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Teachable Moment | Less Is More

Surgical Intervention in Terminal Illness—Doing Everything A Teachable Moment

Tyson A. Oberndorfer, MD, MS1; Debra L. Anoff, MD1; Heidi L. Wald, MD1
[+] Author Affiliations
1Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora
JAMA Intern Med. 2016;176(1):18-19. doi:10.1001/jamainternmed.2015.6335.
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This Teachable Moment describes the case of a man with metastatic masses in his brain who underwent surgery and died shortly thereafter and calls for more careful consideration of treatment options.

Article InformationCorresponding Author: Tyson A. Oberndorfer, MD, MS, Internal Medicine Residency Program, University of Colorado School of Medicine, 12631 E 17th Ave, B177, Aurora, CO 80045 (tyson.oberndorfer@ucdenver.edu).

Published Online: November 9, 2015. doi:10.1001/jamainternmed.2015.6335.

Conflict of Interest Disclosures: None reported.

Additional Contributions: We thank the family of the patient for granting permission to publish this information.

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The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
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When will we learn?
Posted on November 10, 2015
Patty Murphy, ANP
self
Conflict of Interest: None Declared
My mother died after two years in a vegetative state in 1978. She had an astrocytoma and was treated with a \"linear accelerator\" in 1976. At that time, not much thought had been given to the outcomes of our new therapies. I became a hospice nurse and later a nurse practitioner based on this difficult experience. She had been decorticate for 6 months due to damage to her brain from the resultant hydocephalous caused by scar tissue. Regardless, the surgeon placed a shunt, allowing her to live another two years until her tumor had become large enough to cause her death. I understand this was a new therapy but I had hoped that doing salvage surgery had become less pervasive. My disappointment in the inability of medicine to speak compassionately to families about the ultimate outcomes of excessive intervention continues. We must continue to be truthful to families and not err on the side of fear, when we know that the outcomes are detrimental to the patients who suffer and the families who are given false hope.
Importance of a check list
Posted on January 5, 2016
Andrea Semplicini
Department of Medicine, University of Padua, Italy
Conflict of Interest: None Declared
In my early practice as doctor and medical teacher, I used to find difficulties on how to address critical choices in patients like the one that has been described. The solution came after long lasting discussions with my collaborators and postdoc students.
I summarize the recommended approach to the patients and their family care givers according to the following check list:
1. Review the therapeutic choices according to guidelines and clinical judgment
2. Consider previous personal experience in patients like this, their clinical course, complications and outcome
3. Among the therapeutic possibilities, figure out what would be preferred for our beloved ones
4. Present that choice to the patient and his/her primary caregiver as the one that you would do for yourself and your beloved ones
5. Encourage the patient and family care givers to look for a second opinion, if they need it
6. Make explicit promise to take care of the patient and care givers after any kind of decision
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