Palliative care: A surgical perspective

Theword “palliative” is derived from the Latinword “pallium,” referring to the woolen cloak used as an ecclesiastical vestment in the Roman Catholic Church and for many centuries bestowed by the pope as a symbol of the jurisdiction he delegated to them. Similarly, the Latin verb “palliare”means “to cloak,” even if this coverage is not intended to hide something but to protect and provide comfort from an offensive agent (https://www.merriam-webster.com/dictionary/palliative). That is more of the meaning intended today, where palliative care refers to the specialty of providing peoplewith relief—comfort—from the symptoms and stress of a serious illness. According to the World Health Organization, palliative care is “an approach that improves the quality of life of patients, both adults and children, and their families who are facing problems associated with life-threatening illness.”1 Perhaps nowhere is the focus on palliative care as complex and challenging as in the field of pediatric oncology. Despite survival rates that have consistently improved in recent decades, 15-20% of children with malignancies still die from their disease.2 A recent paper by Kaye et al3 acknowledges advances in palliative care in pediatric oncology settings over the last 10 years, even if debate remains over the role of early access to such care in terms of quality of life and the role of various members of the care team— medical and surgical—in the palliative care process. In fact, pediatric surgeons often can have a primary role in ensuring that their patients experience the highest standard of palliative care theymay require. This obligation is reflected in theDeclarationofPediatric Surgeons made in 2001 by the World Federation of Associations of Pediatric Surgeons4 and clearly affirmed 4 years later in the statement of principles of palliative care by the American College of Surgeons, which asserted that “the control of suffering is of equal importance to the cure of disease” and “the surgeon is positioned to take a leadership role in advocating for palliative care for all patients.”5 But how do pediatric surgeons practically live up to these obligations to our oncology patients given that surgery often is considered an aggressive treatment not generally eligible for palliative care plans? We do so by recognizing that our overriding goal is to provide the best quality of life for the longest period possible, or a better one for patients in the future, through care aimed at comforting our patients even if we cannot always cure them. The surgeon must recognize that pediatric oncology patients may pose unique challenges, as palliation may be a consideration early in the treatment process, when a tumor is unresectable and minimally invasive procedures may be indicated as the first step along a long and difficult road. On the other hand, for terminally ill patients, surgeons must try to anticipate the needs of the child over whatever period of time for which they provide care, helping the family and sometimes the patient understand the risks and benefits of any further surgical options.6 Shelton and Jackson emphasize these concepts, stating that “even when operations are not part of the palliative care plan, surgeons can offer their presence, which may provide comfort to the family,” since a “surgeon’s expertise at communicating risks and benefits can be invaluable in discussions regarding the plan of care for patients with life-limiting illness, whether surgical candidates or not.”7 Together with other caregivers, then, pediatric surgeonsmust aim to protect and cover, like the ancient palliumdid, terminally ill children as themost appropriate clinical course for them. This can apply broadly but ismost important in situationswhere the risk of harms overweighs potential benefits of surgery. Indeed, surgical palliation should not be considered as a single step but as a structured path through different stages over the course of the disease—at diagnosis, during treatment, and, of course, at the end of life when the goal is optimal symptom control aimed at achieving the most significant quality of life possible.8 In this context, surgeons may face different clinical situations, including the following: