOSING (ADULT, >60 kg)COMMENTSMild persistent pain, visual analogue scale (VAS) 1–3 Acetaminophen (Tylenol)325–650 mg PO four times a day Maximum = 3200 mg/24 hUse <2400 mg if other potentially hepatotoxic drugs taken. Acetaminophen contained in concurrent nonprescription medications can easily exceed maximum daily allowable dose. Aspirin600–1500 mg PO four times a dayGastric bleeding, platelet dysfunction Choline magnesium trisalicylate (Trilisate)750–1500 mg PO twice a dayUseful for avoiding platelet | [
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Surgery_Schwartz_13528 | Surgery_Schwartz | daily allowable dose. Aspirin600–1500 mg PO four times a dayGastric bleeding, platelet dysfunction Choline magnesium trisalicylate (Trilisate)750–1500 mg PO twice a dayUseful for avoiding platelet dysfunction Ibuprofen (Advil, Motrin)200–400 mg PO four times a day Maximum = 3200 mg/24 hGastropathy, nephropathy, decreased platelet aggregation Naproxen (Naprosyn)250 mg PO twice a day Maximum = 1300 mg/24 hAvailable as a transcutaneous gelModerate persistent pain, VAS 4–6 Hydrocodone (Vicodin, Lortab)5–7.5 mg PO every 4 hoursMost prescribed drug in the United StatesAcetaminophen in compounded drug limits use to moderate pain Oxycodone5 mg PO every 4 hoursSold as single agent or compounded with aspirin or acetaminophenSlow release form available (Oxycontin)Severe persistent pain, VAS 7–10 Morphine10 mg PO every 2–4 hours 2–4 mg IV, SC every 1–2 hoursStandard drug for comparison to alternative opioids. Avoid or caution when giving to older adults, patients with diminished glomerular | Surgery_Schwartz. daily allowable dose. Aspirin600–1500 mg PO four times a dayGastric bleeding, platelet dysfunction Choline magnesium trisalicylate (Trilisate)750–1500 mg PO twice a dayUseful for avoiding platelet dysfunction Ibuprofen (Advil, Motrin)200–400 mg PO four times a day Maximum = 3200 mg/24 hGastropathy, nephropathy, decreased platelet aggregation Naproxen (Naprosyn)250 mg PO twice a day Maximum = 1300 mg/24 hAvailable as a transcutaneous gelModerate persistent pain, VAS 4–6 Hydrocodone (Vicodin, Lortab)5–7.5 mg PO every 4 hoursMost prescribed drug in the United StatesAcetaminophen in compounded drug limits use to moderate pain Oxycodone5 mg PO every 4 hoursSold as single agent or compounded with aspirin or acetaminophenSlow release form available (Oxycontin)Severe persistent pain, VAS 7–10 Morphine10 mg PO every 2–4 hours 2–4 mg IV, SC every 1–2 hoursStandard drug for comparison to alternative opioids. Avoid or caution when giving to older adults, patients with diminished glomerular | [
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Surgery_Schwartz_13529 | Surgery_Schwartz | mg PO every 2–4 hours 2–4 mg IV, SC every 1–2 hoursStandard drug for comparison to alternative opioids. Avoid or caution when giving to older adults, patients with diminished glomerular filtration rate, or liver disease. Slow release PO form available (MS Contin). Hydromorphone1–3 mg PO, PR every 4 hours 1 mg IV, SC every 1–2 hoursSuppository form availableOral dose forms limited to 4 mg maximum Fentanyl, transdermal12 μg/h patch every 72 hoursNot for acute pain management. Do not use on opioid-naive patients. Absorption unpredictable in cachectic patients. MethadoneConsultation with pain management, clinical pharmacists, or palliative care/hospice services skilled in methadone use is recommended for those inexperienced in prescribing methadone.Not a first-line agent, although very effective, especially for pain with a neuropathic componentVery inexpensiveCan be given PO, IV, SC, PR, sublingually, and vaginallyIts long half-life makes dosing more difficult than alternative opioids and | Surgery_Schwartz. mg PO every 2–4 hours 2–4 mg IV, SC every 1–2 hoursStandard drug for comparison to alternative opioids. Avoid or caution when giving to older adults, patients with diminished glomerular filtration rate, or liver disease. Slow release PO form available (MS Contin). Hydromorphone1–3 mg PO, PR every 4 hours 1 mg IV, SC every 1–2 hoursSuppository form availableOral dose forms limited to 4 mg maximum Fentanyl, transdermal12 μg/h patch every 72 hoursNot for acute pain management. Do not use on opioid-naive patients. Absorption unpredictable in cachectic patients. MethadoneConsultation with pain management, clinical pharmacists, or palliative care/hospice services skilled in methadone use is recommended for those inexperienced in prescribing methadone.Not a first-line agent, although very effective, especially for pain with a neuropathic componentVery inexpensiveCan be given PO, IV, SC, PR, sublingually, and vaginallyIts long half-life makes dosing more difficult than alternative opioids and | [
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Surgery_Schwartz_13530 | Surgery_Schwartz | especially for pain with a neuropathic componentVery inexpensiveCan be given PO, IV, SC, PR, sublingually, and vaginallyIts long half-life makes dosing more difficult than alternative opioids and close monitoring is required when initiating.Numerous medications, alcohol, and cigarette smoking can alter its serum levels.Physicians who write methadone prescriptions for pain should specify this indication. Methadone use for drug withdrawal treatment requires special licensure.Risk factors for NSAID-induced nephropathy include: advanced age, decreased glomerular filtration rate, congestive heart failure, hypovolemia, pressors, hepatic dysfunction, concomitant nephrotoxic agents. Dose reduction and hydration reduce risk.Opioids compounded with aspirin or acetaminophen are limited to treatment of moderate persistent pain because of dose-limiting toxicities of acetaminophen and aspirin.Slow-release preparations of morphine and oxycodone may be given rectally.Timed-release tablets or patches | Surgery_Schwartz. especially for pain with a neuropathic componentVery inexpensiveCan be given PO, IV, SC, PR, sublingually, and vaginallyIts long half-life makes dosing more difficult than alternative opioids and close monitoring is required when initiating.Numerous medications, alcohol, and cigarette smoking can alter its serum levels.Physicians who write methadone prescriptions for pain should specify this indication. Methadone use for drug withdrawal treatment requires special licensure.Risk factors for NSAID-induced nephropathy include: advanced age, decreased glomerular filtration rate, congestive heart failure, hypovolemia, pressors, hepatic dysfunction, concomitant nephrotoxic agents. Dose reduction and hydration reduce risk.Opioids compounded with aspirin or acetaminophen are limited to treatment of moderate persistent pain because of dose-limiting toxicities of acetaminophen and aspirin.Slow-release preparations of morphine and oxycodone may be given rectally.Timed-release tablets or patches | [
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Surgery_Schwartz_13531 | Surgery_Schwartz | of moderate persistent pain because of dose-limiting toxicities of acetaminophen and aspirin.Slow-release preparations of morphine and oxycodone may be given rectally.Timed-release tablets or patches should never be crushed or cut.Opioid analgesics are the agents of choice for severe cancer-related pain. Sedation is a common side effect when initiating opioid therapy. Tolerance to this usually develops within a few days. If sedation persists beyond a few days, a stimulant (methylphenidate 2.5–5 mg PO twice a day) can be given.Initiate bowel stimulant prophylaxis for constipation when prescribing opioids unless contraindicated.Adjuvant or coanalgesic agents are drugs that enhance analgesic efficacy of opioids, treat concurrent symptoms that exacerbate pain, or provide independent analgesia for specific types of pain (e.g., a tricyclic antidepressant for treatment of neuropathic pain). Coanalgesics can be initiated for persistent pain at any visual analogue scale level. Gabapentin is | Surgery_Schwartz. of moderate persistent pain because of dose-limiting toxicities of acetaminophen and aspirin.Slow-release preparations of morphine and oxycodone may be given rectally.Timed-release tablets or patches should never be crushed or cut.Opioid analgesics are the agents of choice for severe cancer-related pain. Sedation is a common side effect when initiating opioid therapy. Tolerance to this usually develops within a few days. If sedation persists beyond a few days, a stimulant (methylphenidate 2.5–5 mg PO twice a day) can be given.Initiate bowel stimulant prophylaxis for constipation when prescribing opioids unless contraindicated.Adjuvant or coanalgesic agents are drugs that enhance analgesic efficacy of opioids, treat concurrent symptoms that exacerbate pain, or provide independent analgesia for specific types of pain (e.g., a tricyclic antidepressant for treatment of neuropathic pain). Coanalgesics can be initiated for persistent pain at any visual analogue scale level. Gabapentin is | [
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Surgery_Schwartz_13532 | Surgery_Schwartz | for specific types of pain (e.g., a tricyclic antidepressant for treatment of neuropathic pain). Coanalgesics can be initiated for persistent pain at any visual analogue scale level. Gabapentin is commonly used as an initial agent for neuropathic pain.No place for meperidine (Demerol), propoxyphene (Darvon, Darvocet, or mixed agonist-antagonist agents [Stadol, Talwin]) in management of persistent pain.Always consider alternative approaches (axial analgesia, operative approaches, etc.) when managing severe persistent pain.Note: These are not recommendations for specific patients. The interand intraindividual variability to opioids requires individualizing dosing and titration to effect.Adapted with permission from Cameron JL: Current Surgical Therapy, 9th ed. Philadelphia, PA: Elsevier; 2008.Brunicardi_Ch48_p2061-p2076.indd 207019/02/19 1:49 PM 2071ETHICS, PALLIATIVE CARE, AND CARE AT THE END OF LIFECHAPTER 48Table 48-7Examples of adjuvant medications for treatment of neuropathic, | Surgery_Schwartz. for specific types of pain (e.g., a tricyclic antidepressant for treatment of neuropathic pain). Coanalgesics can be initiated for persistent pain at any visual analogue scale level. Gabapentin is commonly used as an initial agent for neuropathic pain.No place for meperidine (Demerol), propoxyphene (Darvon, Darvocet, or mixed agonist-antagonist agents [Stadol, Talwin]) in management of persistent pain.Always consider alternative approaches (axial analgesia, operative approaches, etc.) when managing severe persistent pain.Note: These are not recommendations for specific patients. The interand intraindividual variability to opioids requires individualizing dosing and titration to effect.Adapted with permission from Cameron JL: Current Surgical Therapy, 9th ed. Philadelphia, PA: Elsevier; 2008.Brunicardi_Ch48_p2061-p2076.indd 207019/02/19 1:49 PM 2071ETHICS, PALLIATIVE CARE, AND CARE AT THE END OF LIFECHAPTER 48Table 48-7Examples of adjuvant medications for treatment of neuropathic, | [
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Surgery_Schwartz_13533 | Surgery_Schwartz | 207019/02/19 1:49 PM 2071ETHICS, PALLIATIVE CARE, AND CARE AT THE END OF LIFECHAPTER 48Table 48-7Examples of adjuvant medications for treatment of neuropathic, visceral, and bone painaDRUG CLASSINITIAL DOSING (ADULT, >60 kg)COMMENTSTricyclic antidepressants Best for continuous burning or tingling pain and allodynia Efficacy for pain not due to antidepressant effectAmitriptyline 10–25 mg PO before bedNortriptyline 10–25 mg PO one per daySedating properties may be useful for relief of other concurrent symptoms. Side effects may precede benefit. Avoid in older adult patients due to anticholinergic side effects. Dose generally less than that required for antidepressant effectDoxepin 10–25 mg PO before bedLess anticholinergic effect Dose titrated up every few days until effect. Pain may respond to alternative antidepressants if no response to initial agent.Imipramine 10–25 mg PO one per day Anticonvulsants For shooting, stabbing painGabapentin 100–1200 mg PO three times a day. | Surgery_Schwartz. 207019/02/19 1:49 PM 2071ETHICS, PALLIATIVE CARE, AND CARE AT THE END OF LIFECHAPTER 48Table 48-7Examples of adjuvant medications for treatment of neuropathic, visceral, and bone painaDRUG CLASSINITIAL DOSING (ADULT, >60 kg)COMMENTSTricyclic antidepressants Best for continuous burning or tingling pain and allodynia Efficacy for pain not due to antidepressant effectAmitriptyline 10–25 mg PO before bedNortriptyline 10–25 mg PO one per daySedating properties may be useful for relief of other concurrent symptoms. Side effects may precede benefit. Avoid in older adult patients due to anticholinergic side effects. Dose generally less than that required for antidepressant effectDoxepin 10–25 mg PO before bedLess anticholinergic effect Dose titrated up every few days until effect. Pain may respond to alternative antidepressants if no response to initial agent.Imipramine 10–25 mg PO one per day Anticonvulsants For shooting, stabbing painGabapentin 100–1200 mg PO three times a day. | [
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Surgery_Schwartz_13534 | Surgery_Schwartz | may respond to alternative antidepressants if no response to initial agent.Imipramine 10–25 mg PO one per day Anticonvulsants For shooting, stabbing painGabapentin 100–1200 mg PO three times a day. Titrate up rapidly as needed. Max: 3600 mg daily in divided dosesCommonly used first-line agent. Generally well tolerated. Does not require blood level monitoring. Carbamazepine 200 mg PO every 12 hoursPregabalin starting dose 25–50 mg PO three times a dayEffective. Well studied. Requires blood monitoring.Does not require blood monitoring. Valproic acid 250 mg PO three times a day Local anesthetics Systemic use requires monitoring. Nebulized local anesthetics (lidocaine, bupivacaine) can be used for severe, refractory cough.Lidocaine transdermal patch 5%. Apply to painful areas. Max: 3 simultaneous patches over 12 hours (each patch contains 700 mg lidocaine).Lidocaine/prilocaine topical. Apply to painful areas.Systemic toxicity can result from applying more than recommended number per | Surgery_Schwartz. may respond to alternative antidepressants if no response to initial agent.Imipramine 10–25 mg PO one per day Anticonvulsants For shooting, stabbing painGabapentin 100–1200 mg PO three times a day. Titrate up rapidly as needed. Max: 3600 mg daily in divided dosesCommonly used first-line agent. Generally well tolerated. Does not require blood level monitoring. Carbamazepine 200 mg PO every 12 hoursPregabalin starting dose 25–50 mg PO three times a dayEffective. Well studied. Requires blood monitoring.Does not require blood monitoring. Valproic acid 250 mg PO three times a day Local anesthetics Systemic use requires monitoring. Nebulized local anesthetics (lidocaine, bupivacaine) can be used for severe, refractory cough.Lidocaine transdermal patch 5%. Apply to painful areas. Max: 3 simultaneous patches over 12 hours (each patch contains 700 mg lidocaine).Lidocaine/prilocaine topical. Apply to painful areas.Systemic toxicity can result from applying more than recommended number per | [
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Surgery_Schwartz_13535 | Surgery_Schwartz | patches over 12 hours (each patch contains 700 mg lidocaine).Lidocaine/prilocaine topical. Apply to painful areas.Systemic toxicity can result from applying more than recommended number per unit time and in patients with liver failure. Effective for postherpetic neuralgia.MiscellaneousBisphosphonates (pamidronate, zoledronic acid)For bone pain and reduced incidence of skeletal complications secondary to malignancy—best results in myeloma and breast cancer. Contraindicated in renal failure. Calcitonin nasal sprayRefractory bone pain DexamethasoneFor bone pain, acute nerve compression, visceral pain secondary to tumor infiltration or luminal obstruction by reducing inflammatory component of tumor Radionuclides (Sr-89)For malignant bone pain secondary to osteoclastic activity. 4–6 wk delay in benefit. Requires adequate bone marrow reserve. For prognosis of more than 3 mo. OctreotideReduces GI secretions that contribute to visceral painaRecommendations are based on experience of | Surgery_Schwartz. patches over 12 hours (each patch contains 700 mg lidocaine).Lidocaine/prilocaine topical. Apply to painful areas.Systemic toxicity can result from applying more than recommended number per unit time and in patients with liver failure. Effective for postherpetic neuralgia.MiscellaneousBisphosphonates (pamidronate, zoledronic acid)For bone pain and reduced incidence of skeletal complications secondary to malignancy—best results in myeloma and breast cancer. Contraindicated in renal failure. Calcitonin nasal sprayRefractory bone pain DexamethasoneFor bone pain, acute nerve compression, visceral pain secondary to tumor infiltration or luminal obstruction by reducing inflammatory component of tumor Radionuclides (Sr-89)For malignant bone pain secondary to osteoclastic activity. 4–6 wk delay in benefit. Requires adequate bone marrow reserve. For prognosis of more than 3 mo. OctreotideReduces GI secretions that contribute to visceral painaRecommendations are based on experience of | [
