Life’s journey often takes us down unexpected paths. When I made the decision to apply to anesthesiology in medical school, I never imagined my future self working in oncology – attending tumor boards, performing nerve blocks, and leading goals-of-care conversations, sometimes all within in a single day. Most of all, I never anticipated experiencing the sense of inner fulfillment so early in my career – the feeling that stems from building meaningful longitudinal relationships with my patients and their families. Every day, I am humbled by the challenges that my patients face, not only dealing with the complex symptoms of their underlying disease and associated treatments, but the emotional and existential stress of living with, say, a cancer diagnosis and preparing for the multitude of unknowns along each step of the way.

“The perception that palliative care is synonymous with “comfort care” and withdrawing aggressive levels of care is incorrect. People are often surprised when palliative care teams are the ones who recommend treatment escalation or surgery for a patient. Palliative care, by definition, focuses on improving the quality of life of patients, their families, and their caregivers through managing complex symptoms and supporting the emotional and spiritual well-being of those diagnosed with serious illnesses.”

Prior to residency, I had no exposure to palliative care. I admit, as a medical student, I had a limited view of an anesthesiologist’s role as being confined to the OR. I am grateful to have trained at a place like Stanford University, where supportive leadership and encouraging mentorship allowed me to explore a path I was not even aware of. Residency training was rigorous, comprehensive, and unexpectedly eye-opening.

The misconception that palliative care is equivalent to hospice or end-of-life care is extremely common, surprisingly more so among nurses, physicians, and other health care providers than among patients and their family members (Am J Hosp Palliat Care 2018;35:431-9). For many anesthesiologists, our limited encounters with palliative care specialists frequently take place in the ICU with a dying patient. Alternatively, anesthesiologists are often asked to care for high-risk surgical patients in the OR, and when a bad outcome arises, the surgeon might suggest “consulting palliative care.”

The perception that palliative care is synonymous with “comfort care” and withdrawing aggressive levels of care is incorrect. People are often surprised when palliative care teams are the ones who recommend treatment escalation or surgery for a patient. Palliative care, by definition, focuses on improving the quality of life of patients, their families, and their caregivers through managing complex symptoms and supporting the emotional and spiritual well-being of those diagnosed with serious illnesses (J Pain Symptom Manage 2020;60:754-64). Palliative care specialists are adept at utilizing various communication techniques to elucidate patients’ goals and values, getting to the core of “what matters most.” Our role as patient advocates can thus include recommending invasive interventions to meet those desired goals, all while ensuring that patients and family members understand the associated risks. Importantly, palliative care enhances a patient’s current care and can be provided from the time of diagnosis, alongside any curative treatments. This is a clear distinction from hospice care or end-of-life care, where patients transition from curative treatments to focus only on symptom management. Hospice patients must also meet certain criteria, including a limited prognosis and estimated life expectancy of six months or less (Crit Care Med 2014;42:2418-28).

As my interest in palliative care grew throughout residency training, I became increasingly aware of patient populations coming to the OR where palliative medicine was intricately involved in their care. This not only included critically ill ICU patients and oncologic patients scheduled for debulking surgeries, but also complex cardiac, renal, and liver patients as well. For any patient with heart failure being considered for mechanical circulatory support (MCS), the Centers for Medicare & Medicaid Services and The Joint Commission require a palliative care specialist to be part of the multidisciplinary MCS team (AMA J Ethics 2019;21:E435-42). The American Society of Nephrology and American Gastroenterological Association have similarly proposed earlier integration of palliative care in advanced chronic kidney disease and end-stage liver disease, respectively, as patients often have palliative care needs from high symptom burden and functional decline well before the point of evaluation for transplant (Clin J Am Soc Nephrol 2019;14:635-41; Clin Gastroenterol Hepatol 2021;19:646-56.e3).

