Episode 4: Surgical Palliative Care? Navigating Options and Providing Value-Concordant Care in High-Risk Emergency Surgery
PalliEM Podcast – Episode 4 – Surgical Palliative Care? Navigating Options and Providing Value-Concordant Care in High-Risk Emergency Surgery – Buddy Marterre, MD
Audio Editing Assistant: Cole Brandser
Transcription Editing Assistant: John Levi
Total Time: 34:15
patient, palliative care, surgeon, surgery, surgical, high risk, values, pathway, life, surgical patients, suffering, emergency, conversations, situations, preoperatively, emergency medicine, family, care, decision, surrogates
Justin Brooten, MD, Buddy Marterre, MD
Justin Brooten, MD 00:01
This is the PalliEM podcast, a production of palliEM.org at the intersection of palliative Emergency Medicine. I’m your host, Justin Brooten. Today I’m joined by Dr. Buddy Marterre. Dr. Marterre is one of the fewer than 80 physicians nationwide who is dual certified in surgery and hospice and palliative medicine. In addition to being a surgeon, he completed a Master of Divinity at Wake Forest University. He focuses on providing palliative care to surgical patients with life-threatening illnesses. He is a co-director of both the Wake Forest School of Medicine’s fourth-year medical student clinical clerkship in geriatrics and palliative care, as well as the third-year clerkship and surgery. He is a founding counselor of the surgical palliative care society. He was also recently invited to the Surgical Council on Resident Education editorial board, tasked with updating surgical palliative care learning goals for all the general surgery residents in the US. Buddy, thank you so much for joining me today.
Buddy Marterre, MD 00:58
Well, thank you, Justin, it’s, it’s a pleasure to be here.
Justin Brooten, MD 01:02
So Buddy, you have had a very unique journey in your role from being a surgeon to being a palliative care specialist who focuses on surgical patients, and also education. Tell us a little bit about your journey from becoming a surgeon to becoming a palliative care specialist.
Buddy Marterre, MD 01:18
Yeah, okay, thanks. That’s a great question. I’ve got the long answer or the short answer, I assume you’d rather have the short answer. So, I guess the short answer is, I’ve always been fascinated with death, which probably makes me kind of a weird guy. My father died when I was 16 years old, and I held his hand in the in the coronary care unit, as he died. And I’m sure that’s what sparked my interest in medicine. There are no other doctors in my family, or heritage. Unfortunately, I experienced a good two or three decades of complicated grief. But I think that’s what got me rolling. After becoming a surgeon. I started out in transplant surgery, but I wound up doing a lot of hepatobiliary pancreatic surgery, and therefore cancer surgery. And I just really got inspired by my dying cancer surgery patients. As they were facing death, they were just so brave, and they just had so much courage. And I mean, I really just literally was blown away and found that I enjoyed sitting at their bed sides, at least as much as I did, cutting their liver in half, or doing a Whipple on them or whatever. And found that that time spent with them, was not only challenging, but it was just extremely powerful. It was a very auspicious time, and have subsequently come to believe that caring for the dying is really one of the most powerful things that we can do in medicine or surgery.
Justin Brooten, MD 03:05
I really like your response and that’s so true. It’s interesting, you go into the medicine for various reasons. And being the doctor is really interesting, but I agree with you. It’s some of the most profound experiences I’ve had have been with, with patients as you watch them go on that journey. And it’s so profound just to be able to be an observer in those situations, let alone to take care of them. It has an impact on you that it’s hard to even put to words, but it’s just I really like hearing that hearing that perspective from you. So one thing that I find interesting is, and in our conversations that we’ve had, you’ve referred to surgery at times as being palliative. And that can sound like an oxymoron to many people in healthcare. How do these two concepts interconnect?
