Malignant tumor has become one of the biggest killers of people’s health in our country. It and cardiovascular diseases have become two major difficulties in medicine. At present, there are about 1.5 million new cancer cases and 800,000 deaths from cancer in China every year on average. Due to the limitation of diagnosis and the imbalance of economic development in China, many cancer patients are already in advanced stage when they come to the hospital. At this time, palliative care is very important. Most of the patients admitted to general surgery departments of most hospitals in China are oncology patients. A large number of these oncology patients are faced with the option of palliative care. How do general surgeons choose the most suitable treatment for advanced tumor patients? How to prevent over treatment? How can surgeons choose the best treatment when there are many treatment options available? Under the impact of the current commodity economy, how do surgeons deal with the conflict of interest in palliative oncology treatment? How can the wishes and rights of patients in palliative cancer care be effectively protected by law? Have the mental health factors of patients in tumor palliative care been considered? These are the questions that we surgeons should seriously think about. Reasonable and scientific surgical decision is the most important factor in treating advanced tumor patients. 1, clinical assessment of malignant tumor and the concept of palliative treatment Palliative treatment (palliative treatment) refers to the effective overall treatment given to patients in the process of disease progression. It includes the treatment of pain and other symptoms and psychological prevention. In foreign countries, palliative treatment for oncology is usually provided by special physicians who are specially trained for this purpose. In China, surgeons actually encounter oncology patients who need palliative care from time to time. Proper management of patients who need to receive palliative care should begin with a proper assessment of their condition. Internationally, the evaluation of palliative care is usually performed with reference to the ECOG method commonly used in clinical practice. Table 1 WHO recommended Eastern Cooperative Oncology Group (ECOG) physical status score for oncology patients 0 able to perform all activities, asymptomatic 1 slightly symptomatic, unable to perform heavy physical activities 2 self-care, less than 50% of time in bed 3 poor self-care, more than 50% of time in bed 4 completely unable to care for themselves, completely in bed Some cancer cures or long-term control is impossible, so the goal of palliative care is To achieve: alleviate symptoms, improve quality of life and prolong life. The means include chemotherapy, radiotherapy, surgery, Chinese herbal medicine, biological therapy, etc., only the dose, intensity and mode used are different. Symptom control is the general principle of palliative care. For example, for pain, according to the location (visceral or bone), cause (direct tumor compression, invasion or metastasis) and patient’s physical condition (physical strength classification), palliative chemotherapy, radiotherapy and pain medication can be used to achieve the purpose of tumor control and pain relief. Another example is the dyspnea caused by lung cancer, if it is caused by the tumor and the patient’s physical condition is good (ECOG classification 0-1, part 2), palliative chemotherapy can be used. Therefore, the World Health Organization has expanded the definition of palliative care, which means “many palliative care measures and tools that can be used in combination with anti-cancer treatment (surgery, radiotherapy, chemotherapy) in the early stages of the disease to alleviate and treat cancer-related symptoms and signs, so that all cancer patients can receive adequate pain-free treatment”, so palliative care is Palliative care is a more humane and comprehensive service and treatment. Palliative care related to surgeons should include: (1) procedures to relieve patients’ pain, such as intraoperative local injections to relieve patients’ posterior back pain in advanced pancreatic cancer, and procedures to reduce the pain of tumor patients by cutting the associated innervated nerves. (2) Palliative resection of various obstructive gastrointestinal tumors with metastases: short-circuit surgery for advanced tumor intestinal obstruction, Hartmann surgery for low rectal cancer when the tumor is fixed and cannot be removed, and distal rectal closure to prepare for further radiotherapy. (3) Surgery to change the patient’s survival status: such as surgery for jejunostomy in advanced gastric cancer patients, although it does not change the patient’s regression, it can change the patient’s nutritional status. 