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Surgery_Schwartz_13536 | Surgery_Schwartz | delay in benefit. Requires adequate bone marrow reserve. For prognosis of more than 3 mo. OctreotideReduces GI secretions that contribute to visceral painaRecommendations are based on experience of practitioners of hospice and palliative medicine and in some instances do not reflect current clinical trials.Brunicardi_Ch48_p2061-p2076.indd 207119/02/19 1:49 PM 2072SPECIFIC CONSIDERATIONSPART IIdevelop, manifested by increasing agitation that may require the use of neuroleptic medications. Increasing amounts of opioids and/or benzodiazepines may exacerbate the delirium (especially in the elderly).Pronouncing Death51If the body is hypothermic or has been hypothermic, such as a drowning victim pulled from the water in the winter, the phy-sician should not declare death until warming attempts have been made. In the hospital, hospice, or home setting, the dec-laration of death becomes part of the medical or legal record of the event. There are a number of physical signs of death a | Surgery_Schwartz. delay in benefit. Requires adequate bone marrow reserve. For prognosis of more than 3 mo. OctreotideReduces GI secretions that contribute to visceral painaRecommendations are based on experience of practitioners of hospice and palliative medicine and in some instances do not reflect current clinical trials.Brunicardi_Ch48_p2061-p2076.indd 207119/02/19 1:49 PM 2072SPECIFIC CONSIDERATIONSPART IIdevelop, manifested by increasing agitation that may require the use of neuroleptic medications. Increasing amounts of opioids and/or benzodiazepines may exacerbate the delirium (especially in the elderly).Pronouncing Death51If the body is hypothermic or has been hypothermic, such as a drowning victim pulled from the water in the winter, the phy-sician should not declare death until warming attempts have been made. In the hospital, hospice, or home setting, the dec-laration of death becomes part of the medical or legal record of the event. There are a number of physical signs of death a | [
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Surgery_Schwartz_13537 | Surgery_Schwartz | attempts have been made. In the hospital, hospice, or home setting, the dec-laration of death becomes part of the medical or legal record of the event. There are a number of physical signs of death a physician should look for in confirming the patient’s demise: complete lack of responsiveness to verbal or tactile stimuli, absence of heart beat and respirations, fixed pupils, skin color change to a waxen hue as blood settles, gradual poikilothermia, and sphincter relaxation with loss of urine and feces. For deaths in the home with patients who have been enrolled in hospice, the hospice nurse on call should be contacted immediately. In some states, deaths at home may require a brief police investiga-tion and report. For deaths in the hospital, the family must be notified (in person, if possible). A coroner or medical examiner may need to be contacted under specific circumstances (e.g., deaths in the operating room), but most deaths do not require their services. The pronouncing | Surgery_Schwartz. attempts have been made. In the hospital, hospice, or home setting, the dec-laration of death becomes part of the medical or legal record of the event. There are a number of physical signs of death a physician should look for in confirming the patient’s demise: complete lack of responsiveness to verbal or tactile stimuli, absence of heart beat and respirations, fixed pupils, skin color change to a waxen hue as blood settles, gradual poikilothermia, and sphincter relaxation with loss of urine and feces. For deaths in the home with patients who have been enrolled in hospice, the hospice nurse on call should be contacted immediately. In some states, deaths at home may require a brief police investiga-tion and report. For deaths in the hospital, the family must be notified (in person, if possible). A coroner or medical examiner may need to be contacted under specific circumstances (e.g., deaths in the operating room), but most deaths do not require their services. The pronouncing | [
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Surgery_Schwartz_13538 | Surgery_Schwartz | if possible). A coroner or medical examiner may need to be contacted under specific circumstances (e.g., deaths in the operating room), but most deaths do not require their services. The pronouncing physician will need to complete a death certificate according to local regulations. Survivors may also be approached, if appropriate, regarding potential autopsy and organ donation. Finally, it is important to accommodate religious rituals that may be important to the dying patient or the family. Bereavement is the experience of loss by death of a person to whom one is attached. Mourning is the process of adapting to such a loss in the thoughts, feelings, and behaviors that one experiences after the loss.52 Although grief and mourn-ing are accentuated in the immediate period around death, it is important to note that patients and families may have begun the process of bereavement well before the time of death as patients and families grieve incremental losses of independence, vitality, and | Surgery_Schwartz. if possible). A coroner or medical examiner may need to be contacted under specific circumstances (e.g., deaths in the operating room), but most deaths do not require their services. The pronouncing physician will need to complete a death certificate according to local regulations. Survivors may also be approached, if appropriate, regarding potential autopsy and organ donation. Finally, it is important to accommodate religious rituals that may be important to the dying patient or the family. Bereavement is the experience of loss by death of a person to whom one is attached. Mourning is the process of adapting to such a loss in the thoughts, feelings, and behaviors that one experiences after the loss.52 Although grief and mourn-ing are accentuated in the immediate period around death, it is important to note that patients and families may have begun the process of bereavement well before the time of death as patients and families grieve incremental losses of independence, vitality, and | [
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Surgery_Schwartz_13539 | Surgery_Schwartz | important to note that patients and families may have begun the process of bereavement well before the time of death as patients and families grieve incremental losses of independence, vitality, and control. In addition to the surviving loved ones, it is impor-tant to acknowledge that caregivers also experience grief for the loss of their patients.53,54Aid in DyingFive European countries, Canada, and six U.S. states have legal-ized physician-assisted suicide, medical assistance in dying, or aid-in-dying, in some form, ranging from hospital-based pro-grams to provision of fatal doses of medications for home self-administration.55-57 Medical assistance in dying is a complex ethical and legal issues with divergent opinions among the pub-lic and healthcare providers.58,59 While aid-in-dying laws passed in the United States vary somewhat, these laws essentially all allow physicians to prescribe a lethal dose of medication to men-tally, competent, terminally ill adult patients for the | Surgery_Schwartz. important to note that patients and families may have begun the process of bereavement well before the time of death as patients and families grieve incremental losses of independence, vitality, and control. In addition to the surviving loved ones, it is impor-tant to acknowledge that caregivers also experience grief for the loss of their patients.53,54Aid in DyingFive European countries, Canada, and six U.S. states have legal-ized physician-assisted suicide, medical assistance in dying, or aid-in-dying, in some form, ranging from hospital-based pro-grams to provision of fatal doses of medications for home self-administration.55-57 Medical assistance in dying is a complex ethical and legal issues with divergent opinions among the pub-lic and healthcare providers.58,59 While aid-in-dying laws passed in the United States vary somewhat, these laws essentially all allow physicians to prescribe a lethal dose of medication to men-tally, competent, terminally ill adult patients for the | [
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Surgery_Schwartz_13540 | Surgery_Schwartz | laws passed in the United States vary somewhat, these laws essentially all allow physicians to prescribe a lethal dose of medication to men-tally, competent, terminally ill adult patients for the purpose of achieving the end of life.60,61 Key areas of ethical consideration in this area include the benefit and harm of death; the relation-ship between passive euthanasia, active euthanasia, withholding treatment, and withdrawing treatment; the morality of physician and nursing participation in deliberately causing death; and the management of conscientious objection.60,62 Although surgeons outside of the critical care arena may only infrequently be asked to participate in aid-in-dying, it is important to be familiar with local legislation so that appropriate information can be provided to patients who request it.PROFESSIONAL ETHICS: CONFLICT OF INTEREST, RESEARCH, AND CLINICAL ETHICSConflict of InterestConflicts of interest for surgeons can arise in many situations in which the potential | Surgery_Schwartz. laws passed in the United States vary somewhat, these laws essentially all allow physicians to prescribe a lethal dose of medication to men-tally, competent, terminally ill adult patients for the purpose of achieving the end of life.60,61 Key areas of ethical consideration in this area include the benefit and harm of death; the relation-ship between passive euthanasia, active euthanasia, withholding treatment, and withdrawing treatment; the morality of physician and nursing participation in deliberately causing death; and the management of conscientious objection.60,62 Although surgeons outside of the critical care arena may only infrequently be asked to participate in aid-in-dying, it is important to be familiar with local legislation so that appropriate information can be provided to patients who request it.PROFESSIONAL ETHICS: CONFLICT OF INTEREST, RESEARCH, AND CLINICAL ETHICSConflict of InterestConflicts of interest for surgeons can arise in many situations in which the potential | [
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Surgery_Schwartz_13541 | Surgery_Schwartz | who request it.PROFESSIONAL ETHICS: CONFLICT OF INTEREST, RESEARCH, AND CLINICAL ETHICSConflict of InterestConflicts of interest for surgeons can arise in many situations in which the potential benefits or gains to be realized by the surgeon are, or are perceived to be, in conflict with the respon-sibility to put the patient’s interests before the surgeon’s own. Conflicts of interest for the surgeon can involve actual or per-ceived situations in which the individual stands to gain mon-etarily by his or her role as a physician or investigator. In the academic community, monetary gain may not be the primary factor. Instead, motivators such as power, tenure, or authorship on a publication may serve as potential sources of conflict of interest. For example, the accrual of subjects in research studies or patients in surgical series may ensure surgeons better author-ship or more financial gains. The dual-role of the surgeon-scien-tist therefore needs to be considered because the duty as | Surgery_Schwartz. who request it.PROFESSIONAL ETHICS: CONFLICT OF INTEREST, RESEARCH, AND CLINICAL ETHICSConflict of InterestConflicts of interest for surgeons can arise in many situations in which the potential benefits or gains to be realized by the surgeon are, or are perceived to be, in conflict with the respon-sibility to put the patient’s interests before the surgeon’s own. Conflicts of interest for the surgeon can involve actual or per-ceived situations in which the individual stands to gain mon-etarily by his or her role as a physician or investigator. In the academic community, monetary gain may not be the primary factor. Instead, motivators such as power, tenure, or authorship on a publication may serve as potential sources of conflict of interest. For example, the accrual of subjects in research studies or patients in surgical series may ensure surgeons better author-ship or more financial gains. The dual-role of the surgeon-scien-tist therefore needs to be considered because the duty as | [
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Surgery_Schwartz_13542 | Surgery_Schwartz | studies or patients in surgical series may ensure surgeons better author-ship or more financial gains. The dual-role of the surgeon-scien-tist therefore needs to be considered because the duty as surgeon can conflict with the role of scientist or clinical researcher.Research EthicsOver the last three decades in the United States, the ethical requirements for the conduct of human subject research have been formalized and widely accepted. Although detailed informed consent is a necessary condition for the conduct of ethically good human subject research, other factors also deter-mine whether research is designed and conducted ethically. Emanuel and colleagues63 described seven requirements for all clinical research studies to be ethically sound: (a) value—enhancement(s) of health or knowledge must be derived from the research; (b) scientific validity—the research must be methodologically rigorous; (c) fair subject selection—scientific objectives, not vulnerability or privilege, and the | Surgery_Schwartz. studies or patients in surgical series may ensure surgeons better author-ship or more financial gains. The dual-role of the surgeon-scien-tist therefore needs to be considered because the duty as surgeon can conflict with the role of scientist or clinical researcher.Research EthicsOver the last three decades in the United States, the ethical requirements for the conduct of human subject research have been formalized and widely accepted. Although detailed informed consent is a necessary condition for the conduct of ethically good human subject research, other factors also deter-mine whether research is designed and conducted ethically. Emanuel and colleagues63 described seven requirements for all clinical research studies to be ethically sound: (a) value—enhancement(s) of health or knowledge must be derived from the research; (b) scientific validity—the research must be methodologically rigorous; (c) fair subject selection—scientific objectives, not vulnerability or privilege, and the | [
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Surgery_Schwartz_13543 | Surgery_Schwartz | must be derived from the research; (b) scientific validity—the research must be methodologically rigorous; (c) fair subject selection—scientific objectives, not vulnerability or privilege, and the potential for and distribution of risks and benefits, should deter-mine communities selected as study sites and the inclusion cri-teria for individual subjects; (d) favorable risk-benefit ratio—within the context of standard clinical practice and the research protocol, risks must be minimized, potential benefits enhanced, and the potential benefits to individuals and knowl-edge gained for society must outweigh the risks; (e) independent review—unaffiliated individuals must review the research and approve, amend, or terminate it; (f) informed consent—individuals should be informed about the research and pro-vide their voluntary consent; and (g) respect for enrolled subjects—subjects should have their privacy protected, the opportunity to withdraw, and their well-being monitored.63Special | Surgery_Schwartz. must be derived from the research; (b) scientific validity—the research must be methodologically rigorous; (c) fair subject selection—scientific objectives, not vulnerability or privilege, and the potential for and distribution of risks and benefits, should deter-mine communities selected as study sites and the inclusion cri-teria for individual subjects; (d) favorable risk-benefit ratio—within the context of standard clinical practice and the research protocol, risks must be minimized, potential benefits enhanced, and the potential benefits to individuals and knowl-edge gained for society must outweigh the risks; (e) independent review—unaffiliated individuals must review the research and approve, amend, or terminate it; (f) informed consent—individuals should be informed about the research and pro-vide their voluntary consent; and (g) respect for enrolled subjects—subjects should have their privacy protected, the opportunity to withdraw, and their well-being monitored.63Special | [
