Optimal palliative decision making is facilitated through effective interactions among the patient, family members, and the surgeon via a dynamic relationship described by the palliative triangle. The three corners of the triangle are made up of the patient, the family, and the physician, and center of the triangle focuses on hope. Emphasis must be placed on those things that can realistically be delivered with the goal of providing the patient with a good quality of life, symptom resolution, technically superior palliative operations, dignity, and compassion [16] (Fig. 2).

The dynamics of the triangle allow the patients and families complaints, values, and goals to be considered against the known medical and surgical alternatives. Outcome data for palliative procedures are useful for the surgeon to be able to deliver accurate information to patients regarding chance of success, procedure-related durability, the possibility for complications, and anticipated survival. Anticipating, understanding, and addressing a patient’s and/or a family’s expectations about the intent of the proposed procedure are the vital aspects of the palliative triangle. The dynamics of the triangle help to moderate incongruent beliefs and guide the decision-making process toward the best possible choice for each individual patient. The palliative intent needs to be understood and explicitly agreed upon by everyone involved in the discussion. The strong relationship formed by the palliative triangle likely explains the observation of high patient satisfaction toward surgeons after palliative operations, even in patients having no demonstrable benefit from surgery and in those experiencing serious complications [5].

Patient selection is the key to performing palliative procedures on patients in order to successfully yield symptom relief at the end of life while minimizing operative morbidity and mortality [1]. A study performed at the Brown University examined the outcomes of patients managed with the palliative triangle method and evaluated the factors associated with effective patient selection. A palliative operation was performed in 106 patients or 46.0 % of patients. Complaints requiring palliative surgery included: gastrointestinal obstruction (35.8 %), local control of tumor-related symptoms (bleeding, pain, malodor) (25.5 %), jaundice (10.4 %), and other (perforation, fistula, or pulmonary/urological/neurological symptoms) (28.3 %). Of these 106 patients who underwent palliative surgery, 5 patients required procedures for recurrent symptoms and 6 for additional symptoms. One hundred and twenty-one patients (or 53.3 %) were not selected for a palliative procedure. The main reasons cited for not undergoing surgery were low symptom severity (23.9 %), decision for nonoperative palliation (19.0 %), patient preference (19.8 %), concerns about complications (15.7 %), and other (21.6 %). During the follow-up period, a palliative operation was later required in seven patients for worsening symptoms severity and in five patients for the development of significant new symptoms for a total of 129 palliative procedures performed. The results of the study revealed that patients selected for a palliative operation had better performance scores (Eastern Cooperative Oncology Group and National Cancer Institute fatigue scores) and nutritional status than those who had undergone nonoperative approach. Patient-reported symptom resolution or improvement was noted in 117 of 129 procedures (90.7 %), and this symptom relief occurred within 30 days after the operation. Palliative procedures were associated with 30-day postoperative morbidity (20.1 %) and mortality (3.9 %). Median survival was 212 days. Their research suggests that palliative operations performed on patients carefully selected by emphasizing the palliative triangle approach were associated with excellent results in terms of symptom resolution and morbidity [5]. In this study, typically either one or two meetings between the patient, family, and surgeon lasting 60–90 min took place before consensus on the appropriate palliative care intervention was achieved. This again highlights the complexity of the decision making involved in palliative procedures.

Palliative surgical treatment options are not right for every patient. Care must be individualized in a multidisciplinary manner, so that the most appropriate treatment option is chosen for each specific patient. Surgeons must be cautious never to promise an outcome that they cannot realistically expect to deliver. Recognizing those patients who are at (1) too high a risk for procedure-related complications or death or (2) those in whom a particular procedure is unlikely to provide a clear benefit is a key component to the triangle. Currently, there is no operative risk assessment tool available for patients undergoing palliative procedures. Vidri et al. looked at the data contained within the ACS-NSQIP database to evaluate its use for operative risk assessment in patients with advanced cancer. The study concluded that the data contained within ACS-NSQIP may provide results that approximate risk (morbidity and mortality outcomes at 30 days), but it lacked the critical information required to make sound decisions regarding palliative care. The authors recommend using this tool with caution, because more suitable outcome measures such as symptom relief, quality of life, pain control, cost effectiveness, and patient satisfaction, which are essential to adequately evaluate the success of a palliative operation, are not included within the data [9, 12, 17].

