Surgical Palliative Care and the Power of Stories

by Dr. Red Hoffman

“There are three deaths.  The first is when the body ceases to function.  The second is when the body is consigned to the grave.  The third is that moment, sometime in the future, when your name is spoken for the last time.”   – David M. Eagleman, Sum: Forty Tales from the Afterlives

When I was nineteen years old, my father was murdered by a terrorist in Cairo, Egypt.   His death – sudden, violent and surrounded by what was then a “weird” set of circumstances  – left me feeling not only heartbroken but extremely isolated. All I wanted to do was tell stories about my dad, but at nineteen I lacked both the insight to entirely process my emotions as well as the language to fully express them.  Somehow, blurting out, “My dad was shot in the head by a terrorist” seemed to shut down any opportunity for story-telling.

I have no doubt that my father’s murder – and the urge to share his story – led me to where I am today.  I attended medical school in Oregon, the first state to legalize Death with Dignity and the birthplace of the Physician Order for Life-Sustaining Treatment(POLST)) form.  Palliative medicine was well-integrated throughout my education and I was able to complete an elective month with the palliative care team.  One of the best skills I learned – and still utilize today – is how to walk into a room full of devastated individuals and encourage them to start telling me stories about their loved one.  I am still amazed by the energetic shift in the room that occurs when families start talking; suddenly it’s as if the patient, who is often intubated and sedated, is now sitting amongst us. Through these stories, I am able to learn what is truly important to this patient, what makes him “tick” and what makes her life “worth living.”  This then allows me to guide families when they are called upon to make difficult decisions on behalf of their loved ones who can no longer speak for themselves.

Surgeons have a rich history when it comes to the practice of palliative medicine.  Few know that the term palliative care was actually coined by a surgeon, Dr. Balfour Mount, in 1972.  Members of the American College of Surgeons have been discussing and researching the intersection of palliative medicine and surgery since at least 1997.   Since 2008, board-eligible surgeons (and surgical residents, after completing three years of residency), can apply for a spot in a Hospice and Palliative Medicine fellowship.  As of 2016, 72 surgeons have passed the Hospice and Palliative Medicine Certifying Exam.

All of us as surgeons are well positioned to provide primary palliative care, defined as those clinical competencies required of all physicians, including, basic symptom management, routine discussions about code status and goals of care and managing the transition to hospice care.  While these skills may not be specifically integrated into your residency curriculum, many of them can be learned through observation and practice. I encourage all learners to pay attention to the attendings who perform these skills well and to carve time out of your day to attend family meetings when you consult the palliative medicine team.   Further, the American College of Surgeons provides a free online comprehensive guide to Surgical Palliative Care.  

While many may think  that surgery and palliative medicine seem at odds with one another, I counter that the two disciplines actually complement each other well.  Armed with our primary palliative care skills, we never have to say, “there is nothing else we can do for you.” Instead, we can honestly say, “while there is nothing more we can offer surgically, we can now shift our focus towards comfort and quality of life.”  This enables us to truly honor the ethical concept of patient non-abandonment; just because we are done operating does not mean we have to be done caring about, or for, the patient. Third, taking the time to inquire about a patient’s life story will likely improve your history taking in general, a skill that is often overlooked when we get busy.  And lastly, truly listening to a patient’s life story may very well offer you a moment of joy and levity during an otherwise hectic and overwhelming day. I can assure you that it will also bring a sense of joy to the family, the same sense of joy I feel when sharing stories about my dad.

 

Dr. Red Hoffman began her career as a naturopathic physician and a yoga teacher.  She is now a board-certified general surgeon with additional training and certification in both Surgical Critical Care and Hospice and Palliative Medicine.  Her clinical interests are in surgical palliative care, physician wellness and medical education. She participates in the American College of Surgeons and currently serves as the Vice-Chair of the Communications Committee for the Resident and Associate Society (RAS) as well as the RAS liaison to the Physician Competency and Health Workgroup of the ACS Board of Governors.  She is also an active and proud member of the Eastern Association of Trauma’s Online Education Committee. Dr. Hoffman works as an acute care surgeon at Mission Hospital in Asheville, North Carolina, picks up occasional (never enough time!) hospice shifts at the John F. Keever Solace Center and was recently named as the co-director of the surgical clerkship for the University of North Carolina Asheville campus.  She is blessed with two naughty cats and an absolutely amazing boyfriend. She is happy to chat with or mentor anyone who is interested in palliative care. You can follow her on Twitter: @redmdnd.

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