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Surgery_Schwartz_13544 | Surgery_Schwartz | and pro-vide their voluntary consent; and (g) respect for enrolled subjects—subjects should have their privacy protected, the opportunity to withdraw, and their well-being monitored.63Special Concerns in Surgical ResearchA significant issue for clinical surgical research is that many surgical studies are retrospective in nature and are not com-monly undertaken in a prospective, double-blind, randomized fashion. For a randomized trial to be undertaken, the researchers should be in a state of equipoise—that is, there must be a state of genuine uncertainty on the part of the clinical investigator or the expert medical community regarding the comparative thera-peutic merits of each arm in a trial.64 To randomize subjects to receive two different treatments, a researcher must believe that the existing data are not sufficient to conclude that one treat-ment strategy is better than another. In designing surgical trials, surgeons usually have biases that one treatment is better than another | Surgery_Schwartz. and pro-vide their voluntary consent; and (g) respect for enrolled subjects—subjects should have their privacy protected, the opportunity to withdraw, and their well-being monitored.63Special Concerns in Surgical ResearchA significant issue for clinical surgical research is that many surgical studies are retrospective in nature and are not com-monly undertaken in a prospective, double-blind, randomized fashion. For a randomized trial to be undertaken, the researchers should be in a state of equipoise—that is, there must be a state of genuine uncertainty on the part of the clinical investigator or the expert medical community regarding the comparative thera-peutic merits of each arm in a trial.64 To randomize subjects to receive two different treatments, a researcher must believe that the existing data are not sufficient to conclude that one treat-ment strategy is better than another. In designing surgical trials, surgeons usually have biases that one treatment is better than another | [
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Surgery_Schwartz_13545 | Surgery_Schwartz | existing data are not sufficient to conclude that one treat-ment strategy is better than another. In designing surgical trials, surgeons usually have biases that one treatment is better than another and often have difficulty maintaining the state of equi-poise. As such, it is frequently difficult to demonstrate that a 77Brunicardi_Ch48_p2061-p2076.indd 207219/02/19 1:49 PM 2073ETHICS, PALLIATIVE CARE, AND CARE AT THE END OF LIFECHAPTER 48Table 48-8ICMJE criteria for authorshipAccording to ICMJE best practices recommendations, authors should fulfill each of the following four criteria67:1. Substantial contributions to the conception or design of the work; or the acquisition, analysis, or interpretation of data for the work2. Drafting the work or revising it critically for important intellectual content3. Final approval of the version to be published4. Agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part | Surgery_Schwartz. existing data are not sufficient to conclude that one treat-ment strategy is better than another. In designing surgical trials, surgeons usually have biases that one treatment is better than another and often have difficulty maintaining the state of equi-poise. As such, it is frequently difficult to demonstrate that a 77Brunicardi_Ch48_p2061-p2076.indd 207219/02/19 1:49 PM 2073ETHICS, PALLIATIVE CARE, AND CARE AT THE END OF LIFECHAPTER 48Table 48-8ICMJE criteria for authorshipAccording to ICMJE best practices recommendations, authors should fulfill each of the following four criteria67:1. Substantial contributions to the conception or design of the work; or the acquisition, analysis, or interpretation of data for the work2. Drafting the work or revising it critically for important intellectual content3. Final approval of the version to be published4. Agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part | [
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Surgery_Schwartz_13546 | Surgery_Schwartz | content3. Final approval of the version to be published4. Agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolvedContributors who do not fulfill all four criteria should be named in the manuscript in the acknowledgment section.Adapted with permission from Cameron JL: Current Surgical Therapy, 9th ed. Philadelphia, PA: Elsevier; 2008.randomized trial is necessary or feasible, and treatment options that question the validity of clinical tenets are difficult to accept. Meakins has suggested that a slightly different hierarchy of evi-dence applies to evidence-based surgery.65A second major issue for surgical trials is whether it is ethically acceptable to have a placebo-controlled surgical trial. Some commentators have argued that sham surgery is always wrong because, unlike a placebo medication that is harmless, every surgical procedure carries some risk.66 | Surgery_Schwartz. content3. Final approval of the version to be published4. Agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolvedContributors who do not fulfill all four criteria should be named in the manuscript in the acknowledgment section.Adapted with permission from Cameron JL: Current Surgical Therapy, 9th ed. Philadelphia, PA: Elsevier; 2008.randomized trial is necessary or feasible, and treatment options that question the validity of clinical tenets are difficult to accept. Meakins has suggested that a slightly different hierarchy of evi-dence applies to evidence-based surgery.65A second major issue for surgical trials is whether it is ethically acceptable to have a placebo-controlled surgical trial. Some commentators have argued that sham surgery is always wrong because, unlike a placebo medication that is harmless, every surgical procedure carries some risk.66 | [
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Surgery_Schwartz_13547 | Surgery_Schwartz | placebo-controlled surgical trial. Some commentators have argued that sham surgery is always wrong because, unlike a placebo medication that is harmless, every surgical procedure carries some risk.66 Others have argued that sham operations are essential to the design of a valid ran-domized clinical trial because, without a sham operation, it is not possible to know if the surgical intervention is the cause of improvement in patient symptoms or whether the improve-ment is due to the effect of having surgery.67,68 Most surgeons readily agree that designing an appropriately low-risk sham sur-gical procedure would create problems for the surgeon-patient relationship in that the surgeon would need to keep the sham a secret.69 In this sense, a sham surgical arm of a trial is very different from a placebo medication in that there cannot be blinding of the surgeon as to which procedure was undertaken. As a result, to have a sham surgery arm in a clinical trial, the interactions between the | Surgery_Schwartz. placebo-controlled surgical trial. Some commentators have argued that sham surgery is always wrong because, unlike a placebo medication that is harmless, every surgical procedure carries some risk.66 Others have argued that sham operations are essential to the design of a valid ran-domized clinical trial because, without a sham operation, it is not possible to know if the surgical intervention is the cause of improvement in patient symptoms or whether the improve-ment is due to the effect of having surgery.67,68 Most surgeons readily agree that designing an appropriately low-risk sham sur-gical procedure would create problems for the surgeon-patient relationship in that the surgeon would need to keep the sham a secret.69 In this sense, a sham surgical arm of a trial is very different from a placebo medication in that there cannot be blinding of the surgeon as to which procedure was undertaken. As a result, to have a sham surgery arm in a clinical trial, the interactions between the | [
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Surgery_Schwartz_13548 | Surgery_Schwartz | a placebo medication in that there cannot be blinding of the surgeon as to which procedure was undertaken. As a result, to have a sham surgery arm in a clinical trial, the interactions between the surgeon and the subject must be lim-ited, and the surgeon performing the procedure should not be the researcher who follows the subject during the trial. Despite difficulties with designing a surgical trial in which the surgeon could ethically perform a sham operation, there are specific cir-cumstances that allow for placebo operations to be conducted, so long as certain criteria are met and are analyzed on a case by case basis.70,71Surgical InnovationAn important issue is whether surgical innovation should be treated as research or as standard of care. Throughout history, many advances in surgical techniques and technologies have resulted from innovations of individual surgeons crafted dur-ing the course of challenging operations—such innovations and technologies have served to move the | Surgery_Schwartz. a placebo medication in that there cannot be blinding of the surgeon as to which procedure was undertaken. As a result, to have a sham surgery arm in a clinical trial, the interactions between the surgeon and the subject must be lim-ited, and the surgeon performing the procedure should not be the researcher who follows the subject during the trial. Despite difficulties with designing a surgical trial in which the surgeon could ethically perform a sham operation, there are specific cir-cumstances that allow for placebo operations to be conducted, so long as certain criteria are met and are analyzed on a case by case basis.70,71Surgical InnovationAn important issue is whether surgical innovation should be treated as research or as standard of care. Throughout history, many advances in surgical techniques and technologies have resulted from innovations of individual surgeons crafted dur-ing the course of challenging operations—such innovations and technologies have served to move the | [
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Surgery_Schwartz_13549 | Surgery_Schwartz | techniques and technologies have resulted from innovations of individual surgeons crafted dur-ing the course of challenging operations—such innovations and technologies have served to move the field of surgery forward.72 In the Korean and Vietnam wars, military guidelines for treat-ment of vascular injuries recommended ligation and amputation rather than interposition grafting of vascular injuries. Individual surgeons chose to ignore those guidelines and subsequently demonstrated the value of the reconstructive techniques that ultimately became the standard of care. It is debated whether modifications to an accepted surgical technique in an individual patient based on their circumstances and within the skill and judg-ment of an individual surgeon should require the same type of prior approval that enrollment in a clinical trial would warrant.73 However, if a surgeon decides to use a new technique on sev-eral occasions and to study the outcomes, Institutional Review Board approval and | Surgery_Schwartz. techniques and technologies have resulted from innovations of individual surgeons crafted dur-ing the course of challenging operations—such innovations and technologies have served to move the field of surgery forward.72 In the Korean and Vietnam wars, military guidelines for treat-ment of vascular injuries recommended ligation and amputation rather than interposition grafting of vascular injuries. Individual surgeons chose to ignore those guidelines and subsequently demonstrated the value of the reconstructive techniques that ultimately became the standard of care. It is debated whether modifications to an accepted surgical technique in an individual patient based on their circumstances and within the skill and judg-ment of an individual surgeon should require the same type of prior approval that enrollment in a clinical trial would warrant.73 However, if a surgeon decides to use a new technique on sev-eral occasions and to study the outcomes, Institutional Review Board approval and | [
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Surgery_Schwartz_13550 | Surgery_Schwartz | that enrollment in a clinical trial would warrant.73 However, if a surgeon decides to use a new technique on sev-eral occasions and to study the outcomes, Institutional Review Board approval and all other ethical requirements for research are necessary. These situations require strict oversight as well as explicit consent by the patient.74 In particular, when developing new and innovative techniques, the surgeon should work in close consultation with his or her senior colleagues, including the chairperson of the department. Frequently, more senior individuals can provide sage ethical advice regarding what constitutes minor innovative changes in a technique vs. true novel research.Compared to the formalized process for new drug approval by the Food and Drug Administration, the process for a surgeon developing an innovative operation can be relatively unregu-lated and unsupervised.The Ethics of AuthorshipAuthorship specifies who is responsible for published research. It confers both | Surgery_Schwartz. that enrollment in a clinical trial would warrant.73 However, if a surgeon decides to use a new technique on sev-eral occasions and to study the outcomes, Institutional Review Board approval and all other ethical requirements for research are necessary. These situations require strict oversight as well as explicit consent by the patient.74 In particular, when developing new and innovative techniques, the surgeon should work in close consultation with his or her senior colleagues, including the chairperson of the department. Frequently, more senior individuals can provide sage ethical advice regarding what constitutes minor innovative changes in a technique vs. true novel research.Compared to the formalized process for new drug approval by the Food and Drug Administration, the process for a surgeon developing an innovative operation can be relatively unregu-lated and unsupervised.The Ethics of AuthorshipAuthorship specifies who is responsible for published research. It confers both | [
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Surgery_Schwartz_13551 | Surgery_Schwartz | a surgeon developing an innovative operation can be relatively unregu-lated and unsupervised.The Ethics of AuthorshipAuthorship specifies who is responsible for published research. It confers both recognition for academic achievement as well as responsibility for the academic integrity of the published con-tent. Authorship is the stock in trade of productivity for aca-demic surgeons, and it plays a significant role in promotion and tenure. It can also be commodified in the form of intellectual property and patents in which the author and the author’s insti-tution have vested interests. Yet it can also become a liability if a given piece of work becomes embroiled in accusations of plagiarism, data fabrication, or other academic misconduct.In the past, criteria for authorship were unspecified: Those submitting manuscripts simply listed the authors with little or no need to substantiate their contribution to the work. Unfortu-nately, this informal process led to confusion and even abuse. | Surgery_Schwartz. a surgeon developing an innovative operation can be relatively unregu-lated and unsupervised.The Ethics of AuthorshipAuthorship specifies who is responsible for published research. It confers both recognition for academic achievement as well as responsibility for the academic integrity of the published con-tent. Authorship is the stock in trade of productivity for aca-demic surgeons, and it plays a significant role in promotion and tenure. It can also be commodified in the form of intellectual property and patents in which the author and the author’s insti-tution have vested interests. Yet it can also become a liability if a given piece of work becomes embroiled in accusations of plagiarism, data fabrication, or other academic misconduct.In the past, criteria for authorship were unspecified: Those submitting manuscripts simply listed the authors with little or no need to substantiate their contribution to the work. Unfortu-nately, this informal process led to confusion and even abuse. | [
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Surgery_Schwartz_13552 | Surgery_Schwartz | Those submitting manuscripts simply listed the authors with little or no need to substantiate their contribution to the work. Unfortu-nately, this informal process led to confusion and even abuse. For example, there has been a long tradition of awarding author-ship to the investigator who supervised or obtained funding for research, regardless of that person’s specific contribution to the manuscript. However, current recommendations specify that supervision and funding, by themselves, are insufficient criteria for authorship, and thus such individuals should only be included as authors if they make direct contributions to the work.75,76 A more disturbing example is the practice of “ghost writing” by which senior investigators publish industry-written research under their own name to bolster their productivity while providing a luster of academic integrity to industry.To address these conflicts of interest and to provide guid-ance to investigators, the International Committee of | Surgery_Schwartz. Those submitting manuscripts simply listed the authors with little or no need to substantiate their contribution to the work. Unfortu-nately, this informal process led to confusion and even abuse. For example, there has been a long tradition of awarding author-ship to the investigator who supervised or obtained funding for research, regardless of that person’s specific contribution to the manuscript. However, current recommendations specify that supervision and funding, by themselves, are insufficient criteria for authorship, and thus such individuals should only be included as authors if they make direct contributions to the work.75,76 A more disturbing example is the practice of “ghost writing” by which senior investigators publish industry-written research under their own name to bolster their productivity while providing a luster of academic integrity to industry.To address these conflicts of interest and to provide guid-ance to investigators, the International Committee of | [