Anesthesiologists are uniquely positioned to provide a broad dimension of care for their patients in the health care system. Beyond the perioperative setting, anesthesiologists make great leaders in critical care, pain medicine, and palliative care. The nature of our job requires us to assess a situation and then integrate and synthesize a plan in a short amount of time. We also must gain the trust of complete strangers in times of high stress and vulnerability and allay their concerns and fears surrounding intense surgical experiences. It is easy to forget that anesthesiologists are one of the few physicians who see both within and beyond the OR doors. We have a rare insight into the perioperative world and can help patients understand the intricacies of the surgical process.

While on the surface, palliative care may seem like an unfamiliar term, I would argue that many OR anesthesiologists already integrate key aspects of primary palliative care in their everyday practice (J Multidiscip Healthc 2021;14:2719-30). Much of palliative care revolves around symptom management and patient communication. Managing acute postoperative pain, nausea, and delirium is already part of the daily repertoire of any anesthesiologist. Preoperative counseling and soothing patient anxiety are considered components of primary palliative care as well. There may also be patients with more complex physical and/or psychological symptomatology who would benefit from specialist palliative care, a subspecialized multidisciplinary team.

Palliative care was recognized by the Accreditation Council for Graduate Medical Education in 2006, with subspecialty boarding available since 2008. It is recognized by 10 specialty boarding organizations, including the American Board of Anesthesiology (ABA). However, it is still a relatively unknown subspecialty within anesthesiology. To provide some context, more than 8,500 subspecialty certificates were issued by the ABA in the past 10 years, from 2013 to 2023. The two most popular subspecialties were pediatric anesthesiology, with 4,300 certificates issued, and pain medicine, with 2,600 certificates issued. Only a total of 36 anesthesiologists became board-certified in hospice and palliative medicine over this same period (asamonitor.pub/4gfBAxK).

As treatment options for serious illnesses continue to advance, patients are now living longer. More patients are candidates for widely available minimally invasive procedures. While less invasive, many of these cases still require general anesthesia and its inherent risks. Anesthesiologists face increasingly challenging clinical scenarios with the growth of this population. These patients are often elderly and frail, with multiple serious medical comorbidities. They may have unclear existing health directives and complex family dynamics. Thus, there is a growing need for expertise in perioperative palliative care to help plan and optimally care for this high-risk surgical population.

As a specialty, anesthesiologists are well-positioned to contribute to the growing palliative care community, not only through sharing our breadth of knowledge in pharmacology, physiology, and interventional skills, but also by providing useful pre-, intra-, and postoperative knowledge for the overall surgical patient experience. There is tremendous leadership potential for perioperative palliative care anesthesiologists. Beyond providing a “good bedside manner,” a palliative care anesthesiologist can assess for frailty and provide high-quality family counseling around major risks of postoperative morbidity.

Most anesthesiologists are comfortable managing a symptomatic patient, even one with complex symptoms. A high level of comfort in pharmacology and physiology knowledge forms the foundation of our training. However, varying levels of discomfort may arise when asked to discuss other topics, including preferences for life-prolonging interventions and post-surgery level of care. Although training in palliative care communication skills have been increasingly incorporated into internal medicine residencies, we have not seen similar trends in anesthesiology residency curricula (J Palliat Med 2021;24:354-75). A rotation in palliative care should be required, or at least available, for all anesthesiology residents to gain exposure to palliative care principles. Even more importantly, we need stronger perioperative communication workshops, ideally led by specialist perioperative palliative care anesthesiologists. As you can imagine, perioperative language is very different from “breaking bad news” in an outpatient primary care clinic, which is the communication framework most often taught in medical school.

While there are relatively few palliative care-trained anesthesiologists compared to those trained in other subspecialties, I am grateful for those who have paved the way before me, providing me guidance as I carved my own path. The need for perioperative palliative care expertise will continue to grow. As a specialty, I hope more anesthesiologists are encouraged to seek out and embrace primary palliative care in their own practices so they can provide the best care for our ever-growing and changing surgical population.