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One of the authors once asked a great transplant surgeon what came to his mind when asked about palliative care. He had two answers: the first,was somewhat simplistic; the second was profound. He said that this type of service was helpful in the ICU when there was not much more to be done surgically for a patient who was dying; the second, was a story about an individual whom he had transplanted three times (who survived!) because he and his team did not want the patient and family to give up hope. The second answer is fundamentally more in keeping with the philosophy of palliative care, despite the extraordinary specific circumstances. The surgeon demonstrated ongoing presence and non abandonment. This patient was palliated, although few surgeons could have accomplished this by doing two retransplantations! Fortunately, for the less gifted and lucky, there are many ways in which to continue a meaningful presence to an ailing or dying patient on a transplant service that do not require a transplantation procedure. One wonders why palliative care and transplantation have not been more formally acquainted in the past given the extensive overlap of the populations served, the nature of the day-to-day problems, and the intensity of the commitment to the patient. The time is ripe for a formal mutual acquaintance between palliative care specialists and transplant teams,perhaps in the format of a work group that is similar to the work groups that promoted excellence in palliative care, such as the End Stage Renal Disease Workgroup, that were grant funded by the Robert Wood Johnson Foundation. The fields of transplantation and palliative care have a treasure trove of experience that is lacking in the other that could be exchanged profitably with a great sense of satisfaction for all.

Thomas R. Russell [49], Executive Director of the ACS pointed out ina recent editorial that the culture of surgery is changing and evolving, along with long-held values. He notes, "No longer is it 'my' patient, but it is 'our'patient." This shared responsibility for the surgical patient is not without peril, although this ethic has a positive application in the interdisciplinary model of palliative care. The principle of autonomy suggests that the patient, himself, shares some responsibility for a good QOL outcome. Although the focus of his remarks is fundamental change in residency training, his comments apply equally to the norms of surgical practice,especially palliative care: "We can start by building a sense of mutual respect for the broad range of individuals [including the patient and his family] involved in the care of our surgical patients, from nurses to allied health care professionals, from anesthesiologists to environmental service workers. As surgeons we must improve our communication and leadership skills, so these individuals will view us in a more positive light." Surgical palliative care is a philosophy of care that can answer this challenge. Surgeons have always been up to the challenges of their era. They never have disappointed those whom they serve in their degree of courage,practicality, and innovation, but the changing landscape of illness and culture offer new opportunities for other insights and strengths to emerge.