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Surgery_Schwartz_13553 | Surgery_Schwartz | bolster their productivity while providing a luster of academic integrity to industry.To address these conflicts of interest and to provide guid-ance to investigators, the International Committee of Medical Journal Editors (ICMJE) provides recommendations on criteria for authorship so that individuals who contributed to the intel-lectual content of a work get appropriate credit and that all those listed as authors take responsibility and are accountable for the published work. The ICMJE recommendations for authorship can be found in Table 48-8.75 Furthermore, the ICMJE recom-mends that each author should be able to identify the contribu-tion that each other author made to the work and be confident regarding the integrity of their co-authors. The ICMJE also recommends that individuals who do not meet these criteria be acknowledged in the manuscript, providing appropriate pro-cedures for such acknowledgement. Additionally, the ICMJE Brunicardi_Ch48_p2061-p2076.indd 207319/02/19 1:49 | Surgery_Schwartz. bolster their productivity while providing a luster of academic integrity to industry.To address these conflicts of interest and to provide guid-ance to investigators, the International Committee of Medical Journal Editors (ICMJE) provides recommendations on criteria for authorship so that individuals who contributed to the intel-lectual content of a work get appropriate credit and that all those listed as authors take responsibility and are accountable for the published work. The ICMJE recommendations for authorship can be found in Table 48-8.75 Furthermore, the ICMJE recom-mends that each author should be able to identify the contribu-tion that each other author made to the work and be confident regarding the integrity of their co-authors. The ICMJE also recommends that individuals who do not meet these criteria be acknowledged in the manuscript, providing appropriate pro-cedures for such acknowledgement. Additionally, the ICMJE Brunicardi_Ch48_p2061-p2076.indd 207319/02/19 1:49 | [
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Surgery_Schwartz_13554 | Surgery_Schwartz | not meet these criteria be acknowledged in the manuscript, providing appropriate pro-cedures for such acknowledgement. Additionally, the ICMJE Brunicardi_Ch48_p2061-p2076.indd 207319/02/19 1:49 PM 2074SPECIFIC CONSIDERATIONSPART IIspecifically excludes certain types of contributions including acquisition of funding, general supervision of a research group, administrative support, writing assistance, technical editing, language editing, and proofreading.75Many journals have adopted these criteria, operational-izing them at the time of submission by having each author specify his or her contributions. These contributions are then disclosed in the published manuscript to further specify how credit and responsibility is shared.77 This approach has been shown to provide valuable information and has proved feasible in several journals, including The Lancet.78As research becomes increasingly interdisciplinary with ever-expanding teams of contributors, it can be difficult to determine | Surgery_Schwartz. not meet these criteria be acknowledged in the manuscript, providing appropriate pro-cedures for such acknowledgement. Additionally, the ICMJE Brunicardi_Ch48_p2061-p2076.indd 207319/02/19 1:49 PM 2074SPECIFIC CONSIDERATIONSPART IIspecifically excludes certain types of contributions including acquisition of funding, general supervision of a research group, administrative support, writing assistance, technical editing, language editing, and proofreading.75Many journals have adopted these criteria, operational-izing them at the time of submission by having each author specify his or her contributions. These contributions are then disclosed in the published manuscript to further specify how credit and responsibility is shared.77 This approach has been shown to provide valuable information and has proved feasible in several journals, including The Lancet.78As research becomes increasingly interdisciplinary with ever-expanding teams of contributors, it can be difficult to determine | [
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Surgery_Schwartz_13555 | Surgery_Schwartz | and has proved feasible in several journals, including The Lancet.78As research becomes increasingly interdisciplinary with ever-expanding teams of contributors, it can be difficult to determine which contributions warrant full authorship rather than simple acknowledgement. Individuals working together on research endeavors should have clear discussions early in the planning process about authorship, and those discus-sions should be continued throughout the project or study.Clinical Ethics: Disclosure of ErrorsDisclosure of error—either in medical or research matters—is important, but often difficult (see Chapter 12). Errors of judg-ment, errors in technique, and system errors are responsible for most errors that result in complications and deaths. Hospitals are evaluated based on the number of complications and deaths that occur in surgical patients, and surgeons traditionally review their complications and deaths in a formal exercise known as the mortality and morbidity conference, | Surgery_Schwartz. and has proved feasible in several journals, including The Lancet.78As research becomes increasingly interdisciplinary with ever-expanding teams of contributors, it can be difficult to determine which contributions warrant full authorship rather than simple acknowledgement. Individuals working together on research endeavors should have clear discussions early in the planning process about authorship, and those discus-sions should be continued throughout the project or study.Clinical Ethics: Disclosure of ErrorsDisclosure of error—either in medical or research matters—is important, but often difficult (see Chapter 12). Errors of judg-ment, errors in technique, and system errors are responsible for most errors that result in complications and deaths. Hospitals are evaluated based on the number of complications and deaths that occur in surgical patients, and surgeons traditionally review their complications and deaths in a formal exercise known as the mortality and morbidity conference, | [
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Surgery_Schwartz_13556 | Surgery_Schwartz | of complications and deaths that occur in surgical patients, and surgeons traditionally review their complications and deaths in a formal exercise known as the mortality and morbidity conference, or M&M. The exercise places importance on the attending surgeon’s responsibility for errors made, whether he or she made them themselves, and the value of the exercise is related to the effect of “peer pressure”— the entire department knows about the case—on reducing repeated occurrences of such an error. Although a time-honored ritual in surgery, the M&M conference is nonetheless a poor method for analyzing causes of error and for developing methods to prevent them. Moreover, the proceedings of the M&M con-ference are protected from disclosure by the privilege of “peer review,” and the details are thus rarely shared with patients or those outside the department.A report from the United States Institute of Medicine titled “To Err Is Human” highlighted the large number of medi-cal errors that | Surgery_Schwartz. of complications and deaths that occur in surgical patients, and surgeons traditionally review their complications and deaths in a formal exercise known as the mortality and morbidity conference, or M&M. The exercise places importance on the attending surgeon’s responsibility for errors made, whether he or she made them themselves, and the value of the exercise is related to the effect of “peer pressure”— the entire department knows about the case—on reducing repeated occurrences of such an error. Although a time-honored ritual in surgery, the M&M conference is nonetheless a poor method for analyzing causes of error and for developing methods to prevent them. Moreover, the proceedings of the M&M con-ference are protected from disclosure by the privilege of “peer review,” and the details are thus rarely shared with patients or those outside the department.A report from the United States Institute of Medicine titled “To Err Is Human” highlighted the large number of medi-cal errors that | [
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Surgery_Schwartz_13557 | Surgery_Schwartz | thus rarely shared with patients or those outside the department.A report from the United States Institute of Medicine titled “To Err Is Human” highlighted the large number of medi-cal errors that occur and encouraged efforts to prevent patient harm.79 Medical errors are generally considered to be “prevent-able adverse medical events.”80 Medical errors occur with some frequency, and the question is what and how should patients be informed that a medical error has occurred.81Disclosure of error is consistent with the ethical virtue of candor (e.g., transparency and openness) and the ethical prin-ciple of respect for persons by involving patients in their care. In contrast, failing to disclose errors to patients under-mines public trust in medicine and potentially compro-mises adequate treatment of the consequences of errors and effective intervention to prevent future errors. In addition, fail-ure to self-disclose medical errors can be construed as a breach of professional ethics, as | Surgery_Schwartz. thus rarely shared with patients or those outside the department.A report from the United States Institute of Medicine titled “To Err Is Human” highlighted the large number of medi-cal errors that occur and encouraged efforts to prevent patient harm.79 Medical errors are generally considered to be “prevent-able adverse medical events.”80 Medical errors occur with some frequency, and the question is what and how should patients be informed that a medical error has occurred.81Disclosure of error is consistent with the ethical virtue of candor (e.g., transparency and openness) and the ethical prin-ciple of respect for persons by involving patients in their care. In contrast, failing to disclose errors to patients under-mines public trust in medicine and potentially compro-mises adequate treatment of the consequences of errors and effective intervention to prevent future errors. In addition, fail-ure to self-disclose medical errors can be construed as a breach of professional ethics, as | [
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Surgery_Schwartz_13558 | Surgery_Schwartz | of the consequences of errors and effective intervention to prevent future errors. In addition, fail-ure to self-disclose medical errors can be construed as a breach of professional ethics, as it is a failure to act in the patient’s best interests. Information regarding a medical error may be needed so that patients can make independent and well-informed deci-sions about future aspects of their care. The principles of auton-omy and justice dictate that surgeons need to respect individuals by being fair in providing accurate information about all aspects of their care—even when an error has occurred.Disclosing one’s own errors is therefore part of the ethi-cal standard of honesty and putting the patient’s interests above one’s own. Disclosing the errors of others is more complicated and may require careful consideration and consultation. Sur-geons sometimes discover that a prior operation has included an apparent error; an injured bile duct or a stenotic anastomosis may lead to the | Surgery_Schwartz. of the consequences of errors and effective intervention to prevent future errors. In addition, fail-ure to self-disclose medical errors can be construed as a breach of professional ethics, as it is a failure to act in the patient’s best interests. Information regarding a medical error may be needed so that patients can make independent and well-informed deci-sions about future aspects of their care. The principles of auton-omy and justice dictate that surgeons need to respect individuals by being fair in providing accurate information about all aspects of their care—even when an error has occurred.Disclosing one’s own errors is therefore part of the ethi-cal standard of honesty and putting the patient’s interests above one’s own. Disclosing the errors of others is more complicated and may require careful consideration and consultation. Sur-geons sometimes discover that a prior operation has included an apparent error; an injured bile duct or a stenotic anastomosis may lead to the | [
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Surgery_Schwartz_13559 | Surgery_Schwartz | may require careful consideration and consultation. Sur-geons sometimes discover that a prior operation has included an apparent error; an injured bile duct or a stenotic anastomosis may lead to the condition for which the surgeon is now treating the patient. Declaring a finding as an “error” may be inaccurate, however, and a nonjudgmental assessment of the situation is usually advisable. When clear evidence of a mistake is at hand, the surgeon’s responsibility is defined by his or her obligation to act as the patient’s agent.REFERENCESEntries highlighted in bright blue are key references. 1. Aristotle. Nichomachean Ethics, Book VI. In Ackrill J, ed. A New Aristotle Reader. Princeton, NJ: Princeton University Press; 1987:416. 2. Beauchamp TL, Childress JF. Principles of Biomedical Ethics, 3rd ed. New York: Oxford University Press; 1989. 3. Bosk C. Forgive and Remember, 2nd ed. Chicago, University of Chicago Press, 2003 (1979). 4. McCullough LB, Jones JW, Brody BA, eds. Surgical | Surgery_Schwartz. may require careful consideration and consultation. Sur-geons sometimes discover that a prior operation has included an apparent error; an injured bile duct or a stenotic anastomosis may lead to the condition for which the surgeon is now treating the patient. Declaring a finding as an “error” may be inaccurate, however, and a nonjudgmental assessment of the situation is usually advisable. When clear evidence of a mistake is at hand, the surgeon’s responsibility is defined by his or her obligation to act as the patient’s agent.REFERENCESEntries highlighted in bright blue are key references. 1. Aristotle. Nichomachean Ethics, Book VI. In Ackrill J, ed. A New Aristotle Reader. Princeton, NJ: Princeton University Press; 1987:416. 2. Beauchamp TL, Childress JF. Principles of Biomedical Ethics, 3rd ed. New York: Oxford University Press; 1989. 3. Bosk C. Forgive and Remember, 2nd ed. Chicago, University of Chicago Press, 2003 (1979). 4. McCullough LB, Jones JW, Brody BA, eds. Surgical | [
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Surgery_Schwartz_13562 | Surgery_Schwartz | PA, Dobbs B, Frizelle F. Informed con-sent: what do patients want to know? N Z Med J. 1998;111: 340-342. 15. Streat S. Clinical review: moral assumptions and the pro-cess of organ donation in the intensive care unit. Crit Care. 2004;8:382-388. 16. Williams MA, Lipsett PA, Rushton CH, et al. The physician’s role in discussing organ donation with families. Crit Care Med. 2003;31:1568-1573. 17. Pearson IY, Zurynski Y. A survey of personal and professional attitudes of intensivists to organ donation and transplantation. Anaesth Intensive Care. 1995;23:68-74. 18. Sulmasy DP, Lehmann LS, Levine DM, et al. Patients’ percep-tions of the quality of informed consent for common medical procedures. J Clin Ethics. 1994;5:189-194. 19. Ubel PA, Loewenstein G, Jepson C. Whose quality of life? A commentary exploring discrepancies between health state 8899Brunicardi_Ch48_p2061-p2076.indd 207419/02/19 1:49 PM 2075ETHICS, PALLIATIVE CARE, AND CARE AT THE END OF LIFECHAPTER 48evaluations of patients | Surgery_Schwartz. PA, Dobbs B, Frizelle F. Informed con-sent: what do patients want to know? N Z Med J. 1998;111: 340-342. 15. Streat S. Clinical review: moral assumptions and the pro-cess of organ donation in the intensive care unit. Crit Care. 2004;8:382-388. 16. Williams MA, Lipsett PA, Rushton CH, et al. The physician’s role in discussing organ donation with families. Crit Care Med. 2003;31:1568-1573. 17. Pearson IY, Zurynski Y. A survey of personal and professional attitudes of intensivists to organ donation and transplantation. Anaesth Intensive Care. 1995;23:68-74. 18. Sulmasy DP, Lehmann LS, Levine DM, et al. Patients’ percep-tions of the quality of informed consent for common medical procedures. J Clin Ethics. 1994;5:189-194. 19. Ubel PA, Loewenstein G, Jepson C. Whose quality of life? A commentary exploring discrepancies between health state 8899Brunicardi_Ch48_p2061-p2076.indd 207419/02/19 1:49 PM 2075ETHICS, PALLIATIVE CARE, AND CARE AT THE END OF LIFECHAPTER 48evaluations of patients | [
