Introduction

Advances in modern medicine and medical interventions throughout the 20th century have substantially contributed to increased life expectancy in Australia and New Zealand.1  As people live longer, technical innovation advances and more life sustaining treatments are introduced, the inevitable human experience of dying will continue to evolve.

Experiences for individuals reaching the end of their life differ considerably depending on several factors, including the pathway to death.1  End of life care is commonly associated with experiences of chronic and progressive decline in health and function associated with older age, rather than sudden death.1

People are ‘approaching the end of life’ when they are likely to die within the next 12 months.1  End of life care includes the physical, spiritual and psychosocial assessment, care and treatment delivered by healthcare professionals, including the support of families and carers, and care of the patient’s body after their death.1 Palliative care is an approach to treatment, which improves the quality of life of patients and their families facing life-limiting illness, primarily through the prevention and relief of suffering.1

Key words

End of life care, life-limiting illness, palliative care, palliative surgery, advance care planning, advance care directives (ACD), surgical intervention, euthanasia, Voluntary Assisted Dying (VAD)

Summary of RACS position

The Royal Australasian College of Surgeons (RACS) is committed to excellence in all areas of clinical practice and encourages medical practitioners, health services and governments to actively consider policy and practice which contributes to high quality end of life care.  RACS does not have a position on euthanasia or Voluntary Assisted Dying (VAD).

Surgeons often play an important role in end of life care process, helping to relieve suffering and support the quality of life for patients approaching the end of their life.  RACS will continue to educate and support surgeons in the multidisciplinary end of life care environment.  RACS affirms:

  • Patients should be provided with the means to make informed choices regarding their treatment, and where appropriate, plan for the end of their life
  • Patients and their carers should be supported to develop realistic expectations of surgery, its objectives and potential outcomes in an end of life care context
  • Patients should be strongly encouraged to develop Advance Care Directives (ACD)
  • Surgeons and other healthcare professionals should honour the wishes of the patient as expressed in an ACD

Palliative care

Palliative care is a multidisciplinary specialty which aims to relieve suffering and support quality of life for patients and their families.2  The role of the surgeon regularly intersects with those of intensive care, services for the elderly and palliative care physicians.

RACS supports the rights of patients facing life-limiting illness to receive palliative care. Surgeons have a responsibility to ensure patients are provided with appropriate, timely and high quality palliation, to relieve suffering where possible.  This may include palliative surgery, which are interventions by surgeons for the relief of problems associated with all incurable illness.3  In some cases, surgical intervention will be appropriate for critically ill and high-risk patients to improve a patient’s medical condition.  The provision of appropriate pain relief to alleviate symptoms and reduce suffering in patients facing life-limiting illnesses is consistent with a principled approach to end of life care.

RACS recognises the provision of palliative care for the primary purpose of pain relief or to alleviate symptoms may occasionally hasten the death of a patient. In accordance with the position under the law, RACS does not recognise any circumstances where palliative care may be used for the primary purpose of bringing about or accelerating the death of a patient.

Low efficacy surgical intervention

The decision to pursue a surgical intervention often requires multidisciplinary team input and careful evaluation of risks and expected outcomes. Surgeons exercise professional judgement on a case by case basis to determine whether an intervention will improve a patient’s medical condition or be of little benefit.  In some cases, surgical intervention is futile or will not improve the quantity or quality of life of the patient.   

A decision to withhold a surgical intervention can be difficult for all involved, and compounded by differing views regarding the benefits of an intervention.  Where surgeons determine procedures will be futile or of a low efficacy to a patient, patients should be provided with information about alternative treatment options. Patients, families and carers should be equipped with necessary information to make informed choices as to whether to proceed with a surgical intervention or treatment.

Advance care planning in the surgical context

Advance care planning is a way for patients to communicate their wishes in situations where they may be unable to give informed consent. Patients can express their expectations about future medical treatment should certain situations arise. RACS strongly encourages patients to develop ACDs, which can benefit all patients. An ACD provides a patient with a means of communicating their beliefs, values and goals, and guides surgeons, patients and carers when deciding how to proceed in any given situation.  Physician-patient discussions should also be ongoing to ensure ACDs are modified to best reflect a patient’s wishes at any given point in time. 

In practice, not all eventualities can be predicted or discussed with a patient prior to the development of an illness or situation, which may require surgery. As well, surgical intervention may result in a period of increased risk and expected transient or permanent deterioration in patient function.  On occasion, an ACD may conflict with the care required for a successful outcome of surgery, such as when a patient has chosen not to undergo intubation and ventilation. In many cases surgery is undertaken with the understanding patients will accept an increased level of circulatory or respiratory support where this would not normally be the case. Surgeons, anaesthetists and intensivists should be mindful of this when discussing advance care planning in the perioperative context, and when determining patient’s wishes in unexpected but potentially salvageable deterioration in the immediate postoperative period.

References

  1.  Australian Institute of Health and Welfare. Australia’s Health: End-of-life care. Australian Government. 2016; 5(199): 1-12. From: https://www.aihw.gov.au/getmedia/68ed1246-886e-43ff- af35-d52db9a9600c/ah16-6-18-end-of-life-care.pdf.aspx.
  2.  Lilley EJ, Cooper Z, Schwarze ML, Mosenthal AC. Palliative Care in Surgery. Annals of Surgery. 2018; 267(1): 66-72. doi: 10.1097/SLA.0000000000002253
  3.  Dunn GP, Johnson AG. Surgical Palliative Care. Oxford Scholarship Online. 2011: doi: 10.1093/acprof:oso/9780198510000.001.0001.
  4.  Australian and New Zealand Intensive Care Society (ANZICS). ANZICS Statement on Care and Decision-Making at the End of Life for the Critically Ill [Internet]. 2014. From: https://www.clinicalguidelines.gov.au/portal/2434/anzics-statement-care-and-decision-making-end-life-critically-ill.
  5. Royal Australasian College of Physicians. Improving Care at the End of Life [Internet]. 2016. From: https://www.racp.edu.au/advocacy/policy-and-advocacy-priorities/end-of-life.
  6. Australian Commission on Safety and Quality in Health Care. National Consensus Statement: essential elements for safe and high-quality end-of-life care [Internet]. 2015. From: https://www.safetyandquality.gov.au/publications-and-resources/resource-library/national-consensus-statement-essential-elements-safe-and-high-quality-end-life-care.
  7. Australian and New Zealand Society of Palliative Medicine (ANZSPM). Position Statement Quality end of life care. Part 1: Essential elements for quality, safety and appropriate clinical care at the end of life [Internet]. 2014. From: http://www.anzspm.org.au/c/anzspm?a=da&did=1005077.