The following letter was written in response to the article by Dr. Thomas Marzili, entitled “What’s Going to Happen to Brave Surgeons and Patients?”

Dear Dr. Marzili, I just read your essay in the April Pharmacy and Therapeutics. I enjoyed the article. As a surgeon who is often asked to take on such difficult cases, I can tell you the decision-making process is never easy.

The American College of Surgeons has been more proactive of late in the ethics of palliation and end-of-life care. Many surgeons are slowly realizing that much so-called palliation is, in reality, futile care given to assuage the consciences of the patient, family, and physician. Simple procedures, such as gastrostomy tubes, may cause temporary pain but allow the patient to avoid the suffering of starvation. Procedures of medium complexity, such as dialysis access, may stabilize a patient’s condition briefly so that he can complete end-of-life preparation. Major surgical procedures, such as extensive tumor excisions, may make us feel better because “we did what we could,” but they often result in painful prolonged postoperative care and may easily result in permanent loss of independence and enjoyment of what time remains. canadian pharmacy viagra

I think that you would agree that the outcome for your patient could have easily been a surgical catastrophe. Despite your patient’s declaration of indifference to death during surgery, the surgeon was most likely not interested in becoming an accomplice in euthanasia. Major surgery is painful and traumatic. Wounds must heal, physiology must recover, and infections must be avoided. All this is difficult in a compromised patient (as with a malignancy). In fact, your patient could have easily ended up with pneumonia, a bronchopleu-ral fistula, ventilator dependence, or the like, resulting in a prolonged hospital stay with all the attendant suffering that goes with it. I am certain he was willing to die; was he willing to suffer and not die? I don’t pretend to know the right answer.

For many physicians, a “cure” is the only goal of any treatment. When one is reasonably certain that cure is not possible, the continued use of curative therapy, especially if painful or morbid, should be questioned. In my opinion, palliative surgery should primarily be used to relieve existing or anticipated physical suffering. In your patient’s case, if the surgery that was done had no real likelihood of significantly improving the quantity or quality of his life, then the surgery had no benefit for him but did entail all the risk of such a procedure. If one can only break even or lose, why play the game?
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I congratulate you on the care you gave this unfortunate man. I can tell by the tone of your article that you did the right thing by him and I trust he has continued to thrive. Thank you once again for the courage to address this subject. I believe that more physicians need to become aware of end-of-life issues so that we can have a more proactive voice in the relief of suffering.