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Surgery_Schwartz_13563 | Surgery_Schwartz | exploring discrepancies between health state 8899Brunicardi_Ch48_p2061-p2076.indd 207419/02/19 1:49 PM 2075ETHICS, PALLIATIVE CARE, AND CARE AT THE END OF LIFECHAPTER 48evaluations of patients and the general public. Qual Life Res. 2003;12:599-607. 20. Schneider CE. After autonomy. Wake Forest Law Review. 2006;41:411. 21. Shalowitz DI, Garrett-Mayer E, Wendler D. The accuracy of surrogate decision makers: a systematic review. Arch Intern Med. 2006;166(5): 493-497. 22. Sulmasy DP, Hughes MT, Thompson RE, et al. How would terminally ill patients have others make decisions for them in the event of decisional incapacity? A longitudinal study. J Am Geriatr Soc. 2007;55:1981-1988. 23. SUPPORT Principle Investigators. A controlled trial to improve care for seriously ill hospitalized patients. The study to under-stand prognoses and preferences for outcomes and risks of treatments (SUPPORT). The SUPPORT Principal Investigators. JAMA. 1995;274:1591-1598. 24. Pawlik TM. Withholding and | Surgery_Schwartz. exploring discrepancies between health state 8899Brunicardi_Ch48_p2061-p2076.indd 207419/02/19 1:49 PM 2075ETHICS, PALLIATIVE CARE, AND CARE AT THE END OF LIFECHAPTER 48evaluations of patients and the general public. Qual Life Res. 2003;12:599-607. 20. Schneider CE. After autonomy. Wake Forest Law Review. 2006;41:411. 21. Shalowitz DI, Garrett-Mayer E, Wendler D. The accuracy of surrogate decision makers: a systematic review. Arch Intern Med. 2006;166(5): 493-497. 22. Sulmasy DP, Hughes MT, Thompson RE, et al. How would terminally ill patients have others make decisions for them in the event of decisional incapacity? A longitudinal study. J Am Geriatr Soc. 2007;55:1981-1988. 23. SUPPORT Principle Investigators. A controlled trial to improve care for seriously ill hospitalized patients. The study to under-stand prognoses and preferences for outcomes and risks of treatments (SUPPORT). The SUPPORT Principal Investigators. JAMA. 1995;274:1591-1598. 24. Pawlik TM. Withholding and | [
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Surgery_Schwartz_13564 | Surgery_Schwartz | The study to under-stand prognoses and preferences for outcomes and risks of treatments (SUPPORT). The SUPPORT Principal Investigators. JAMA. 1995;274:1591-1598. 24. Pawlik TM. Withholding and withdrawing life-sustain-ing treatment: a surgeon’s perspective. J Am Coll Surg. 2006;202:990-994. 25. In re Quinlan. 355 A2d 647 (JN). Vol 429 US 9221976. 26. Cruzan vs. Director, Missouri Dept of Health, 497(1990). 27. Annas GJ. Nancy Cruzan and the right to die. N Engl J Med. 1990;323:670-673. 28. Sykes N, Thorns A. The use of opioids and sedatives at the end of life. Lancet Oncol. 2003;4:312-318. 29. Trotter JF, Adam R, Lo CM, Kenison J. Documented deaths of hepatic lobe donors for living donor liver transplantation. Liver Transpl. 2006;12(10):1485-1488. 30. Singer PA, Siegler M, Whitington PF, et al. Ethics of liver transplantation with living donors. N Engl J Med. 1989;321(9):620-622. 31. Fournier V, Foureur N, Rari E. The ethics of living donation for liver transplant: beyond donor | Surgery_Schwartz. The study to under-stand prognoses and preferences for outcomes and risks of treatments (SUPPORT). The SUPPORT Principal Investigators. JAMA. 1995;274:1591-1598. 24. Pawlik TM. Withholding and withdrawing life-sustain-ing treatment: a surgeon’s perspective. J Am Coll Surg. 2006;202:990-994. 25. In re Quinlan. 355 A2d 647 (JN). Vol 429 US 9221976. 26. Cruzan vs. Director, Missouri Dept of Health, 497(1990). 27. Annas GJ. Nancy Cruzan and the right to die. N Engl J Med. 1990;323:670-673. 28. Sykes N, Thorns A. The use of opioids and sedatives at the end of life. Lancet Oncol. 2003;4:312-318. 29. Trotter JF, Adam R, Lo CM, Kenison J. Documented deaths of hepatic lobe donors for living donor liver transplantation. Liver Transpl. 2006;12(10):1485-1488. 30. Singer PA, Siegler M, Whitington PF, et al. Ethics of liver transplantation with living donors. N Engl J Med. 1989;321(9):620-622. 31. Fournier V, Foureur N, Rari E. The ethics of living donation for liver transplant: beyond donor | [
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Surgery_Schwartz_13568 | Surgery_Schwartz | US Department of Health and Human Services, Public Health Service; 1994. 48. Storey P, Knight C. UNIPAC Three: Assessment and Treat-ment of Pain in the Terminally Ill. 2nd ed. New York: Mary Ann Liebert Inc; 2003. 49. Rubenfeld GD, Crawford SW. Principles and practice of with-drawing life-sustaining treatment in the ICU. In: Curtis JR, Rubenfeld GD, eds. Managing Death in the Intensive Care Unit. New York: Oxford University Press; 2001. 50. Rousseau P. Existential distress and palliative sedation. Anesth Analg. 2005;101:611-612, 51. The EPEC-O Project, Educating Physicians in End-of-Life Care-Oncology: Module 6: Last Hours of Living. Bethesda: National Cancer Institute; 2007. 52. Worden J. Bereavement Care. Philadelphia: Lippincott Williams and Wilkins; 2002. 53. Bishop JP, Rosemann PW, Schmidt FW. Fides ancilla medici-nae: on the ersatz liturgy of death in biopsychosociospiritual medicine. Heythrop J. 2008;49:20. 54. Schroeder-Sheker T. Transitus: A Blessed Death in the Modern World. | Surgery_Schwartz. US Department of Health and Human Services, Public Health Service; 1994. 48. Storey P, Knight C. UNIPAC Three: Assessment and Treat-ment of Pain in the Terminally Ill. 2nd ed. New York: Mary Ann Liebert Inc; 2003. 49. Rubenfeld GD, Crawford SW. Principles and practice of with-drawing life-sustaining treatment in the ICU. In: Curtis JR, Rubenfeld GD, eds. Managing Death in the Intensive Care Unit. New York: Oxford University Press; 2001. 50. Rousseau P. Existential distress and palliative sedation. Anesth Analg. 2005;101:611-612, 51. The EPEC-O Project, Educating Physicians in End-of-Life Care-Oncology: Module 6: Last Hours of Living. Bethesda: National Cancer Institute; 2007. 52. Worden J. Bereavement Care. Philadelphia: Lippincott Williams and Wilkins; 2002. 53. Bishop JP, Rosemann PW, Schmidt FW. Fides ancilla medici-nae: on the ersatz liturgy of death in biopsychosociospiritual medicine. Heythrop J. 2008;49:20. 54. Schroeder-Sheker T. Transitus: A Blessed Death in the Modern World. | [
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Surgery_Schwartz_13569 | Surgery_Schwartz | FW. Fides ancilla medici-nae: on the ersatz liturgy of death in biopsychosociospiritual medicine. Heythrop J. 2008;49:20. 54. Schroeder-Sheker T. Transitus: A Blessed Death in the Modern World. Mt. Angel: St. Dunstan’s Press; 2001. 55. Li M, Watt S, Escaf M, et al. Medical assistance in dying—implementing a hospital-based program in Canada. N Engl J Med. 2017;376(21):2082-2088. 56. Emanuel EJ, Onwuteaka-Philipsen BD, Urwin JW, Cohen J. Attitudes and practices of euthanasia and physician-assisted suicide in the United States, Canada, and Europe. JAMA. 2016;316:79-90. 57. Trice Loggers E, Starks H, Shannon-Dudley M, Back AL, Appelbaum FR, Stewart FM. Implementing a Death with Dignity program at a comprehensive cancer center. N Engl J Med. 2013;368:1417-1424. 58. Rhee JY, Callaghan KA, Stahl A, et al. Physician-assisted sui-cide and euthanasia is incompatible with medicine: a response from medical students. Crit Care Med. 2017;45(6):e626-e627. doi: | Surgery_Schwartz. FW. Fides ancilla medici-nae: on the ersatz liturgy of death in biopsychosociospiritual medicine. Heythrop J. 2008;49:20. 54. Schroeder-Sheker T. Transitus: A Blessed Death in the Modern World. Mt. Angel: St. Dunstan’s Press; 2001. 55. Li M, Watt S, Escaf M, et al. Medical assistance in dying—implementing a hospital-based program in Canada. N Engl J Med. 2017;376(21):2082-2088. 56. Emanuel EJ, Onwuteaka-Philipsen BD, Urwin JW, Cohen J. Attitudes and practices of euthanasia and physician-assisted suicide in the United States, Canada, and Europe. JAMA. 2016;316:79-90. 57. Trice Loggers E, Starks H, Shannon-Dudley M, Back AL, Appelbaum FR, Stewart FM. Implementing a Death with Dignity program at a comprehensive cancer center. N Engl J Med. 2013;368:1417-1424. 58. Rhee JY, Callaghan KA, Stahl A, et al. Physician-assisted sui-cide and euthanasia is incompatible with medicine: a response from medical students. Crit Care Med. 2017;45(6):e626-e627. doi: | [
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Surgery_Schwartz_13571 | Surgery_Schwartz | Care Med. 2017;45(2):149-155. doi: 10.1097/CCM.0000000000001818. 63. Emmanuel EJ, Wendler D, Grady C. What makes clinical research ethical? JAMA. 2000;283:2701-2711. 64. Freedman B. Equipoise and the ethics of clinical research. N Engl J Med. 1987;317:141-145. 65. Meakins J. Innovation in surgery. The rules of evidence. Am J Surg. 2002;183:399-405. 66. Lefering R, Neugebauer E. Problems of randomized controlled trials in surgery. Paper presented at: Nonrandomized Compara-tive Clinical Studies. Heidelberg, 1997. 67. Flum DR. Interpreting surgical trials with subjective out-comes: avoiding UnSPORTsmanlike conduct. JAMA. 2006;296:2483-2485.Brunicardi_Ch48_p2061-p2076.indd 207519/02/19 1:49 PM 2076SPECIFIC CONSIDERATIONSPART II 68. Moseley JB, O’Malley K, Petersen NJ, et al. A controlled trial of arthroscopic surgery for osteoarthritis of the knee. N Engl J Med. 2002;347:81. Summary for patients in: J Fam Pract. 2002;51:813. 69. Angelos PA. Sham surgery in research: a surgeon’s view. | Surgery_Schwartz. Care Med. 2017;45(2):149-155. doi: 10.1097/CCM.0000000000001818. 63. Emmanuel EJ, Wendler D, Grady C. What makes clinical research ethical? JAMA. 2000;283:2701-2711. 64. Freedman B. Equipoise and the ethics of clinical research. N Engl J Med. 1987;317:141-145. 65. Meakins J. Innovation in surgery. The rules of evidence. Am J Surg. 2002;183:399-405. 66. Lefering R, Neugebauer E. Problems of randomized controlled trials in surgery. Paper presented at: Nonrandomized Compara-tive Clinical Studies. Heidelberg, 1997. 67. Flum DR. Interpreting surgical trials with subjective out-comes: avoiding UnSPORTsmanlike conduct. JAMA. 2006;296:2483-2485.Brunicardi_Ch48_p2061-p2076.indd 207519/02/19 1:49 PM 2076SPECIFIC CONSIDERATIONSPART II 68. Moseley JB, O’Malley K, Petersen NJ, et al. A controlled trial of arthroscopic surgery for osteoarthritis of the knee. N Engl J Med. 2002;347:81. Summary for patients in: J Fam Pract. 2002;51:813. 69. Angelos PA. Sham surgery in research: a surgeon’s view. | [
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Surgery_Schwartz_13572 | Surgery_Schwartz | trial of arthroscopic surgery for osteoarthritis of the knee. N Engl J Med. 2002;347:81. Summary for patients in: J Fam Pract. 2002;51:813. 69. Angelos PA. Sham surgery in research: a surgeon’s view. Am J Bioeth. 2003;3:65-66. 70. Miller FG. Sham surgery: an ethical analysis. Sci Eng Ethics. 2004;10:157-166. 71. Angelos P. Sham surgery in clinical trials. JAMA. 2007;297:1545-1546, author reply 1546. 72. Riskin DJ, Longaker MT, Gertner M, et al. Innovation in sur-gery: a historical perspective. Ann Surg. 2006;244:686-693. 73. Biffl WL, Spain DA, Reitsma AM, et al. Responsible develop-ment and application of surgical innovations: a position state-ment of the Society of University Surgeons. J Am Coll Surg. 2008;206(6):1204-1209. 74. McKneally MF, Daar AS. Introducing new technologies: pro-tecting subjects of surgical innovation and research. World J Surg. 2003;27:930-934. 75. International Committee of Medical Journal Editors. Defin-ing the role of authors and contributors. Available at: | Surgery_Schwartz. trial of arthroscopic surgery for osteoarthritis of the knee. N Engl J Med. 2002;347:81. Summary for patients in: J Fam Pract. 2002;51:813. 69. Angelos PA. Sham surgery in research: a surgeon’s view. Am J Bioeth. 2003;3:65-66. 70. Miller FG. Sham surgery: an ethical analysis. Sci Eng Ethics. 2004;10:157-166. 71. Angelos P. Sham surgery in clinical trials. JAMA. 2007;297:1545-1546, author reply 1546. 72. Riskin DJ, Longaker MT, Gertner M, et al. Innovation in sur-gery: a historical perspective. Ann Surg. 2006;244:686-693. 73. Biffl WL, Spain DA, Reitsma AM, et al. Responsible develop-ment and application of surgical innovations: a position state-ment of the Society of University Surgeons. J Am Coll Surg. 2008;206(6):1204-1209. 74. McKneally MF, Daar AS. Introducing new technologies: pro-tecting subjects of surgical innovation and research. World J Surg. 2003;27:930-934. 75. International Committee of Medical Journal Editors. Defin-ing the role of authors and contributors. Available at: | [
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Surgery_Schwartz_13574 | Surgery_Schwartz | JM, Donaldson MS. To Err Is Human: Building a Safer Health System. Washington: National Academy Press; 2000. 80. Brennan TA, Leape LL, Laird NM, et al. Incidence of adverse events and negligence in hospitalized patients. Results of the Harvard Medical Practice Study I. N Engl J Med. 1991;324:370-376. 81. Hebert PC, Levin AV, Robertson G. Bioethics for clinicians: 23. Disclosure of medical error. CMAJ. 2001;164:509-513.Brunicardi_Ch48_p2061-p2076.indd 207619/02/19 1:49 PM | Surgery_Schwartz. JM, Donaldson MS. To Err Is Human: Building a Safer Health System. Washington: National Academy Press; 2000. 80. Brennan TA, Leape LL, Laird NM, et al. Incidence of adverse events and negligence in hospitalized patients. Results of the Harvard Medical Practice Study I. N Engl J Med. 1991;324:370-376. 81. Hebert PC, Levin AV, Robertson G. Bioethics for clinicians: 23. Disclosure of medical error. CMAJ. 2001;164:509-513.Brunicardi_Ch48_p2061-p2076.indd 207619/02/19 1:49 PM | [
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Surgery_Schwartz_13575 | Surgery_Schwartz | Global SurgeryKatherine E. Smiley, Haile T. Debas, Catherine R. deVries, and Raymond R. Price 49chapterINTRODUCTIONModern surgery can save lives, help expand economies, and offer hope to individuals and communities. Prior to the accep-tance and availability of aseptic technique to prevent or decrease infections, and improved anesthesia for controlling pain, sur-gery as a specialty was held in very low esteem by medical doc-tors and the general public. Over the last 100 years, surgery has developed into a highly regarded discipline that not only pro-vides opportunities for curing certain diseases but also fulfills a special role in preventing and mitigating disability.Yet, surgery is currently unavailable to most people world-wide. The vast majority—90%—of the world’s population receives only 10% of the surgical care delivered. Said another way, 90% of surgical resources are consumed by the most privi-leged 10% of the world’s population. More than 5 billion people lack access to safe, | Surgery_Schwartz. Global SurgeryKatherine E. Smiley, Haile T. Debas, Catherine R. deVries, and Raymond R. Price 49chapterINTRODUCTIONModern surgery can save lives, help expand economies, and offer hope to individuals and communities. Prior to the accep-tance and availability of aseptic technique to prevent or decrease infections, and improved anesthesia for controlling pain, sur-gery as a specialty was held in very low esteem by medical doc-tors and the general public. Over the last 100 years, surgery has developed into a highly regarded discipline that not only pro-vides opportunities for curing certain diseases but also fulfills a special role in preventing and mitigating disability.Yet, surgery is currently unavailable to most people world-wide. The vast majority—90%—of the world’s population receives only 10% of the surgical care delivered. Said another way, 90% of surgical resources are consumed by the most privi-leged 10% of the world’s population. More than 5 billion people lack access to safe, | [
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Surgery_Schwartz_13576 | Surgery_Schwartz | 10% of the surgical care delivered. Said another way, 90% of surgical resources are consumed by the most privi-leged 10% of the world’s population. More than 5 billion people lack access to safe, timely, and affordable surgical care.1 Very few surgical procedures occur in countries spending less than U.S. $100 per person on health care per year compared to coun-tries spending greater than U.S. $1000 per person (Fig. 49-1).2Examples of disparities abound. In many countries, including the wealthiest, islands of poverty coexist within cities replete with material resources. Tertiary level hospitals operate within eyesight of slums whose inhabitants have no access to even basic care. Most of the people without access—people in rural areas and in countries with poor infrastructure—are the very people most at risk for death or disability due to lack of surgical care. Often the poor accept and endure many painful and potentially correctable fatal conditions as a fact of life.3-6 Care for | Surgery_Schwartz. 10% of the surgical care delivered. Said another way, 90% of surgical resources are consumed by the most privi-leged 10% of the world’s population. More than 5 billion people lack access to safe, timely, and affordable surgical care.1 Very few surgical procedures occur in countries spending less than U.S. $100 per person on health care per year compared to coun-tries spending greater than U.S. $1000 per person (Fig. 49-1).2Examples of disparities abound. In many countries, including the wealthiest, islands of poverty coexist within cities replete with material resources. Tertiary level hospitals operate within eyesight of slums whose inhabitants have no access to even basic care. Most of the people without access—people in rural areas and in countries with poor infrastructure—are the very people most at risk for death or disability due to lack of surgical care. Often the poor accept and endure many painful and potentially correctable fatal conditions as a fact of life.3-6 Care for | [
