Symptom management Pain Chronic postoperative pain syndromes Malignant neoplastic cancer syndromes Geriatric pain syndromes Pain in the surgical intensive care unit Posttraumatic pain syndromes Vascular pain syndromes

Symptom management and palliative medicine have gained growing interest among physicians and other health care providers. One reason might be the profound shift in patient demographics and associated diseases. What was once a formidable condition, such as an acute coronary occlusion, for the most part follows a straightforward clinical protocol today with interventional cardiology and cardiac procedures. Sudden death from acute myocardial events among people in their sixth or seventh decade has become relatively uncommon. Instead, the elderly population is chronically plagued by heart failure, a condition present in nearly every other person more than 85 years of age. In the younger population of 65 to 74 years of age, advanced cancer has surpassed heart disease as the most frequently cited cause of death. We live in a rapidly aging society; 78% of people in the United States will live past their 65th birthday. Congestive heart failure, advanced cancer, stroke, and dementia—the four formidable chronic morbidities—all share one common characteristic. There is no cure for their underlying disease process. Most current treatment modalities aim for disease control and symptom palliation rather than cure in the strict sense. Surgeons might wonder how palliative care fits into their surgical practice. This might be because of the surgical myth that the principal role of the surgeon is to cure the patient and the business of palliation is deemed best relegated to the nonsurgeons. But the presumed delineation between cure and palliation is becoming increasingly blurred because of the underlying patient demographics and associated disease processes that are fundamentally incurable, at least from today’s vantage point. In the end, it might be more constructive to consider the role of palliative care in surgery in terms of specific patient-oriented clinical outcomes, rather than in terms of the elusive cure versus palliation. In addition to survival, examples of patient-oriented clinical outcomes include functional status; relief from symptoms such as pain, dyspnea, and cachexia; and emotional and psychological well-being—all of which contribute to quality of life. In the aforementioned context, there is a need to define what palliative surgery is, and what a palliative surgeon is. Palliative surgery is not to be construed as a type of surgery exclusive of any intent to cure. When cure is possible, palliative surgery is inclusive of curative intervention. In addition, palliative surgery does not connote any degree of diminishment or retrenchment of care. If anything, palliative surgery might provide more aggressive care, recognizing the value of medical, procedural, or other interventions leading to symptom relief and enhanced quality of life. Symptom palliation might even result in increased patient survival, whether or not cure is possible in the traditional sense. What distinguishes palliative surgery is the palliative surgeon’s expansion of clinical outcomes beyond surgical morbidity or mortality outcomes and recurrence of disease to include outcomes that are meaningful to the patient. Palliative surgeons acknowledge that death can be a natural and expected outcome of an advanced disease process, such as cancer and systemic atherosclerotic disease. They aim to set appropriate goals of care and to offer other clinical services for the total care of the patient and family. For most patients with advancing atherosclerotic disease, malignancy, and dementia, relief from debilitating symptoms and quality of life might be just as or more important than the number of years lived. A concenNo competing interests declared.