Buddy Marterre, MD 03:52
Well, yeah, I think you’re right, Justin. Many surgeons see surgery and palliative care as mutually exclusive, that you do everything that you can do surgically and technically for your patient. And when you’ve run out of technical options and you’re at the end of the road, then it’s time to call palliative. But, you know, it’s interesting. Palliative care, the father of palliative care is a surgeon, Balfour Mount, he’s a neurologic cancer surgeon in Canada. And he started palliative care in 1973. After visiting Dame Cicely Saunders in the United Kingdom, who had started the hospice movement, and he coined the term palliative care, which we still use today. He is the first recipient of the AAHPM’s [American Academy of Hospice and Palliative Medicine] Lifetime Achievement Award. And, interestingly, the most recent recipient of the AAHPM’s Lifetime Achievement Award is also a surgeon Geoff Dunn, who really brought palliative care to the fore with particularly the American College of Surgeons, and banded it around a group of interested surgeons who really got the ball rolling in America. That’s one of the misconceptions that we’re doing our best to overcome the concept that palliative care and surgery need to be mutually exclusive. I particularly like one of the models of palliative care that was introduced a couple of years ago called the bow-tie model. The left sided bow on the bow tie, if you will, are disease directed treatments. And the right sided bow of the bow tie is palliative care. And as you move from the left to the right, and disease directed treatments become less and less efficacious, or narrower in scope. Ideally, the palliative care portion or principles increase. Another misconception that we, you know, we’re constantly battling is that palliative care is to be equated with hospice or only end of life care. And nothing, as you know, could be could be farther from the truth, we’re perfectly happy taking care of patients that survive and have rehab and get better. So, in that bow tie model, the middle part of the bow tie is pain and symptom management. I think that’s another area that we can really have a positive impact with our surgical patients is to make sure that their pain is controlled, and that they’re not suffering really in any aspect of their humanity, be it physical suffering, psychological suffering, social suffering, or spiritual suffering. That’s probably going to keep my career going for the rest of my life is trying to overcome those misconceptions.
Justin Brooten, MD 07:23
And I can say that one of the things amongst your many other gifts, one of the things that you bring to our team at Wake, is you speak surgeon. And that goes a long way is that just having that ability to take those concepts and make them relevant to somebody who understands the surgical side of things, I think is so important to bridge that gap. So one thing that comes to mind that I’ve been interested in, that you work on, and I think it’s particularly relevant to people who present to the emergency department with acute surgical issues, is navigating high-risk surgery, or situations where surgery could be palliative, but it comes with risk. And you have a way of approaching that helps handle that complexity. Could you tell us more about that?
Buddy Marterre, MD 08:07
You know, it’s a tough question. When a when a patient presents to the emergency room with any sudden acute crisis that is unexpected, at least from the patient and the family’s perspective. And, you know, this is what you all in emergency medicine deal with all the time. Of course, it doesn’t just have to be a sudden, unexpected, acute surgical crisis. It could be a medical crisis of any form. And from the emergency department perspective, part of what makes that really tough, (and frankly, my hat is off to you all, I don’t know how you do it) you know, you have no relationship with the patient or the family. You have built no rapport, and they come in with an expectation, essentially, to be fixed. And of course, the emergency surgery patients are part of that. And as we know evidence-based medicine is phenomenal. And a lot of times we can fix them, so to speak. But a lot of times in emergency settings, as you well know and as you experience I’m sure every time you’re in the ED [Emergency Department], although there may be a portion of their overall problem that can be fixed, [you] can’t fix the big picture. And that’s really where we are in emergency surgery, be it emergency general surgery or emergency vascular surgery, or just a seemingly straightforward surgical problem. A patient that comes to the ED and they get their scan and uh-oh, there’s also undiagnosed, stage four cancer amidst the mix. And so these are just very, very challenging situations. And from my perspective, you know, there’s a little bit of a difference between trauma and emergency surgery. Because emergency surgery, a lot of times, you’ve got a day or two or three, or at least a few hours, where you can have a fairly in-depth conversation with the patient. Whereas, if they show up with, you know, certain traumatic injuries, those are truly emergent folks that have to go straight to the operating room. I think in those folks, the folks where you have some period of time, say, an hour or more, I think it behooves us all (and you all in the emergency department can get this ball rolling, but certainly the surgeon that’s consulted) to go down this path, as well. It behooves us all to elicit the patient’s values. And this is something that I tell all my learners at every level, avoid the word “want,” because it’s not about what they want. Unfortunately, the word “want” easily evokes unrealistic fear based wishes and short-circuits a good shared decision making process, which should be based, ideally, on their values, and some reflection on those values; not just a simple yes or no question or a binary choice. Do you want surgery? Do you not want surgery? That’s really a meaningless question. That frankly, I think does a lot of patients and families pretty deep injury.
