A 53-year-old with recurrent squamous cell carcinoma of the tongue s/p multiple resection, head and neck dissection, chemotherapy, and radiation presented to the hospital with difficulty managing secretions and impending respiratory failure. The patient was intubated shortly after admission using an awake fiberoptic technique and with ENT on standby for tracheostomy due to anatomy and tumor burden. Salvage chemotherapy and steroids were initiated. The patient failed multiple extubation attempts and subsequently went into cardiac arrest and eventually expired during airway management efforts after the last try.

This case illustrates how medical teams may be influenced by fixation on a hopeful outcome versus the worst case possibility. The hope for a successful extubation and the possible negative misperceptions of seeking palliative care may have influenced the team’s approach. Given the prognosis of the patient’s clinical condition, the final two patient-centric pathways could have been either a planned surgical airway or a controlled withdrawal of support in the event the patient would not tolerate extubation. The case demonstrated that there was an opportunity to improve the patient’s/patient surrogate’s understanding of the prognosis of the underlying illness, discuss potential risks and benefits of all treatment options, and review the patient’s desire for resuscitation. These are the underlying principles in a palliative care approach to high-risk surgical patients.

With greater advancements in therapeutic surgical treatments, anesthesiologists are increasingly faced with treating medically complex patients. Historically, the concept of palliative care seemed contradictory to the goals of surgical treatment aimed at cures. This is a misperception and may create barriers for patients to receive palliative care.

Complex surgical patients would strongly benefit from a palliative care approach due to their significant comorbidities and burdening symptoms in which surgical treatment may impact their quality of life. Despite the benefits associated with an early palliative care approach to surgical oncology patients, previous studies have demonstrated there is an underutilization of palliative care among these patients (J Clin Oncol 2009;27:3052-8). Recent Medicare data indicates one in three patients requires a surgical procedure a year before death (Lancet 2011;378:1408-13). Current literature suggests that the majority of surgical oncology patients were less likely to undergo palliative care consultations for symptom management compared to medical oncology patients (Lancet 2011;378:1408-13). In particular, one study found that, despite significant medical comorbidities and postoperative risk, only 3.4% of surgical patients received a palliative care consult (Jt Comm J Qual Patient Saf 2022;48:280-6).


The principles behind palliative care originated in the 1960s through hospice care. Modern-day applications of palliative care have evolved from end-of-life care to a patient-centered approach aimed at relieving suffering and improving the quality of life for the surgical patient. Since 2005, the American College of Surgeons has recognized a need to incorporate palliative care principles for the surgical patient throughout all disease stages (J Am Coll Surg 2020;231:179-85). These principles include:

  • Surgical palliative care focuses on relieving suffering and improving the quality of life for patients under surgical care
  • Care to enhance the quality of life is delivered with life-prolonging therapies
  • The unit of care includes the patient and family
  • Surgery or other interventions are considered based on the ability to meet the patient’s goals and are not limited by the ability to change disease trajectory
  • Prognostication includes morbidity, mortality, and patient-centered outcomes, such as quality of life, function, and independence
  • Surgical palliative care at the end of life should relieve suffering in physical, emotional, social, and spiritual domains, and may include surgery.

While there is a growing need for palliative care in hospitals, anesthesiologists can facilitate and incorporate palliative care principles for the management of surgical oncology patients.

Anesthesiologists are uniquely positioned to offer their experience and include palliative care principles through Perioperative Surgical Home principles. The recent concept of the Perioperative Surgical Home has similar principles in creating a multidisciplinary team, coordinating care, reducing complications, length of stay, and utilization of resources. These principles would include a multidisciplinary approach that incorporates risk mitigation, preoperative assessment, intraoperative considerations, and postoperative care planning. Cobert et al. suggested the Anesthesia-Guided Palliative Care in the Perioperative Surgical Home Model (Anesth Analg 2018;127:284-8). Risk calculators such as ACS-NSQIP, Revised Cardiac Risk Index (RCRI), American Geriatrics Society (AGS) frailty index, or postoperative respiratory distress calculator are used to identify patients who are high risk (Anesth Analg 2018;127:284-8). Patients demonstrating a high probability of postoperative complications or mortality, increased length of stay, or likelihood of discharge to a skilled nursing facility would then be referred. In their model, the anesthesia team reviews these aspects along with patient optimization. A subsequent multidisciplinary plan is then presented to the patient and family.

A palliative care approach is not successful unless the patient’s goals can be assessed and prognostic outcomes can be communicated effectively to the patient and their family. Utilizing a communication tool may guide anesthesiologists in incorporating palliative care principles in their preoperative assessment and discussion. One potential approach is utilizing the following mnemonic, DIGNI-T.

Anesthesiologists continue to manage more complex and high-risk surgical patients during the perioperative period. While advances in risk assessment and mitigation have improved, there continues to be an opportunity to offer a patient-centric approach. These benefits also offer the ability to reduce morbidity and mortality, length of stay, and costs. With surgical oncological patients, anesthesiologists can continue to serve as leaders of the Perioperative Surgical Home through the implementation of standardized protocols and include a palliative care approach in their risk assessment and plan. While surgical treatment may not alter the disease trajectory, the benefits of incorporating palliative care principles may offer enhanced quality of life to the patient. In addition, utilizing this approach may offer patient-centered treatment established through trust, continuity, and informed decision-making.