Volume 168, December 2022, Pages 139-145Background

Neurosurgical conditions are often incurable and lead to disability, severe physical symptoms, and distress for patients and families. Neurosurgeons may be responsible for transitioning management from curative to palliative. We sought to analyze the ethics of transitioning care from curative to palliative in patients in one's own specialty.

Methods

This was a case-based narrative review. PubMed and Google Scholar were searched with no restrictions on date. Studies relevant to the topic were included.

Results

After providing an introductory case, we defined the curative and palliative neurosurgical treatment paradigms, clarified the concept of transition of care from curative to palliative, and contrasted generalist and specialist palliative care. Next, we provided an overview of core ethical principles. We then described key considerations involved in transitioning patients from curative to palliative care in one's own specialty, namely, knowledge, communication, uncertainty, and futility. Finally, we provided an analysis of the introductory case, highlighting the conflict of interest inherent in the transition.

Conclusions

It is acceptable for neurosurgeons and other specialists with adequate palliative care training to manage the transition to palliative care in most cases, preferably as part of multidisciplinary care teams. While we discuss the example of neurosurgery, this analysis applies to other specialties where care transitions from curative to palliative intent occur. Across specialties, patient preferences and values are foundational in the timing and specifics of this transition.

Introduction

Approximately 22.6 million patients worldwide experience neurological disorders or injuries that necessitate neurosurgical involvement each year, with 13.8 million requiring surgery.1 Although some neurosurgical conditions are curable in certain cases, other cases have no cure and lead to disability, severe physical symptoms, and distress for patients and families. Furthermore, initially curable conditions may progress to become incurable if treatment is not initiated in time or if they become refractory to treatment. Neurosurgeons may be responsible for transitioning management from curative to palliative. However, the associated ethical considerations have not been rigorously analyzed. In this article, we delineate core ethical principles involved in transitioning patients from curative to palliative care and key considerations during this transition. Although we use a neurosurgical example, these arguments can apply to many other specialties that may be involved in the transition from curative to palliative intent (e.g., cardiology, nephrology, oncology, respirology).

Section snippetsMaterials and Methods

This is a case-based narrative review. We present a neurosurgical case and then describe key ethical considerations.

Neurosurgical Treatment Paradigms

Most often, neurosurgeons perform surgery to minimize morbidity and mortality. Common examples of so-called curative intent are resecting meningiomas, clipping aneurysms, decompressing intracranial pressure in patients with traumatic brain injury, and decompressing spinal levels for patients with myelopathy or radiculopathy secondary to disc herniations. The term palliative is often used variably and improperly in neurosurgery to denote surgeries that are unexpected to eliminate the pathology

Conclusions

Neurosurgeons harness their knowledge, communication strategies, and understanding of uncertainty and futility to provide treatments that are likely to achieve the patient's goals while minimizing unwanted effects. Although neurosurgeons with adequate training in palliative care may be subject to bias while transitioning patients from curative to palliative care, it is generally ethically acceptable for them to manage the transition in most cases, preferably as part of multidisciplinary care

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