Justin Brooten, MD 12:08
Yeah, that’s a good point. And when you ask people what they want, just like you said, you’re going to get a list of wishes. It takes out the idea of shared decision making where we really have to get into what are the potential outcomes of those of wants, or wishes, and what’s even feasible, medically. One of the situations that I think of where I feel like your approach is really helpful [is when] (a part of the problem, like you mentioned before, is we’re having to have these conversations, sometimes people we have, we’ve had no connection with them, we don’t have a rapport with them, maybe they’re really high risk to have a surgical intervention.) in my experience, a lot of times families are pressed with a really critical decision right away, like you mentioned, a life and death kind of decision. Do you want surgery? Do you not want surgery? Sometimes that backs them into a corner. With particularly the high risk surgery patients, the idea of surgery as potentially a treatment trial, I think could be foreign to a lot of people. But that’s one of those situations where maybe you can bridge that gap between somebody who (or their family) is not comfortable saying, “Well, let’s not intervene at all.” But they [the patient or family] also wouldn’t want to put the patient through, you know, unnecessary suffering, and you’re kind of having to straddle that line. So take a high risk surgery patient, how can surgery look like a treatment trial, where you’ve pre-negotiated a way to navigate outcomes?
Buddy Marterre, MD 13:33
Yeah, I think that’s a great question, Justin. Before we go to the treatment trial, or say wrapping a “Hail Mary” operation into a time-limited trial, I think one of the most important points here is that we try our best to educate our patients up-front and then involve them in the decision making in an informed consent system that, frankly, from an ethical standpoint, is outdated. There’s no way that we can educate our patients, particularly when they come in with an acute crisis situation and are experiencing tremendous existential angst. There are two centers in the country (University of Wisconsin and Harvard) that have transcripts of discussions between surgeons and patients and their family members. And a lot of these transcripts have been transcribed and analyzed with thematic analysis. And what we’ve learned from that is: “A” the patients are just terrified. They don’t have clear heads, don’t feel like they can participate in a shared decision. And “B” their values are rarely discerned preoperatively. Almost never frankly. Survivors of emergency surgery don’t recall ever having their goals or values questioned preoperatively. And see, almost uniformly, when patients choose surgery, they don’t feel like they have an option. They feel like they must choose surgery because from the patient perspective, choosing surgery is choosing life over death. And almost all human beings, at least in America, are going to choose life over death. But that’s not what they’re choosing. As you and I know, when they’re choosing a high risk surgery, they’re also placing themselves in the position of needing a lot of highly technical care in the intensive care unit postoperatively that is either life support or close to it. And they’re also potentially choosing pathways that are very incongruent with their values. Because most, most (and again, you know, you can’t apply population statistics to any given patient) say older patients with emergency general surgical problems would hate the thought of going to a skilled nursing facility. They hate the thought of burdening their loved ones. They hate the thought of tracheostomies and don’t even really understand invasive mechanical ventilation. And so, to the best of our ability to formulate a good shared decision making process preoperatively, we as surgeons need to elicit their values and their fears. And what I call non-negotiables. Non-negotiables are things like life support. Maybe you’re okay with life support for a time, but getting stuck on life support might be non-negotiable for you. Similarly, maybe you’re okay with a short-term sniff or a little bit of rehab, but getting stuck in a sniff might be a non-negotiable. Those types of trade-offs need to be discussed preoperatively. And then, the surgeon needs to take all the surgeon’s knowledge and all their risk calculations and the prognosis and the patient’s frailty and all of those things and realize what treatment options are out there. And then ultimately make a recommendation to the patient. Rather than ask them what they want, or rather than ask them, “Do you want surgery or not?” And so that’s a really tough process. And it’s particularly tough when the clock is running, you know, when they when they have free air. Where you’re contemplating maybe they have dead bowel, or something along those lines. But, again, I think if you have a period of time, say 45 minutes, maybe you call the OR [operating room] and you get them scheduled, but use whatever time you have, before they get there to elicit these values and do a really good shared decision making process that involves a patient-centered value-congruent recommendation. That’s the ideal.
