The Surgical clinics of North America
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Palliative care for the critically ill has become an increasingly important component of care in the SICU. As the population ages, medical technology continues to offer new treatments that can prolong life, and more and more Americans die in the hospital in critical care settings, the appropriate management of the end-of-life must be part of the clinical expertise of surgeons and intensivists. ⋯ Attention to the principles of good pain management, communication with patient and family, and discussion of goals of care are not just for patients who are at the end-of-life, but are appropriate care for all critically ill patients, regardless of prognosis. In this framework, "intensive care"encompasses palliative and curative care.
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The primary intent of surgical procedures traditionally has been the achievement of cure. Palliative surgery is emerging as an equally legitimate strategy of care; its goals are symptom relief and enhanced quality of life based on the patient's preferences. The key to successful palliative surgery is understanding patient and family dynamics, interdisciplinary team approaches, and producing a consistent and rational treatment plan. Far from condemning a patient, palliative surgery has a potential place in many treatment plans for enhanced quality of life and longevity.
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The perceived risk of legal liability looms large as a major barrier to optimal palliative care among surgeons. Aggressive pain management may cause respiratory depression and death, whereas withdrawal of support may lead to a charge of manslaughter. Citing legal principles and precedents, this article explains why there is legal support for terminal analgesia and sedation, balanced chronic pain management, and effective surgeon-patient communication in the setting of good surgical palliative care.
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Morbid obesity has reached epidemic proportions in the United States. Laparoscopic gastric bypass is rapidly becoming the procedure of choice for treatment of morbid obesity. ⋯ Outcomes are similar to open gastric bypass,but with markedly lower incidences of wound-related and cardiopulmonary complications. Patients also have shorter hospital stay, decreased pain and faster recovery.