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Surgery_Schwartz_13577 | Surgery_Schwartz | people most at risk for death or disability due to lack of surgical care. Often the poor accept and endure many painful and potentially correctable fatal conditions as a fact of life.3-6 Care for trauma and obstetrical emergencies is considered a basic surgical need but is absent in many rural regions. Other chronic conditions—often equally debilitating—progress to death or serious disability due to lack of available, safe surgery and anesthesia.Many factors contribute to the disparity in access to surgi-cal care. Poverty, a primary risk factor for all types of diseases, is a major obstacle hindering access to surgery. Healthcare pro-fessionals, including surgeons, migrate from areas of need due to a lack of infrastructure (hospitals, roadways, and stable elec-trical sources), limited supplies and equipment, lack of human resources, few opportunities for professional development, and concerns for personal safety. Until recently, there has been a significant lack of information | Surgery_Schwartz. people most at risk for death or disability due to lack of surgical care. Often the poor accept and endure many painful and potentially correctable fatal conditions as a fact of life.3-6 Care for trauma and obstetrical emergencies is considered a basic surgical need but is absent in many rural regions. Other chronic conditions—often equally debilitating—progress to death or serious disability due to lack of available, safe surgery and anesthesia.Many factors contribute to the disparity in access to surgi-cal care. Poverty, a primary risk factor for all types of diseases, is a major obstacle hindering access to surgery. Healthcare pro-fessionals, including surgeons, migrate from areas of need due to a lack of infrastructure (hospitals, roadways, and stable elec-trical sources), limited supplies and equipment, lack of human resources, few opportunities for professional development, and concerns for personal safety. Until recently, there has been a significant lack of information | [
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Surgery_Schwartz_13578 | Surgery_Schwartz | supplies and equipment, lack of human resources, few opportunities for professional development, and concerns for personal safety. Until recently, there has been a significant lack of information regarding the burden of surgical disease and surgery’s positive impact on communities. Current research substantiates that investment in surgical care improves economies and is an integral and necessary component of global health.7,8Disparities in care and outcomes are multidimensional, and no simple solution exists to improve access to appro-priate and affordable surgical care. Yet, five major forces are reshaping priorities and strategies leading the charge for the globalization of surgical care.1. The epidemiologic transition of diseases from primarily in-fectious to more chronic conditions2. The mobile nature of the world’s populations, allowing peo-ple to move freely between more isolated areas of the world, leading to a more integrated global community3. Ubiquitous information access | Surgery_Schwartz. supplies and equipment, lack of human resources, few opportunities for professional development, and concerns for personal safety. Until recently, there has been a significant lack of information regarding the burden of surgical disease and surgery’s positive impact on communities. Current research substantiates that investment in surgical care improves economies and is an integral and necessary component of global health.7,8Disparities in care and outcomes are multidimensional, and no simple solution exists to improve access to appro-priate and affordable surgical care. Yet, five major forces are reshaping priorities and strategies leading the charge for the globalization of surgical care.1. The epidemiologic transition of diseases from primarily in-fectious to more chronic conditions2. The mobile nature of the world’s populations, allowing peo-ple to move freely between more isolated areas of the world, leading to a more integrated global community3. Ubiquitous information access | [
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Surgery_Schwartz_13579 | Surgery_Schwartz | mobile nature of the world’s populations, allowing peo-ple to move freely between more isolated areas of the world, leading to a more integrated global community3. Ubiquitous information access exponentially enabling wide-spread participation in understanding and designing innova-tive opportunities for high-quality surgical care4. A revolution for equity and human rights where the world’s poor are demanding benefits to surgical care similar to those found in high-income countries (HICs)5. Recognition of the cost-effectiveness of surgical care and its potential to build economies, demonstrating the value of in-cluding surgery in global health strategies9-12The greatest burden of disease occurs in areas where human resources—physicians, nurses, pharmacists, and other healthcare workers—are scarce (Fig. 49-2).13 The proportion of physicians is low both in high-population areas and in areas where the population is growing most rapidly (Fig. 49-3).14,15 Fully trained surgeons and | Surgery_Schwartz. mobile nature of the world’s populations, allowing peo-ple to move freely between more isolated areas of the world, leading to a more integrated global community3. Ubiquitous information access exponentially enabling wide-spread participation in understanding and designing innova-tive opportunities for high-quality surgical care4. A revolution for equity and human rights where the world’s poor are demanding benefits to surgical care similar to those found in high-income countries (HICs)5. Recognition of the cost-effectiveness of surgical care and its potential to build economies, demonstrating the value of in-cluding surgery in global health strategies9-12The greatest burden of disease occurs in areas where human resources—physicians, nurses, pharmacists, and other healthcare workers—are scarce (Fig. 49-2).13 The proportion of physicians is low both in high-population areas and in areas where the population is growing most rapidly (Fig. 49-3).14,15 Fully trained surgeons and | [
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Surgery_Schwartz_13580 | Surgery_Schwartz | scarce (Fig. 49-2).13 The proportion of physicians is low both in high-population areas and in areas where the population is growing most rapidly (Fig. 49-3).14,15 Fully trained surgeons and anesthesiologists comprise only a small proportion of the total number of the Human Resources in Health (HRH), and efforts to meet the 12Introduction 2077Defining Global Surgery 2079Global Surgery Ecosystem / 2079Human Resources / 2081Burden of Surgical Disease / 2081Strategies for Development 2086Essential Surgery: Current and Evolving Concepts / 2086Outreach and Engagement / 2087International Organizations / 2088Global Surgery and Public Health / 2091Cancer Initiatives / 2098Integrating Value into Global Surgery / 2102Advanced Surgical Care for Resource-Poor Areas / 2102Academic Global Surgery / 2103Ethics / 2105Innovation in Global Surgery / 2106The Future for Global Surgery 2106Brunicardi_Ch49_p2077-p2112.indd 207713/02/19 5:53 PM 2078surgical needs are now embracing a multifaceted | Surgery_Schwartz. scarce (Fig. 49-2).13 The proportion of physicians is low both in high-population areas and in areas where the population is growing most rapidly (Fig. 49-3).14,15 Fully trained surgeons and anesthesiologists comprise only a small proportion of the total number of the Human Resources in Health (HRH), and efforts to meet the 12Introduction 2077Defining Global Surgery 2079Global Surgery Ecosystem / 2079Human Resources / 2081Burden of Surgical Disease / 2081Strategies for Development 2086Essential Surgery: Current and Evolving Concepts / 2086Outreach and Engagement / 2087International Organizations / 2088Global Surgery and Public Health / 2091Cancer Initiatives / 2098Integrating Value into Global Surgery / 2102Advanced Surgical Care for Resource-Poor Areas / 2102Academic Global Surgery / 2103Ethics / 2105Innovation in Global Surgery / 2106The Future for Global Surgery 2106Brunicardi_Ch49_p2077-p2112.indd 207713/02/19 5:53 PM 2078surgical needs are now embracing a multifaceted | [
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Surgery_Schwartz_13581 | Surgery_Schwartz | / 2103Ethics / 2105Innovation in Global Surgery / 2106The Future for Global Surgery 2106Brunicardi_Ch49_p2077-p2112.indd 207713/02/19 5:53 PM 2078surgical needs are now embracing a multifaceted approach, including advanced care practitioners. The Lancet Commission on Global Surgery estimates that an additional 143 million sur-gical procedures are needed each year in LMICs to prevent death and disability caused by lack of care.16The potential benefits of surgical care for economic pro-ductivity are astounding. Considering that the annual eco-nomic loss from road traffic injuries alone exceeds U.S. $500 billion globally, a panel of expert economists at the Copenhagen Consensus of 2012, including four Nobel prize lau-reates, prioritized strengthening surgical capacity as the eighth most cost-effective investment for addressing the world’s most pressing problems. The Consensus reconvened in 2015, syn-chronizing their recommendations to the United Nations’ Sus-tainable Development | Surgery_Schwartz. / 2103Ethics / 2105Innovation in Global Surgery / 2106The Future for Global Surgery 2106Brunicardi_Ch49_p2077-p2112.indd 207713/02/19 5:53 PM 2078surgical needs are now embracing a multifaceted approach, including advanced care practitioners. The Lancet Commission on Global Surgery estimates that an additional 143 million sur-gical procedures are needed each year in LMICs to prevent death and disability caused by lack of care.16The potential benefits of surgical care for economic pro-ductivity are astounding. Considering that the annual eco-nomic loss from road traffic injuries alone exceeds U.S. $500 billion globally, a panel of expert economists at the Copenhagen Consensus of 2012, including four Nobel prize lau-reates, prioritized strengthening surgical capacity as the eighth most cost-effective investment for addressing the world’s most pressing problems. The Consensus reconvened in 2015, syn-chronizing their recommendations to the United Nations’ Sus-tainable Development | [
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Surgery_Schwartz_13582 | Surgery_Schwartz | cost-effective investment for addressing the world’s most pressing problems. The Consensus reconvened in 2015, syn-chronizing their recommendations to the United Nations’ Sus-tainable Development Goals, and reaffirmed that surgery-related initiatives (i.e., circumcision and skilled obstetrical support), offer the best “value-for-money” in terms of alleviating world poverty.17-19 The Lancet Commission on Global Surgery, a research and advisory working group with contributors from 110 nations, echoed these sentiments. Surgery should be viewed as an investment rather than a cost.16,20Much of the economic modeling and strengthening of political will related to surgical and anesthesia care has been carried out by collaborative groups and consortia including aca-demic, nongovernmental, and other organizations. The efforts of these groups truly coalesced in 2015, when several major consensus statements from governmental organizations, such as the World Bank and the World Health Assembly, | Surgery_Schwartz. cost-effective investment for addressing the world’s most pressing problems. The Consensus reconvened in 2015, syn-chronizing their recommendations to the United Nations’ Sus-tainable Development Goals, and reaffirmed that surgery-related initiatives (i.e., circumcision and skilled obstetrical support), offer the best “value-for-money” in terms of alleviating world poverty.17-19 The Lancet Commission on Global Surgery, a research and advisory working group with contributors from 110 nations, echoed these sentiments. Surgery should be viewed as an investment rather than a cost.16,20Much of the economic modeling and strengthening of political will related to surgical and anesthesia care has been carried out by collaborative groups and consortia including aca-demic, nongovernmental, and other organizations. The efforts of these groups truly coalesced in 2015, when several major consensus statements from governmental organizations, such as the World Bank and the World Health Assembly, | [
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Surgery_Schwartz_13583 | Surgery_Schwartz | organizations. The efforts of these groups truly coalesced in 2015, when several major consensus statements from governmental organizations, such as the World Bank and the World Health Assembly, recognized the importance of surgery in public health for the first time. 3$100$101-400$401-1000> $100012,00010,00080006000400020000Number of procedures/100,000 populationUS dollars/person healthcare/yearFigure 49-1. Worldwide distribution of surgical procedures. (Data from Weiser TG, Regenbogen SE, Thompson KD, et al. An estima-tion of the global volume of surgery: a modelling strategy based on available data, Lancet. 2008 Jul 12;372(9633):139-144.)Key Points1 There are five major forces reshaping priorities and strate-gies for the globalization of surgical care:a. The epidemiologic transition of diseasesb. The mobile nature of the world’s populationsc. Ubiquitous information accessd. A revolution for equity and human rightse. Recognition of the cost-effectiveness of surgical care for | Surgery_Schwartz. organizations. The efforts of these groups truly coalesced in 2015, when several major consensus statements from governmental organizations, such as the World Bank and the World Health Assembly, recognized the importance of surgery in public health for the first time. 3$100$101-400$401-1000> $100012,00010,00080006000400020000Number of procedures/100,000 populationUS dollars/person healthcare/yearFigure 49-1. Worldwide distribution of surgical procedures. (Data from Weiser TG, Regenbogen SE, Thompson KD, et al. An estima-tion of the global volume of surgery: a modelling strategy based on available data, Lancet. 2008 Jul 12;372(9633):139-144.)Key Points1 There are five major forces reshaping priorities and strate-gies for the globalization of surgical care:a. The epidemiologic transition of diseasesb. The mobile nature of the world’s populationsc. Ubiquitous information accessd. A revolution for equity and human rightse. Recognition of the cost-effectiveness of surgical care for | [
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Surgery_Schwartz_13584 | Surgery_Schwartz | of diseasesb. The mobile nature of the world’s populationsc. Ubiquitous information accessd. A revolution for equity and human rightse. Recognition of the cost-effectiveness of surgical care for treatment and prevention of disease2 The burden of disease is greatest in areas where human resources—physicians, nurses, pharmacists, and other healthcare workers—are the least.3 Surgery should be viewed as an investment rather than a cost.4 The key components of the global surgery ecosystem include technology, education, community, healthcare, business, and multidisciplinary engagement between a variety of disciplines.5 Understanding and addressing the necessary communica-tion, energy, and transportation technologies along with the underlying cultural context represent the foundation critical to implementing sustainable infrastructure for appropriate surgical care.6 There has been a significant shift from communicable, maternal, neonatal, and nutritional causes of disease to noncommunicable | Surgery_Schwartz. of diseasesb. The mobile nature of the world’s populationsc. Ubiquitous information accessd. A revolution for equity and human rightse. Recognition of the cost-effectiveness of surgical care for treatment and prevention of disease2 The burden of disease is greatest in areas where human resources—physicians, nurses, pharmacists, and other healthcare workers—are the least.3 Surgery should be viewed as an investment rather than a cost.4 The key components of the global surgery ecosystem include technology, education, community, healthcare, business, and multidisciplinary engagement between a variety of disciplines.5 Understanding and addressing the necessary communica-tion, energy, and transportation technologies along with the underlying cultural context represent the foundation critical to implementing sustainable infrastructure for appropriate surgical care.6 There has been a significant shift from communicable, maternal, neonatal, and nutritional causes of disease to noncommunicable | [