2, what is surgical decision-making “decision-making” (Decision-making) means to make a decision or choice. So far, the definition of the concept of decision-making no less than a hundred kinds, but still has not formed a unified view, many definitions are summarized, there are basically the following three understandings: First, the decision is seen as a process that includes raising questions, establishing goals, design and selection of options. This is a broad understanding. Second, the decision is seen as the final choice from several alternative courses of action, the decision maker’s final decision. This is a narrow understanding. The third is to consider decision making as a decision to deal with an eventuality that occurs under uncertainty. Such events have neither precedents nor laws to follow, and the choice is made at a certain risk. In other words, a decision is only a choice that involves a certain amount of risk. This is the narrowest understanding of the concept of decision making. Generally speaking, scientific decision-making includes the following three aspects: ① the implementation of scientific decision-making procedures; ② the use of scientific decision-making techniques; ③ scientific thinking methods to make decisions. Modern scientific decision-making relies on detailed analysis and calculation by experts of consulting organizations and the use of decision support systems. Scientific decision-making process can be generally divided into 8 stages: ①discovery of the problem; ②determination of goals; ③value criteria (evaluation indicators); ④development of the program; ⑤analysis and evaluation; ⑥program selection; ⑦test verification; ⑧universal implementation. Not all the tasks in the scientific decision-making process need to be done by the leader himself. Most of the work can be delegated to experts from consulting organizations. Surgical decision making usually refers to the methods that surgeons are prepared to use for practical problems that they often encounter in their clinical activity, especially when there are multiple options available, and how surgeons choose these methods. Most of the surgeons’ decisions are based on their own clinical experience, the book knowledge they have acquired and the teachings of their predecessors. They have personally experienced numerous clinical cases during their long clinical activities and have laid a solid foundation for their own growth. However, for surgeons, because of the differences in their own upbringing, opportunities, etc., and especially the process by which they acquire knowledge, surgeons’ decisions are significantly different. Different decisions are of crucial importance for patient care. Thus, for patients with advanced malignancies, what surgeons can do is to alleviate the patient’s suffering through surgery or other methods. But we fully estimate the patient’s condition before the proposed surgical method, whether it is acceptable for surgical operation. 3, surgeons face conflicts of interest Under the influence of the tide of the commodity economy, in the rapid development of the global economy today, surgeons around the world are faced with conflicts of interest (interests conflict). This is a real problem that surgeons can not ignore. When faced with a patient who needs palliative care, such as a patient with progressive gastric cancer with multiple lymph node metastases in the abdomen and ascites. As a rule, the outcome of such a patient is not good and the ECOG score does not meet the conditions for surgery. However, due to limited availability of patients and economic accounting interests of the department, some surgeons may perform exploratory surgery on the patient. The patient does not have an obstruction, so they perform a short-circuit procedure and explain to the patient that it is a “prophylactic diversion procedure”. There are many examples of this. Such a patient undergoes a major surgery, suffers a huge financial loss, and receives no benefit from the procedure. Doctors facing such patients should put the patient’s interests first. The current treatment of hepatocellular carcinoma is unsatisfactory. There are also many treatment methods. In fact, many hospitals are treating hepatocellular carcinoma in several departments. However, due to the current system in China, the cooperation among various departments is insufficient. It is very common for liver cancer patients to be treated by whoever encounters them first. However, the treatment of liver cancer has its own industry standard, which type of patients should be operated first, and which type of patients should not be operated immediately and should be treated with other treatments first. Should doctors of various disciplines, including surgeons, put aside their own interests from the patients and consider how to get the best standardized treatment for the patients first? This is also a question of medical ethics. The American College of Surgeons takes an oath of office at the time of membership, and the first item in the oath is: “I pledge to always put the interests and authority of my patients first in my surgical practice. Pledge to always consider the patient’s position in the handling of each patient…” indicating that our surgeons should put the interests of the patient first. This is a guideline that surgeons must follow. 