title: Does regional variation impact decision-making in the management and palliation of pancreatic head adenocarcinoma? Results from an international survey.
abstract: BACKGROUND
  Management and palliation of pancreatic head adenocarcinoma is challenging. End-of-life decision-making is a variable process involving multiple factors.
  
  
  METHODS
  We conducted a qualitative, physician-based, 40-question international survey characterizing the impact of medical, religious, social, training and system factors on care.
  
  
  RESULTS
  A total of 258 international clinicians completed the survey. Respondents were typically fellowship-trained (78%), with a mean of 16 years' experience in a university-affiliated (93%) hepato-pancreato-biliary group (96%) practice. Most (91%) believed resection is potentially curative. Most patients were discussed preoperatively by multidisciplinary teams (94%) and medical assessment clinics (68%), but rarely critical care (21%). Intraoperative surgical palliation included double bypass or no intervention for locally advanced nonresectable tumours (41% and 49% v. 14% and 85%, respectively, for patients with hepatic metastases). Postoperative admission to the intensive care unit was frequent (58%). Severe postoperative complications were often treated with aggressive cardiopulmonary resuscitation, intubation and critical care (96%), with no defined time points for futility (74%). Admitting surgeons guided most end-of-life decisions (97%). Formal medical futility laws were rarely available (26%). Insurance status did not alter treatment (97%) or palliation (95%) in non-universal care regions. Clinician experience, regional culture and training background impacted treatment (all p < 0.05).
  
  
  CONCLUSIONS
  Despite remarkable overall agreement, geographic and training differences are evident in the treatment and palliation of pancreatic head adenocarcinoma.
authors.affiliation: The Department of Surgery, University of Calgary, Calgary, Alta.
authors.forename: Valerie
authors.initials: V
authors.lastname: Hurdle
authors.affiliation: The Department of Surgery, Laval University, Quebec City, Que.
authors.forename: Jean-Francois
authors.initials: JF
authors.lastname: Ouellet
authors.affiliation: The Department of Surgery, University of Calgary, Calgary, Alta.
authors.forename: Elijah
authors.initials: E
authors.lastname: Dixon
authors.affiliation: The Department of Surgery, Community Health Network, Indianapolis, Ind..
authors.forename: Thomas J
authors.initials: TJ
authors.lastname: Howard
authors.affiliation: The Department of Surgery, Harvard University, Massachusetts General Hospital, Boston, Mass.
authors.forename: Keith D
authors.initials: KD
authors.lastname: Lillemoe
authors.affiliation: The Department of Surgery, University of Pennsylvania, Philadelphia, PA.
authors.forename: Charles M
authors.initials: CM
authors.lastname: Vollmer
authors.affiliation: The Department of Surgery, University of Calgary, Calgary, Alta.
authors.forename: Francis R
authors.initials: FR
authors.lastname: Sutherland
authors.affiliation: The Department of Surgery, University of Calgary, Calgary, Alta.
authors.forename: Chad G
authors.initials: CG
authors.lastname: Ball
mesh_terms: D000230:Adenocarcinoma / Q000628:therapy*; D000349:Africa; D001291:Attitude of Health Personnel; D002170:Canada; D003466:Cultural Characteristics; D003657:Decision Making; D005060:Europe; D019538:Health Care Surveys; D006801:Humans; D018447:Medical Futility / Q000331:legislation & jurisprudence; D010166:Palliative Care; D010190:Pancreatic Neoplasms / Q000628:therapy*; D016577:Pancreaticoduodenectomy; D011182:Postoperative Care / Q000379:methods; D017410:Practice Guidelines as Topic; D010818:Practice Patterns, Physicians' / Q000706:statistics & numerical data*; D011300:Preoperative Care / Q000379:methods; D036301:Qualitative Research; D012068:Religion and Medicine; D013727:Terminal Care; D014481:United States