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Surgery_Schwartz_13585 | Surgery_Schwartz | implementing sustainable infrastructure for appropriate surgical care.6 There has been a significant shift from communicable, maternal, neonatal, and nutritional causes of disease to noncommunicable causes, many of which require surgi-cal care.7 Patients and their communities in lowand middle-income countries (LMICs) bear a much greater share of the burden of cancer than high-income countries (HICs).8 Globally, trauma has become a leading cause of death and disability; 90% of trauma deaths occur in LMICs.9 Essential surgical services should be integrated into com-prehensive health care delivery, with the potential to avert 1.5 million deaths per year in LMICs.10 Surgery is gaining an increasingly recognized role for improving public health, having a role in prevention as well as treatment.11 The cost-effectiveness of surgical care has been demon-strated, and its value as a public health investment is increasingly understood by policymakers.12 Developing capabilities for surgical care | Surgery_Schwartz. implementing sustainable infrastructure for appropriate surgical care.6 There has been a significant shift from communicable, maternal, neonatal, and nutritional causes of disease to noncommunicable causes, many of which require surgi-cal care.7 Patients and their communities in lowand middle-income countries (LMICs) bear a much greater share of the burden of cancer than high-income countries (HICs).8 Globally, trauma has become a leading cause of death and disability; 90% of trauma deaths occur in LMICs.9 Essential surgical services should be integrated into com-prehensive health care delivery, with the potential to avert 1.5 million deaths per year in LMICs.10 Surgery is gaining an increasingly recognized role for improving public health, having a role in prevention as well as treatment.11 The cost-effectiveness of surgical care has been demon-strated, and its value as a public health investment is increasingly understood by policymakers.12 Developing capabilities for surgical care | [
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Surgery_Schwartz_13586 | Surgery_Schwartz | cost-effectiveness of surgical care has been demon-strated, and its value as a public health investment is increasingly understood by policymakers.12 Developing capabilities for surgical care has the ability to promote system-strengthening in resource-poor countries and to mitigate migration of health professionals at all levels.13 Academic global surgery provides a unique environment to study health systems, identify solutions and implement them collaboratively, fulfilling many institutions’ mis-sions to strengthen multidisciplinary training, advocacy, and research.14 Surgical innovations that bring value by balancing cost with quality designed for challenging energy environ-ments will foster equity in surgical care for LMICs.Brunicardi_Ch49_p2077-p2112.indd 207813/02/19 5:53 PM 2079GLOBAL SURGERYCHAPTER 49The third edition of World Bank’s Disease Control Priorities (DCP3) and the World Health Assembly’s Resolution 68.15 both specifically discuss the vital nature of surgical care | Surgery_Schwartz. cost-effectiveness of surgical care has been demon-strated, and its value as a public health investment is increasingly understood by policymakers.12 Developing capabilities for surgical care has the ability to promote system-strengthening in resource-poor countries and to mitigate migration of health professionals at all levels.13 Academic global surgery provides a unique environment to study health systems, identify solutions and implement them collaboratively, fulfilling many institutions’ mis-sions to strengthen multidisciplinary training, advocacy, and research.14 Surgical innovations that bring value by balancing cost with quality designed for challenging energy environ-ments will foster equity in surgical care for LMICs.Brunicardi_Ch49_p2077-p2112.indd 207813/02/19 5:53 PM 2079GLOBAL SURGERYCHAPTER 49The third edition of World Bank’s Disease Control Priorities (DCP3) and the World Health Assembly’s Resolution 68.15 both specifically discuss the vital nature of surgical care | [
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Surgery_Schwartz_13587 | Surgery_Schwartz | SURGERYCHAPTER 49The third edition of World Bank’s Disease Control Priorities (DCP3) and the World Health Assembly’s Resolution 68.15 both specifically discuss the vital nature of surgical care as part of any health system.7,21 Such resolutions represent a sea change in terms of how the global policy community views surgical care for LMICs and, indeed, the entire world.This chapter examines the ongoing need to expand and strengthen surgical care globally, explores some of the signifi-cant challenges of global surgery, and presents potential guid-ing concepts along with examples of successful strategies for sustainable surgical development.DEFINING GLOBAL SURGERYGlobal Surgery EcosystemTo understand how surgery fits into healthcare systems and to understand its unique needs, it is helpful to consider global surgery as an ecosystem. The emerging field of global surgery considers surgical care to be a fundamental component of global health. As a system with both local and international | Surgery_Schwartz. SURGERYCHAPTER 49The third edition of World Bank’s Disease Control Priorities (DCP3) and the World Health Assembly’s Resolution 68.15 both specifically discuss the vital nature of surgical care as part of any health system.7,21 Such resolutions represent a sea change in terms of how the global policy community views surgical care for LMICs and, indeed, the entire world.This chapter examines the ongoing need to expand and strengthen surgical care globally, explores some of the signifi-cant challenges of global surgery, and presents potential guid-ing concepts along with examples of successful strategies for sustainable surgical development.DEFINING GLOBAL SURGERYGlobal Surgery EcosystemTo understand how surgery fits into healthcare systems and to understand its unique needs, it is helpful to consider global surgery as an ecosystem. The emerging field of global surgery considers surgical care to be a fundamental component of global health. As a system with both local and international | [
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Surgery_Schwartz_13588 | Surgery_Schwartz | to consider global surgery as an ecosystem. The emerging field of global surgery considers surgical care to be a fundamental component of global health. As a system with both local and international scope, global surgery encompasses not just the medical and technical aspects of surgical care, but also the societal and environmental context in which surgery is per-formed. Global surgery also refers to a worldwide lens through which we view challenges collaboratively; thus, global sur-geons may focus on resource-limited areas where needs are profound, but the ultimate goal should be to make surgical care equitable, accessible, and affordable for every human being.22 Surgery as an ecosystem considers the diverse but interrelated systems that must be functional for quality surgical care to be delivered. Only part of these systems falls within the tradi-tional training of surgeons. Yet, modern surgical care requires these systems to work in a coordinated fashion to support three priorities | Surgery_Schwartz. to consider global surgery as an ecosystem. The emerging field of global surgery considers surgical care to be a fundamental component of global health. As a system with both local and international scope, global surgery encompasses not just the medical and technical aspects of surgical care, but also the societal and environmental context in which surgery is per-formed. Global surgery also refers to a worldwide lens through which we view challenges collaboratively; thus, global sur-geons may focus on resource-limited areas where needs are profound, but the ultimate goal should be to make surgical care equitable, accessible, and affordable for every human being.22 Surgery as an ecosystem considers the diverse but interrelated systems that must be functional for quality surgical care to be delivered. Only part of these systems falls within the tradi-tional training of surgeons. Yet, modern surgical care requires these systems to work in a coordinated fashion to support three priorities | [
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Surgery_Schwartz_13589 | Surgery_Schwartz | delivered. Only part of these systems falls within the tradi-tional training of surgeons. Yet, modern surgical care requires these systems to work in a coordinated fashion to support three priorities critical for expanding surgery globally—accessibility, affordability, and innovation (Fig. 49-4). Global surgery is a way to consider a “systems-based practice” beyond a single hospital or community, for the benefit of people worldwide. Many interrelated components of this surgical ecosystem orig-inate outside the hospital.Disparities in surgical care have geographical, socioeco-nomic, and cultural components. Most people who live in major cities in the northern and western hemispheres take for granted a functioning energy grid. The development of energy beyond major cities has enabled wealthier communities to imagine, and indeed, to expect healthcare to be available at all times and affordable. Yet, a lack of reliable energy sources is a major limiting factor. Communication and | Surgery_Schwartz. delivered. Only part of these systems falls within the tradi-tional training of surgeons. Yet, modern surgical care requires these systems to work in a coordinated fashion to support three priorities critical for expanding surgery globally—accessibility, affordability, and innovation (Fig. 49-4). Global surgery is a way to consider a “systems-based practice” beyond a single hospital or community, for the benefit of people worldwide. Many interrelated components of this surgical ecosystem orig-inate outside the hospital.Disparities in surgical care have geographical, socioeco-nomic, and cultural components. Most people who live in major cities in the northern and western hemispheres take for granted a functioning energy grid. The development of energy beyond major cities has enabled wealthier communities to imagine, and indeed, to expect healthcare to be available at all times and affordable. Yet, a lack of reliable energy sources is a major limiting factor. Communication and | [
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Surgery_Schwartz_13590 | Surgery_Schwartz | wealthier communities to imagine, and indeed, to expect healthcare to be available at all times and affordable. Yet, a lack of reliable energy sources is a major limiting factor. Communication and transportation technologies, for example, the mobile phone and air and ground travel, have dramatically progressed in highand middle-income countries but are still rudimentary in poor countries. Many of the current disparities in health care, particularly surgical care, are due to the lack of penetration of these technologies. Under-standing and addressing the necessary communication, energy, and transportation deficits as well as the underlying cultural nuances are necessary to support the sustainable development of surgical care.Electricity is necessary for all modern surgery. Anesthe-sia monitoring, operating room lighting, cautery, suction, and patient warming devices all require sources of electricity that are stable, without huge electrical surges. Only in the last 50 years or so could | Surgery_Schwartz. wealthier communities to imagine, and indeed, to expect healthcare to be available at all times and affordable. Yet, a lack of reliable energy sources is a major limiting factor. Communication and transportation technologies, for example, the mobile phone and air and ground travel, have dramatically progressed in highand middle-income countries but are still rudimentary in poor countries. Many of the current disparities in health care, particularly surgical care, are due to the lack of penetration of these technologies. Under-standing and addressing the necessary communication, energy, and transportation deficits as well as the underlying cultural nuances are necessary to support the sustainable development of surgical care.Electricity is necessary for all modern surgery. Anesthe-sia monitoring, operating room lighting, cautery, suction, and patient warming devices all require sources of electricity that are stable, without huge electrical surges. Only in the last 50 years or so could | [
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Surgery_Schwartz_13591 | Surgery_Schwartz | operating room lighting, cautery, suction, and patient warming devices all require sources of electricity that are stable, without huge electrical surges. Only in the last 50 years or so could stable electricity be expected in most wealthy cities. However, in rural areas of even wealthy countries, electricity remains unpredictable (Fig. 49-5).23In poorer countries, the cost and availability of electric-ity is frequently the limiting factor for more advanced diagnos-tic and therapeutic technology—from laboratories that require refrigeration to radiology in all of its various branches. Modern design for surgical devices has, for the most part, not taken into account the wide range of energy environments where surgery is practiced. Fragile instruments and monitors that cannot survive the rigors of the real working environment limit the types of surgery that can be provided.4535302520151050Percent of global disease burdenPercent of global | Surgery_Schwartz. operating room lighting, cautery, suction, and patient warming devices all require sources of electricity that are stable, without huge electrical surges. Only in the last 50 years or so could stable electricity be expected in most wealthy cities. However, in rural areas of even wealthy countries, electricity remains unpredictable (Fig. 49-5).23In poorer countries, the cost and availability of electric-ity is frequently the limiting factor for more advanced diagnos-tic and therapeutic technology—from laboratories that require refrigeration to radiology in all of its various branches. Modern design for surgical devices has, for the most part, not taken into account the wide range of energy environments where surgery is practiced. Fragile instruments and monitors that cannot survive the rigors of the real working environment limit the types of surgery that can be provided.4535302520151050Percent of global disease burdenPercent of global | [
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Surgery_Schwartz_13592 | Surgery_Schwartz | and monitors that cannot survive the rigors of the real working environment limit the types of surgery that can be provided.4535302520151050Percent of global disease burdenPercent of global workforceAmericasEuropeWesternPacificSouth-EastAsiaAfricaEasternMediterranean* Even with grants and loans from abroad.054045303520251015Africa suffers from 24% of the global burden of disease but has access to only 3% of health workers and less than 1% of the world's financial resources.*Figure 49-2. Distribution of healthcare workers by burden of disease in WHO regions. (Reproduced with permission from Intermountain Healthcare.)Brunicardi_Ch49_p2077-p2112.indd 207913/02/19 5:53 PM 2080SPECIFIC CONSIDERATIONSPART IIComponents of the Global Surgery Ecosystem. Improve-ments in energy, transportation, and communication are criti-cal to support the growth of surgical care.9 Building capacity for surgical care requires interaction between the various com-ponents that create a functioning, | Surgery_Schwartz. and monitors that cannot survive the rigors of the real working environment limit the types of surgery that can be provided.4535302520151050Percent of global disease burdenPercent of global workforceAmericasEuropeWesternPacificSouth-EastAsiaAfricaEasternMediterranean* Even with grants and loans from abroad.054045303520251015Africa suffers from 24% of the global burden of disease but has access to only 3% of health workers and less than 1% of the world's financial resources.*Figure 49-2. Distribution of healthcare workers by burden of disease in WHO regions. (Reproduced with permission from Intermountain Healthcare.)Brunicardi_Ch49_p2077-p2112.indd 207913/02/19 5:53 PM 2080SPECIFIC CONSIDERATIONSPART IIComponents of the Global Surgery Ecosystem. Improve-ments in energy, transportation, and communication are criti-cal to support the growth of surgical care.9 Building capacity for surgical care requires interaction between the various com-ponents that create a functioning, | [
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Surgery_Schwartz_13593 | Surgery_Schwartz | and communication are criti-cal to support the growth of surgical care.9 Building capacity for surgical care requires interaction between the various com-ponents that create a functioning, sustainable system. When surgeons think of surgery, they usually think in terms of science and hands-on technical expertise. However, global surgery requires a broader understanding of systems in other disciplines. Surgeons must work collaboratively with engineers and busi-ness leaders to develop technology that can function in lower 0–1717–3434–50Physicians (per 10,000 population)2005–201050–67200,000,000–600,000,0000–200,000,000600,000,000–1,400,000,000Population20120.48%–1.96%1.96%–3.45%3.45%–4.93%Population growth rate2012–1.01%– –0.48%Figure 49-3. Number of physicians, world populations, and world population growth rates. (Reproduced with permission from World Health Organization, 2018 (Density of Physicians [total number per 1000 population]); 2013 World Population Data Sheet Interactive Map; | Surgery_Schwartz. and communication are criti-cal to support the growth of surgical care.9 Building capacity for surgical care requires interaction between the various com-ponents that create a functioning, sustainable system. When surgeons think of surgery, they usually think in terms of science and hands-on technical expertise. However, global surgery requires a broader understanding of systems in other disciplines. Surgeons must work collaboratively with engineers and busi-ness leaders to develop technology that can function in lower 0–1717–3434–50Physicians (per 10,000 population)2005–201050–67200,000,000–600,000,0000–200,000,000600,000,000–1,400,000,000Population20120.48%–1.96%1.96%–3.45%3.45%–4.93%Population growth rate2012–1.01%– –0.48%Figure 49-3. Number of physicians, world populations, and world population growth rates. (Reproduced with permission from World Health Organization, 2018 (Density of Physicians [total number per 1000 population]); 2013 World Population Data Sheet Interactive Map; | [