4. Ethical issues in palliative care The ethics (ethics) framework includes four aspects: (1) respect for autonomy, (2) helpfulness, (3) harmlessness, and (4) impartiality. Our doctors should pay high attention to ethics. With the rapid development of our economy, laws and regulations have been gradually improved. Citizens’ awareness of law and ethics has been increasing day by day. More and more ethical issues will be faced in palliative care. Our surgeons are usually very busy and they seldom have time to seriously consider the ethical issues. For example, in solid tumor treatment, we face a lot of ethical issues in the application of new technologies. Especially the use of some new drugs. The subjective desire of the physician is to do what is best for the patient, but there are ethical issues that need to be discussed. Any new technology that we want to carry out on human beings has to be approved by the medical ethics committee (ethic committee) first. This is a legal issue. Some doctors complain that we are trying to do everything we can for our patients, but the law is the law. Therefore, surgeons should pay attention to the appropriate ethical issues in the practice of medicine. Another doctrinal issue related to the surgeon’s profession is informed consent (inform concent ). We surgeons need to obtain the patient’s informed consent for any treatment that we use, and sign an informed consent form. This is because to go against the patient’s subjective wishes is to disrespect the patient’s rights. Surgeons must be aware of these important issues of ethics. Practicing medicine according to the law is a prerequisite for our work. If we do not have the appropriate legal concepts and make decisions simply out of plain emotion, it is the most common mistake made in surgical decision making. We should always remember; is any of the treatments we use beneficial to the patient? Does it cause harm to the patient? Does the patient fully understand the treatment and accept it? 5.How to communicate with patients with advanced tumor Patients with advanced tumor, especially those in palliative care, are physically and mentally exhausted due to the long-term torment of tumor. We often hear surgeons say: we are doing it for his good, but he is too uncomprehending. Some data show that patients with advanced tumor have more or less various psychological problems. Our surgeons should understand that our patients are mentally devastated by the torture of disease, physical and mental exhaustion, family disintegration, financial burden and a series of other problems. Today, the American College of Surgeons and American universities have special courses on how to communicate with patients, teaching doctors to understand and empathize with their patients and teaching them to communicate effectively with their patients. The Columbia University medical student curriculum includes a course on “How to break bad news? The core of communication with the terminally ill is “we have a solution”. Give the patient hope. It is important to understand the patient’s main problems and to listen patiently. The main method of communication with the patient is usually to follow the C-L-A-S-S principle: C – CONTEXT; the atmosphere of the conversation is very important. Surgeons should be prepared, fully understand the patient’s condition, find a quiet environment to show respect for the patient. l-listening (LISTENING SKILLS) in the conversation, we should give the patient sufficient time to state, to have patience to listen; A-emotions (ACKNOWLEDGE EMOTIONS): emotions are more important, we communicate with the heart to the patient is This can not only change the mutual distrust between doctors and patients, but also reduce the occurrence of doctor-patient disputes; S – countermeasures (MANAGEMENT STRATEGY): countermeasures for palliative patients is the center of our conversation, we must fully explain the patient’s current situation, we have to take a variety of treatments to give the patient confidence; S – SUMMARY (SUMMARY): summarize the important content in the conversation, briefly describe our attitude towards palliative care method of choice will make the patient feel safe. 6, palliative care in surgical decision-making to follow the principles of evidence-based medicine Modern medicine has developed to the stage of evidence-based medicine. Surgeons facing patients who need palliative care have to keep learning. By all means, learn about the latest treatment methods available today for the disease. The evidence based medicine approach to treatment gives clinical surgeons options that they can rely on. Surgeons need to carefully collect evidence-based medicine from a professional perspective to guide our surgical decisions. Surgeons have good medical knowledge, evidence-based medicine, conflict of interest and communication with patients, and ethical and legal considerations in palliative oncology care. The right decisions in surgery are made as a result. It is our patients who should benefit from this. The emphasis on training in surgical decision making in palliative care will certainly improve the quality of our surgeons.