Justin Brooten, MD 18:54
Yeah, I like the idea of: You’re preparing for what you need to do intervention wise, but you’re gathering that information in the interim, while that patient’s conscious and alert. I think even conversations with a family that occur before the intervention, you get such a different sense of what they would want or what they wouldn’t want done. Then after the fact when they’re on life support, and now you’re asking the family, “okay, well, things didn’t go the way we wanted, and they’re not coming off of life support. So now we need you to make a decision.” I feel like there’s a different set of stakes involved, when you’re asking them now after the fact then if you talked about it ahead of time.
Buddy Marterre, MD 19:32
Absolutely. Because at that point, everyone has bought into the concept of aggressive care. And sometimes that’s a good concept and that’s congruent with the patient’s values, but many times it’s not. And so you bring up another really good point, Justin, and that is: you need to have a surrogate decision maker, identified preoperatively and on board, preoperatively. All three parties on the triangle: surgeon, patient, surrogate decision maker need to be on the same page before that patient gets anesthetized, before they’re intubated, before they’re delirious. Because post-op, you can no longer have a, you know, a nuanced conversation about values. And so, another point that you bring up, that I think dovetails with the concept of time-limited trial of an operation that’s wrapped into a big time-limited trial, is in the high risk scenario. Even if your intent is curative, you need to have a contingency plan. You need to have some exit strategies, Plan “B”s, if you will. What if the surgery doesn’t go well? What if the patient [is] still on invasive mechanical ventilation, 96 hours post-op? We know we’ve got great data out there. Again, thanks to the Wisconsin program, we’ve got great data that says if you’re an older adult, you have an emergency surgical problem, and you’re intubated for four days post-op, things are not going to go well for you. Very few of that group of people will actually go home and be independent. So, you know, one way of thinking about it is to wrap the whole thing into a big time-limited trial and to say, “Okay, we’re going to do the Hail Mary, we’re going to go to the operating room, we’re going to do our best, we’re going to give you every benefit of the doubt postoperatively. But we know that if you’re still on a ventilator four days postop, given your clinical scenario, that we will end up going down a pathway that actually conflicts with your values. And it’s a pathway that you’re frankly most afraid of.” And so at four days post stop, (to continue with the metaphor) if the receiver drops the ball, or there’s an interception, with the Hail Mary, after four days, we’re going to proceed with a compassionate withdrawal of life support and say, We did our best.