Excellent communication between providers, patients, and family is key to successful palliation, no matter whether surgery is performed or is not even offered [5]. Physicians’ communication skills are associated with important patient and physician outcomes including: patient satisfaction, patient participation in care and adjustment to illness, malpractice liability, and important clinical markers of health. When doctors communicate well with their patients, clinical problems are identified more accurately, patients are more satisfied with their care, treatment plans are more likely to be followed, feelings of distress and vulnerability are lessened, and patient’s well-being is improved [5]. At the end of life, patients and families seek well-developed communication and interpersonal skills from their physicians to guide them during this particularly vulnerable time [5].

While conversations regarding diagnoses, treatment options, and prognoses take place routinely between physicians and patients, effective communication between patients and physicians is often lacking. In a recent study, more than 20 % of patients felt they were told their cancer diagnosis in an impersonal manner, suggesting that many physicians are still unacquainted with or unskilled at good communication. In a significant number of patients, this communication in an impersonal manner was associated with a lack of understanding or a bad relationship with the physician and was cited as a reason for changing physicians [5, 18]. One explanation for this lack of communicative skill in physicians is that there is a shortage of training and literature on surgical palliation. Most surgical training programs have no curriculum to teach palliative care. The Brown University studied this problem by introducing a pilot curriculum in palliative surgical care to its general surgery residents. The program consisted of three 1-h sessions, which included group discussion, role-playing exercises, and instruction in advanced clinical decision making. Residents completed pretest, posttest, and 3-month follow-up surveys designed to measure the program’s success. Forty-seven general surgery residents from the Brown University participated. Most residents (94 %) had “discussed palliative care with a patient or patient’s family” in the past. Initially, 57 % of residents felt “comfortable speaking to patients and patients’ families about end-of-life issues,” whereas at posttest and at 3-month intervals, 80 % and 84 %, respectively, felt comfortable (p <0 .01). Few residents at pretest (9 %) thought that they had “received adequate training in palliation during residency,” but at posttest and at 3-month follow-up, 86 % and 84 % of residents agreed with this statement (p <0.01). All residents believed that “managing end-of-life issues is a valuable skill for surgeons.” Ninety-two percent of residents at 3-month follow-up “had been able to use the information learned in clinical practice.” The study concluded that with a reasonable time commitment, surgical residents are capable of learning about palliative and end-of-life care [19]. This practice should be put to use by all medical residencies.

A practical and effective technique for summarizing and simplifying medical communication is the context, listening, acknowledgment, strategy, and summary (CLASS) protocol of Buchman. Another approach is the setting, patient’s perception, invitation, knowledge, emotions, and strategy/summary (SPIKES) protocol, which is a variation of the CLASS protocol that focuses on communicating bad news with patients and families [5]. These techniques can be quickly and easily reviewed to help improve basic communication fundamentals. Incorporating communication skills to provide excellent perioperative palliative care into medical or surgical practice takes time, effort, experience, understanding, and compassion, but it has repeatedly proven to be essential for effective end-of-life care [5].

Palliative procedures play invaluable roles in patients with disseminated malignancy. With appropriate counseling and patient selection, symptom resolution can be achieved in as many as 80 % of patients [11–13, 20] The effect on patient outcome as determined by: resolution of chief complaints, quality-of-life control, and morbidity of therapy and resource utilization should predominate decisions regarding surgical palliative care [12, 13]. Currently, there is no specific clinical data regarding the use of palliative procedures to alleviate symptoms from specific disease processes such as advanced GIST. There is a continued need for high-quality descriptive research including prospective cohort studies, as well as randomized controlled trials to define optimal management strategies.

