LAUSR

In a study1 of the more than 1⋅8 million elderly Medicare beneficiaries, approximately one-third (31⋅9 per cent) underwent an inpatient surgical procedure during their last year of life, and nearly one in five (18⋅3 per cent) had a procedure in their last month. Considering only patients with advanced cancer, one in four (25⋅0 per cent) underwent an inpatient surgical procedure in the year before death. It is estimated that 20 per cent of the National Health Service budget in the UK is spent on care in the last year of life. Although interventions at the end of life (EoL) may be valuable, they may cause unnecessary suffering and waste resource. Surgery for cancer in the last year of life is now recognized as a potential indicator of poor EoL care2. It is critical that surgeons make good decisions with patients about invasive procedures at the EoL. Surgical decision-making at the EoL is about when and how to operate (or not), and about when to refer for supportive and palliative care. Surgical patients receive less hospice or palliative care than their medical counterparts3. This is despite data showing that giving frail patients the opportunity to be referred to palliative care lowers uptake of surgery4, and that advance care planning, a hallmark of good palliative care, is associated with less time spent in hospital in the last year of life5. Conversely, aggressive care of patients with nonbeneficial treatment is associated with worse quality of life and poor bereavement outcomes for loved ones6. Conducting potentially nonbeneficial operations has been attributed to different prognostic estimates among surgeons, inadequate perceptions about postoperative quality of life and the role of palliative care, a lack of preparation for EoL conversations, and time constraints7. In addition, it was found that sometimes surgeons performed operations they knew would not benefit the patient to give the family time to come to terms with the patient’s demise7. The rescue culture inherent in surgery and death denial can result in the medicalization of death. Atul Gawande, surgeon, author and public health figure, describes a need to ‘understand that damage is greatest if all you do is battle to the bitter end’8. The Lancet Commission on the Value of Death9 is investigating these embedded cultural and healthcare questions, and palliative surgery and non-beneficial treatment are under scrutiny. One study10 of elective surgery found that, before major surgery, 13 per cent of patients could not recall the procedure to be performed, its indications, risks or alternatives, and 33 per cent of patients reported that the decision to proceed with surgery did not address their preferences, values or goals. This clearly raises concern about the quality of shared decision-making before surgery and increases the risk of non-beneficial treatment. A good surgical death requires clear communication to understand patients’ goals of care, and timely and appropriate referral to supportive and palliative care services, when appropriate. There has been limited research on the value of palliative procedures, and there is little evidence about the effect of integrating early palliative care with major surgery. Practice is therefore inconsistent and inequitable. Better care involves improved communication with patients and loved ones, and includes: optimal timing of shared decision-making, better evidence about outcomes for surgical patients approaching the EoL, timely referral to palliative care and, most importantly, culture change to recognize that providing good palliative care is sometimes the best thing to do. It is unclear how best to educate surgeons to talk about death and improve shared decision-making. Suggestions specific to surgical or oncology patients include: using the best case–worst case surgical communication framework11, serious illness conversation training and system change12, sharing decisionmaking with other specialties through the perioperative surgical home13, and use of a multidisciplinary team approach. A specific emphasis on preoperative palliative care consultations is suggested as a means of avoiding non-beneficial or overly-aggressive care, aligning care decisions with patients’ values, and weighing the quality-of-life implications of significant surgery more holistically14. The preoperative phase may be fraught owing to an emergency presentation, or a patient lacking capacity with relatives uncertain of the patient’s wishes. Advance care plans are increasingly being recognized as key to optimizing patient-centred care and reducing