Justin Brooten, MD 22:22
Yeah, and I appreciate like you said, you’re intense curative, but you have to have a contingency plan. And I think that’s hard for people to wrap their heads around that are used to doing interventions to try to save life. Is that acceptance of, I have to plan ahead for the “what if things don’t happen the way we want to,” because you don’t have control over what happens with that patient. Their organ systems are going to do what they’re going to do, even if they do get optimal care in the operating room. And planning ahead of time saves a lot of grief afterwards. I think when you and I have seen consults in the hospital, and they’re on, you know, week x of ICU hospitalization, that gets harder and harder each day the further down that road they’ve gone. So, I think that’s a great way to balance both of those issues of wanting to provide an intervention when that’s what the family and the patient are hoping for, but also planning for things that are frankly out of our control and not taking the patient, as you said, where they don’t want to go; where we put them where we’ve made their biggest fears a reality. So one question I have too, since our audiences is people who, you know, primarily work in the emergency setting, and have an interest in integrating palliative care in the emergency setting: how do we navigate as emergency providers, the care of acute surgical patients who are maybe high risk, where we’re working with maybe the surgical team that’s seeing them? And maybe they don’t see things the way you see them. They haven’t thought about these concepts before. What’s a way that we could maybe introduce some of those concepts to our patients or families or maybe surgeons we may see in the community when we’re referring patients to them when they need a surgeon evaluation, but we’re also concerned about the high risk outcome?
Buddy Marterre, MD 24:08
Yeah, wow. That’s, that’s a tough one. You know, I think all of us in medicine, when push comes to shove, we want to give every one of our patients the benefit of the doubt. Be that you know, if you’re in emergency medicine, be you’re intubating a person with a COPD exacerbation or putting chest tubes in or doing CPR, we all want to give our patients the benefit of the doubt. And yet, if we just keep having that overly optimistic, best case scenario, mentality, I think we cause a lot of suffering, particularly in these in these high risk situations. So, I think to the degree that you can, you need to lay out the patient’s overall big picture prognosis and do so in a very honest and truthful manner. That shows compassion, but you know, don’t pull any punches, don’t use euphemisms, and stay with the big picture. Try not to get stuck in the weeds. And that’s advice that I would give both you all in emergency medicine as well as surgeons. I think we’re all really good at getting stuck in the weeds. And it doesn’t take our patients or family members very long to get stuck in the weeds themselves. And then before you know it, they’re concentrating on things like BUN and creatinine, or oxygen saturation, or peak levels, or what have you. That, I think, does a lot of damage to our patients families, as does when we ask them, essentially, to pull the plug on their loved one. That just does a tremendous amount of damage. Our surrogates are already suffering from tremendous, psycho-spiritual burden when it comes to, you know, fighting for their loved one. And no one wants to say that, right? No one wants to say when it’s time to just let her go much less their spouse or their child or, heaven forbid, their parent. So I think we do a lot. I guess my general advice is, be really careful with what you’re doing, you know, don’t place that burden on the surrogates, do your planning upfront, make sure the surrogate understands the patient’s values, and fears and non-negotiables before they get put to sleep. And then, do the best that you can to introduce the concept of substituted judgment with those surrogates and say- I mean, you know this, because you’re, you know, you’re a great palliative care physician, in addition to being a great emergency medicine, Doc. But so many of us don’t know this, and how to introduce substituted judgment and say, “I’m not asking you to make a decision for your loved one, I am merely asking you to be your loved ones voice.” I can then take that information and make a recommendation. And then, you know, when we finally, in surgery, get to the recommendation, generally, it’s two paths, right? We’re going to the operating room, or we’re not. If we’re not going to the operating room in a high risk patient, we’re typically focusing on comfort. So, that’s the time for the patient education. Because you need (in order to have an ethical, informed consent process) to explain both pathways. And that’s the time when I would say, “I’m recommending…” And it doesn’t matter whether I’m recommending the comfort care pathway or the surgery pathway, I would say something like, “based on what you’ve told me, based on what’s most important to you, and then I understand that to be x, y and z, I am recommending this pathway.” And then, maybe there needs to be some deliberation there, because maybe you don’t understand their values that great. So, maybe they need to push back on you. And then you need to say, “Oh, well help me to understand your values better, because I thought I heard you say this” or “I thought I heard you say that.” Ultimately, you wind up with one pathway that you’re recommending, but you need to discuss the other pathway. And you need to say something like, “the reason I’m not recommending the other pathway is this, this and this. And those things would clearly go against who you are as a person and not honor you as a person.” And maybe “they’re very undignified” or maybe “there’s more pain and suffering there than you’re willing to bear.” But for whatever reasons, contextualize it for the patient, rather than try to do the patient education up front and get them to help you make your difficult decision. Really, these decisions need to be made by us. But they need to be based on the patient and the patient’s values. It still needs to be very patient centered. That’s what makes it shared. It’s not shared, if we just lay out all the information and say do you want surgery or not?