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Surgery_Schwartz_13594 | Surgery_Schwartz | population growth rates. (Reproduced with permission from World Health Organization, 2018 (Density of Physicians [total number per 1000 population]); 2013 World Population Data Sheet Interactive Map; World Bank, population growth (annual %) map.)Brunicardi_Ch49_p2077-p2112.indd 208013/02/19 5:53 PM 2081GLOBAL SURGERYCHAPTER 49resource environments. These innovations can provide a source of economic growth for the community, which in turn supports better health care (Fig. 49-6).No sustainable surgical system in the modern age can function without specialists in bioengineering, sterile process, supply chain, hospital safety, and waste management. These often unappreciated colleagues make possible the daily practice of surgery. Similarly, specialists in anesthesia, nursing, and the diagnostic specialties of radiology, pathology, and laboratory services are fundamental to a fully functional surgical service.Human ResourcesPrimary care physicians, nurses, midwives, or advanced care | Surgery_Schwartz. population growth rates. (Reproduced with permission from World Health Organization, 2018 (Density of Physicians [total number per 1000 population]); 2013 World Population Data Sheet Interactive Map; World Bank, population growth (annual %) map.)Brunicardi_Ch49_p2077-p2112.indd 208013/02/19 5:53 PM 2081GLOBAL SURGERYCHAPTER 49resource environments. These innovations can provide a source of economic growth for the community, which in turn supports better health care (Fig. 49-6).No sustainable surgical system in the modern age can function without specialists in bioengineering, sterile process, supply chain, hospital safety, and waste management. These often unappreciated colleagues make possible the daily practice of surgery. Similarly, specialists in anesthesia, nursing, and the diagnostic specialties of radiology, pathology, and laboratory services are fundamental to a fully functional surgical service.Human ResourcesPrimary care physicians, nurses, midwives, or advanced care | [
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Surgery_Schwartz_13595 | Surgery_Schwartz | specialties of radiology, pathology, and laboratory services are fundamental to a fully functional surgical service.Human ResourcesPrimary care physicians, nurses, midwives, or advanced care practitioners (ACPs) provide much of the basic surgical and anesthetic care in LMICs. Where regulations allow, “task sharing,” or training ACPs to deliver surgery and anesthesia services previously allowed only under the purview of fully trained specialists, can provide expanded access to care.24-26 Non-MD practitioners, known as assistant medical officers (AMOs) or “tecnicos de cirurgia” in Mozambique, often have extensive operative experience, including obstetrical care, and are the pri-mary surgical providers in some regions.27-29 Task sharing with ACPs also occurs in the United States and other countries where they fill a need otherwise unmet by specialists even in major tertiary care centers.30 However, concerns about the quality of care, lack of adequate supervision, and the effect on | Surgery_Schwartz. specialties of radiology, pathology, and laboratory services are fundamental to a fully functional surgical service.Human ResourcesPrimary care physicians, nurses, midwives, or advanced care practitioners (ACPs) provide much of the basic surgical and anesthetic care in LMICs. Where regulations allow, “task sharing,” or training ACPs to deliver surgery and anesthesia services previously allowed only under the purview of fully trained specialists, can provide expanded access to care.24-26 Non-MD practitioners, known as assistant medical officers (AMOs) or “tecnicos de cirurgia” in Mozambique, often have extensive operative experience, including obstetrical care, and are the pri-mary surgical providers in some regions.27-29 Task sharing with ACPs also occurs in the United States and other countries where they fill a need otherwise unmet by specialists even in major tertiary care centers.30 However, concerns about the quality of care, lack of adequate supervision, and the effect on | [
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Surgery_Schwartz_13596 | Surgery_Schwartz | countries where they fill a need otherwise unmet by specialists even in major tertiary care centers.30 However, concerns about the quality of care, lack of adequate supervision, and the effect on prestige and professional development for specialists and ACPs, continue to be topics for debate.31,32Migration of practitioners to economically and culturally favorable locales is universal and not restricted to low-resource countries.33,34 However, the net impact on poor countries is greater. In a 2004 study, more than 23% of U.S. physicians received their medical training from other countries; of these 64% were from low-income countries.35 Using 2013 data, another study showed annual emigration rates of sub-Saharan physicians to the United States are increasing, despite a World Health Organization Global Code of Practice in 2010 aimed at LMIC workforce retention.36 Investments in training greater numbers of doctors in these countries, including surgical spe-cialists, have been only | Surgery_Schwartz. countries where they fill a need otherwise unmet by specialists even in major tertiary care centers.30 However, concerns about the quality of care, lack of adequate supervision, and the effect on prestige and professional development for specialists and ACPs, continue to be topics for debate.31,32Migration of practitioners to economically and culturally favorable locales is universal and not restricted to low-resource countries.33,34 However, the net impact on poor countries is greater. In a 2004 study, more than 23% of U.S. physicians received their medical training from other countries; of these 64% were from low-income countries.35 Using 2013 data, another study showed annual emigration rates of sub-Saharan physicians to the United States are increasing, despite a World Health Organization Global Code of Practice in 2010 aimed at LMIC workforce retention.36 Investments in training greater numbers of doctors in these countries, including surgical spe-cialists, have been only | [
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Surgery_Schwartz_13597 | Surgery_Schwartz | Global Code of Practice in 2010 aimed at LMIC workforce retention.36 Investments in training greater numbers of doctors in these countries, including surgical spe-cialists, have been only partially successful in meeting demand in poor countries. Until economic conditions improve or oppor-tunities for professional development increase, and incentives enticing migration of health care workers to high-income countries abate, it is unlikely that the most skilled practitio-ners will remain in resource-poor areas beyond their immediate obligations.37-41Burden of Surgical DiseaseEpidemiologic Transition of Disease. The population on Earth currently stands at more than 7 billion. While the rate of growth has slowed in recent years, projections estimate that AccessibilityAffordabilityInnovationGLOBALSURGERYFigure 49-4. Global surgery priorities. (Reproduced with permission from University of Utah Center for Global Surgery and Intermountain Healthcare.)Figure 49-5. Map of world electrification. | Surgery_Schwartz. Global Code of Practice in 2010 aimed at LMIC workforce retention.36 Investments in training greater numbers of doctors in these countries, including surgical spe-cialists, have been only partially successful in meeting demand in poor countries. Until economic conditions improve or oppor-tunities for professional development increase, and incentives enticing migration of health care workers to high-income countries abate, it is unlikely that the most skilled practitio-ners will remain in resource-poor areas beyond their immediate obligations.37-41Burden of Surgical DiseaseEpidemiologic Transition of Disease. The population on Earth currently stands at more than 7 billion. While the rate of growth has slowed in recent years, projections estimate that AccessibilityAffordabilityInnovationGLOBALSURGERYFigure 49-4. Global surgery priorities. (Reproduced with permission from University of Utah Center for Global Surgery and Intermountain Healthcare.)Figure 49-5. Map of world electrification. | [
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Surgery_Schwartz_13598 | Surgery_Schwartz | 49-4. Global surgery priorities. (Reproduced with permission from University of Utah Center for Global Surgery and Intermountain Healthcare.)Figure 49-5. Map of world electrification. (Reproduced with permission from NASA, Visible Earth, Available at: http://visibleearth.nasa.gov/view.php?id=79765.)Brunicardi_Ch49_p2077-p2112.indd 208113/02/19 5:53 PM 2082SPECIFIC CONSIDERATIONSPART IIthe population will continue to grow to 9 billion by 2050.42 Population characteristics are changing rapidly. According to United Nations’ estimates, the entire world is aging even in low-income countries, and by 2050, 2 billion people will be over the age of 60. Currently, Asia is home to 55% of the world’s population over the age of 60.43 Just before the year 2020, the percentage of the world’s population over age 65 years is predicted to surpass the percentage of children under age 5 years, on an unprecedented reversal of trajectories for both age demographics. While this represents a victory for | Surgery_Schwartz. 49-4. Global surgery priorities. (Reproduced with permission from University of Utah Center for Global Surgery and Intermountain Healthcare.)Figure 49-5. Map of world electrification. (Reproduced with permission from NASA, Visible Earth, Available at: http://visibleearth.nasa.gov/view.php?id=79765.)Brunicardi_Ch49_p2077-p2112.indd 208113/02/19 5:53 PM 2082SPECIFIC CONSIDERATIONSPART IIthe population will continue to grow to 9 billion by 2050.42 Population characteristics are changing rapidly. According to United Nations’ estimates, the entire world is aging even in low-income countries, and by 2050, 2 billion people will be over the age of 60. Currently, Asia is home to 55% of the world’s population over the age of 60.43 Just before the year 2020, the percentage of the world’s population over age 65 years is predicted to surpass the percentage of children under age 5 years, on an unprecedented reversal of trajectories for both age demographics. While this represents a victory for | [
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Surgery_Schwartz_13599 | Surgery_Schwartz | over age 65 years is predicted to surpass the percentage of children under age 5 years, on an unprecedented reversal of trajectories for both age demographics. While this represents a victory for infectious disease control, the dramatic increase in longevity will present new challenges in terms of treating noncommu-nicable disease in the older adult population.44 At the same time, Sub-Saharan Africa’s population is experiencing a much different trend: a current “baby boom” will lead the region to quadruple its population, from 960 million to 4 billion, by the year 2100.45Until recently, infectious diseases dominated public health strategy. Now with major scourges like polio isolated to rela-tively small regions of the world, and HIV and malaria decreas-ing in their relative impact worldwide, chronic diseases and their complications, as well as the effects of aging, are gaining dominance in health care needs. Many of these chronic diseases are best approached by surgery.The lack of | Surgery_Schwartz. over age 65 years is predicted to surpass the percentage of children under age 5 years, on an unprecedented reversal of trajectories for both age demographics. While this represents a victory for infectious disease control, the dramatic increase in longevity will present new challenges in terms of treating noncommu-nicable disease in the older adult population.44 At the same time, Sub-Saharan Africa’s population is experiencing a much different trend: a current “baby boom” will lead the region to quadruple its population, from 960 million to 4 billion, by the year 2100.45Until recently, infectious diseases dominated public health strategy. Now with major scourges like polio isolated to rela-tively small regions of the world, and HIV and malaria decreas-ing in their relative impact worldwide, chronic diseases and their complications, as well as the effects of aging, are gaining dominance in health care needs. Many of these chronic diseases are best approached by surgery.The lack of | [
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Surgery_Schwartz_13600 | Surgery_Schwartz | chronic diseases and their complications, as well as the effects of aging, are gaining dominance in health care needs. Many of these chronic diseases are best approached by surgery.The lack of metrics and paucity of data identifying the unmet burden of surgical need in many countries have been obstacles facing global surgery initiatives. The 2010 Global Burden of Disease Study was the first worldwide comprehensive burden of disease evaluation since the initial 1990 epidemiologic study. Using the disability-adjusted life year (DALY), a metric that captures both premature mortality and the prevalence and severity of illnesses, disease burdens were calculated for 291 causes in 21 regions of the world (including 187 countries) for 1990, 2005, and 2010 to enable identification of significant trends over time.46 While the global DALYs remained stable from 1990 to 2010, the study identified a significant shift from communicable, maternal, neonatal, and nutritional causes of disease to | Surgery_Schwartz. chronic diseases and their complications, as well as the effects of aging, are gaining dominance in health care needs. Many of these chronic diseases are best approached by surgery.The lack of metrics and paucity of data identifying the unmet burden of surgical need in many countries have been obstacles facing global surgery initiatives. The 2010 Global Burden of Disease Study was the first worldwide comprehensive burden of disease evaluation since the initial 1990 epidemiologic study. Using the disability-adjusted life year (DALY), a metric that captures both premature mortality and the prevalence and severity of illnesses, disease burdens were calculated for 291 causes in 21 regions of the world (including 187 countries) for 1990, 2005, and 2010 to enable identification of significant trends over time.46 While the global DALYs remained stable from 1990 to 2010, the study identified a significant shift from communicable, maternal, neonatal, and nutritional causes of disease to | [
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Surgery_Schwartz_13601 | Surgery_Schwartz | trends over time.46 While the global DALYs remained stable from 1990 to 2010, the study identified a significant shift from communicable, maternal, neonatal, and nutritional causes of disease to noncommuni-cable causes (Fig. 49-7).47In 2015, the previous estimate by the second edition of Disease Control Priorities in 2006 of an 11% global surgical dis-ease burden was updated to 30%, obtained from provider-based survey data from the Lancet Commission.1,10 Using country-wide population surveys (the Surgeons OverSeas Assessment of Surgical Need Survey [SOSAS]) in Sierra Leone, Rwanda, and Nepal, the overall presence of surgically treatable condi-tions was 11.2%, with 25.6% of deaths potentially avoidable had surgical care been available. Applying these percentages to the 48 low-income countries, as defined by the World Bank, suggests that there are 288.2 million people currently living with surgically treatable conditions; providing improved access to surgical care could prevent 5.6 | Surgery_Schwartz. trends over time.46 While the global DALYs remained stable from 1990 to 2010, the study identified a significant shift from communicable, maternal, neonatal, and nutritional causes of disease to noncommuni-cable causes (Fig. 49-7).47In 2015, the previous estimate by the second edition of Disease Control Priorities in 2006 of an 11% global surgical dis-ease burden was updated to 30%, obtained from provider-based survey data from the Lancet Commission.1,10 Using country-wide population surveys (the Surgeons OverSeas Assessment of Surgical Need Survey [SOSAS]) in Sierra Leone, Rwanda, and Nepal, the overall presence of surgically treatable condi-tions was 11.2%, with 25.6% of deaths potentially avoidable had surgical care been available. Applying these percentages to the 48 low-income countries, as defined by the World Bank, suggests that there are 288.2 million people currently living with surgically treatable conditions; providing improved access to surgical care could prevent 5.6 | [
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