Investigators and clinicians face numerous barriers in conducting high-quality research in the palliative patient population. These barriers include lack of funding, difficulties in identifying eligible patients, and a variety of practical and methodological challenges of designing these studies. In addition, there are a variety of ethical challenges that arise in the design and conduct of studies of palliative intent, particularly in the conduct of clinical trials. The development of palliative care research has been challenged by a persistent uncertainty about the ethics of these studies. Many providers, institutional review boards, and investigators remain uncertain about the ethical limits of research involving dying patients. However, one should consider the ethical problems inherent in decisions not to conduct research. Accepting the current standard of evidence will expose future patients to unnecessary surgery and ineffective treatments. Therefore, it is critically important to address these ethical challenges carefully and to advance the current understanding and treatment options for palliative care patients [12, 21].

A prospective analysis of over 1000 consecutive palliative procedures at the Memorial Sloan Kettering Cancer Center thoroughly evaluated the outcomes of palliative procedures for all types of cancers. Patients with advanced GIST typically present with pain, bleeding, and obstruction; therefore, we will focus on the surgical treatment of symptoms associated with the gastrointestinal tract. Four hundred and five patients (out of 1022) underwent 516 palliative procedures performed for gastrointestinal symptoms, and 82 % of these patients reported symptom resolution after the palliative procedure. One hundred and fifty-one patients underwent 206 procedures for duodenal obstruction management, and 79 % of patients experienced symptom resolution. These patients underwent endoscopic dilatation/stenting (84 % reported symptom resolution), operative or endoscopic gastrostomy (72 % reported symptom resolution), gastrojejunostomy (75 % reported symptom resolution), and gastrectomy (100 % reported symptom resolution). One hundred and fifteen patients underwent 140 procedures for small and large bowel obstruction, and 90 % of the patients reported symptom resolution. These patients underwent small bowel resection/bypass (91 % reported symptom resolution), colonic resection/bypass (24 % reported symptom resolution), colostomy (100 % reported symptom resolution), endoscopic dilatation/stenting (100 % reported symptom resolution), ileostomy (70 % reported symptom resolution), and lysis of adhesions (80 % reported symptom resolution). Sixty-four patients underwent 69 procedures for jaundice, and 92 % of patients reported symptom resolution. These patients underwent endoscopic intervention (94 % reported symptom resolution) and operative biliary bypass (90 % reported symptom resolution). Forty patients underwent 44 procedures for poor nutrition, and 77 % of patients reported symptom resolution. These patients were treated with an endoscopic feeding tube (79 % reported symptom resolution) and operative feeding tube (67 % reported symptom resolution). Forty-five patients underwent 57 procedures for “other” complaints, and 58 % patients reported symptom resolution. These patients underwent endoscopic management for bleeding/anemia (67 % reported symptom resolution), operative management for bleeding/anemia (67 % reported symptom resolution), tumor debulking for pain (100 % reported symptom resolution), organ resection for pain (100 % reported symptom resolution), hernia repair for pain (100 % reported symptom resolution), operative management for fistula (10 % reported symptom resolution), endoscopic management for fistula (0 % reported symptom resolution), and other (33 % reported symptom resolution). All patients who experienced symptom relief did so within 30 days of the operation. There was no difference between endoscopic or operative procedures in the frequency of symptom resolution [22]. This study indicates that palliative procedures for almost all the gastrointestinal symptoms associated with advanced GIST can be successful. Interestingly, overall, it was shown that symptom resolution was achieved in 80 % of patients, although further interventions were required for new (25 %) or recurrent (25 %) symptoms. These procedures, however, were associated with significant morbidity (40 %) and mortality (10 %) and limited anticipated survival (approximately 6 months). They concluded that although predictable symptom relief following palliative procedures can be expected in carefully selected patients, recurrence or the development of additional symptoms limits the durability of the intervention [1, 22].