Justin Brooten, MD 30:01
Yep, that’s absolutely true. And I like what you said about, you need to tell them not just what you’re recommending, but also why certain other routes of care would go against it. Because I think we assume that patients and families can read between the lines, but they’re bombarded with so much information, they really need a practical assessment of what the outcomes could look like, under with various decisions made. And I think that, like you said, they look at surgery as, here’s a lifesaving option, but that comes with a price. And that price needs to line up with what they’re willing to accept in other areas. So I think that’s a great way to put it.
Buddy Marterre, MD 30:40
Right. So what I, what I can’t tell you is how to do your job, you know, when [chuckles] (because I’ve heard you say before) I’ve got the laryngoscope in one hand, and I’ve got my palliative care communication skills in the other.
Justin Brooten, MD 30:55
Yeah, no, it’s true. And actually, I’d say for the most part, I would say that I haven’t encountered situations (I mean, probably sometimes) where me being proactive on the palliative care side, when I’m concerned that an aggressive approach is not going to be consistent with the patients or families ultimate wishes, you know, not wanting to impose my own judgment, but really working with what’s important to them. Just recently, I had a situation where I was helping another provider and it was a high risk surgical candidate that would need transfer from a community hospital I was at. And I had a long discussion with two of the patient’s family members on the phone because the patient wasn’t able to have that conversation. And established that even though the prognosis wasn’t great that they wanted to pursue any avenues that were life prolonging. And when the other provider was calling the tertiary center on the other end and talking to that surgeon. Yeah, actually, they wanted to know that. They actually [wanted to know] did anybody talk to this family about how sick this person is. So, it wasn’t viewed as a “don’t meddle with my plan” it was viewed as a “if you’re sending this patient, I want them to know how sick they are ahead of time, because we may or may not even be able to solve this problem.” So, that was actually fairly well received. So, I think there’s definitely times where, you know, I’ve bumped heads with somebody else when we’ve looked at it differently. But I don’t think that those conversations have necessarily been… they haven’t been desired by the specialist on the other end, when we all mutually agree, you know, do what you need to do for the patient, but they’re high risk.
Buddy Marterre, MD 32:30
Right? Yeah. So I think I love the fact that you say it’s wrong for us (we all realize that it’s wrong for us) to impose our values. But it’s just as wrong for us to impose our fears of powerlessness to fix the problem, when the problem is not fixable. And I think it’s just as wrong for us, and perhaps even maybe worse, to march down the aggressive road without focusing on our patients as a person. What makes them tick? Who are they as a human being? You know, Sir William Osler, said, I’m going to mess this up. But he said something like, “it’s not the disease your patient has. Rather we need to focus on the person that the disease has.”
[“The good physician treats the disease; the great physician treats the patient who has the disease.” – Dr. William Osler]
Justin Brooten, MD 33:23
Well, buddy, thank you so much for talking with me. I just really feel like this has been a highly educational session. And I think that the insights that you’ve presented on how we can better address these issues, when we see patients like this in the emergency room will be really helpful. So, thank you for what you’re doing, not just to educate us, but also to educate the young generation of surgeons and medical students that need to learn these communication skills and these approaches to care that all of our patients need when they’re really in distress. So thank you so much.
Buddy Marterre, MD 33:51
You’re welcome, Justin. it is my honor and really appreciate being invited to your show.
Justin Brooten, MD 33:59
For more information on current topics, in the fields of palliative and emergency medicine, please visit PalliEM.org
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