This week-end, I stumbled upon a story written by “BuckEye Surgeon” (Jeffrey Parks), a general surgeon in Cleveland, Ohio that I found provocative. Parks wrote the post back in 2007, but it’s just as relevant today as it was then.
The piece, which is titled “No Chance” describes how and why Buckeye operated on a patient who he knew had no hope of surviving. Whether or not this patient had an operation, he was going to die. The post raises medical ethical questions, and reminds us that in the messy reality of hospitals—where human beings are suffering and dying—the answers are not always so clear-cut. I think BuckEye surgeon was brave to tell this story and that he tells it very well. Did he do the right thing? I’m not a surgeon, so I’m not going to try to second-guess the physicians who read this blog. But I would say, from a patient’s point of view, if I (or a loved one), had been the patient, I would be glad that Buckeye did what he did—for the reasons that he gives. But I suspect I may not be in the majority on this one. Click here to read the post.
What do you think?
Health Beat by Maggie Mahar
I am somewhat confused by the reasoning used for going ahead with the surgery, although I understand that the patient wanted this heroic attempt performed. But as to a more painless death, there is not any mention of what ocurred after the surgical procedure. If the patient awoke from surgery and is aware of what is going on, then it seems little has been accomplished other than to provide another billable procedure for Medicare and place him under sedation for a brief time. If he was kept sedated after his procedure and allowed to slip away from a septic death, then I guess the surgery provided the opportunity to make the patient unresponsive and not allow him to direct his treatment from that point, and allowed his physicians to ease his journey out. So what transpired after the surgery is the critical detail that is left out.
It also highlights the different approaches of surgeons vs cognitve physicians. Surgeons tend to lean toward practicing their surgical craft, and the details of how options were presented to the patient may have made him feel his only option was surgery. What about a hospice option with aggressive use of analgesics and sedatives? Would that not have provided a pain free death? Did the surgeon clearly explain that this patients chances were close to zero of surviving this catastrophy? Did he tell this patient what his life might be like even if he did survive with little of his intestinal track left (unlikely to eat ever again and likely requiring IV hyperalimentation for the rest of his life)?
I am not sure if I was involved that I would have advised that he have the operation. I would relent if the patient was clearly aware of his dire situation and was presented this other option, but it is not clear this was discussed. With other options to control the pain and discomfort, that leaves the surgeons only reasoning to be to practice for future potential use of this procedure. But I think if we allow ourselves to use this reasoning, we have entered a very slippery slope to justifying alot of medically unnecessary procedures in the hopes that our skills attained will benefit someone at some later point in time. That one is a hard sell to me.
In the near future surgeries of this type will not be allowed.
Expensive- check, Ineffective- check
Questionable benefit-Check
And you come down on the side of operation? At least you are er, consistent?
God forbid the guy would 65 healthy and want a knee replacement. You would rather give him some exercises, tylenol and send him to a jedi mind trick focus group, so he doesn’t think he feels the arthitis. Anything to keep from paying for a joint replacement, but you are OK paying for THIS?
So I guess the consistentcy is you are OK with a procedure:
1) If it is completely futile.
2) It’s an abortion.
How often do you think this procedure would be performed under these circumstances in Canada, Western Europe, Japan or Australia? My guess is NEVER. While it’s admittedly a difficult conversation, I think an honest leveling with the patient would have been in order here.
This was an awful case. I’m not sure I would have handled it the same way now, in retrospect, but the difficulty of the choice had little to do with the “cognitve/procedural” dichotomy Mr Sarpolis would have us believe. I spend a great deal of time thinking about the management of my patients. Most general surgeons do. Slotting physicians into “cognitive” vs “procedural” categories is a lazy, demeaning form of discourse.
As for the patient in question. The guy literally looked fantastic. He was only 65 years old or thereabouts. He lacked that sense of “impending doom” that we see in patients in extremis. In a word, he looked salvageable. I was very honest with him. I told him he would surely not survive the night if we did nothing. An operation, if successful, and by successful I mean restoration of blood flow to his bowels before gangrene had set in, even in ideal circumstances, he stood only a 10-20% chance of making it. He was informed of anticipated lengthy ICU time on a vent. He was told about ostomies and TPN dependence. He nodded his head, thought for minute or two…. and said to go for it.
What do you do? It’s easy now to say i wasted resources and subjected the poor guy to an unnecessary operation. But in this case, I held on to a small sliver hope. My gestalt impression was that he just might have a chance. Listen, I’ve counseled hospice/palliative care on plenty of other patients…
For what it’s worth I had an even older guy show up in my ER a few weeks ago with an elevated lactate and a CT scan that showed almost as much portal venous gas as this case. But again, the guy just sort of “looked” OK. I explored him. I found a dead cecum and did a quick right colectomy. He’s now in rehab, eating and ambulating on his own.
It’s a tough game we play. Monday morning quarterbacking is easy to do from afar, but it’s different when youre in the trenches…
And just to clarify: in the linked blog post, I write about “practice” as a reason to do the surgery. My intent going into the surgery was not to “practice” on the patient. What I meant is that once I got inside and identified an unsalvageable situation, I proceeded with a Mattox maneuver anyway, exposing the abdominal aortic branches. It added 6 minutes to the case and gave me valuable experience. I’ve performed the Mattox maneuver (with a confidence perhaps gleaned from this case) on three other patients since then; all to salutary effect…
Buckeye,
I did not mean to make such a “lazy” statement or frame the argument as cognitive vs procedural. But certainly the swirling debate in medicine is the plethora of incentives that exist to do procedures, many of which are fully acknowledged to be inappropriate. In this framework, it is not very insightful of surgeons and other providers to not acknowledge the perverse payment incentives that exist in medicine and lead to our overuse of the most expensive and invasive techniques we have availible. If you can explain the wide disparities in procedural use highlighted in the Dartmouth studies and the fact that current studies are starting to show higher costs and poorer results in regions where specialists are in high numbers and primary care physicians are less plentiful, then I would be willing to reconsider my position. Also where was this patients primary care physician when this was all taking place? I would think that the physician who best knew this man would have some input and influence in his decision.
Buckeye,
In my business we don’t consider it ethical to charge clients for learning things or for activity that doesn’t add value.
How about you? What personal income did you receive for this?
Sarpolis-
Those are good points, but not entirely relevant to the specific case presented. I was the only doctor involved in the case. He didn’t have a primary physician. And to imply that I performed the surgery for financial reasons is about the most insulting thing I have ever heard. It was after midnight and he didn’t even have insurance.
I understand that you have an agenda that you want to promote. I’m a proponent of limiting unnecessary interventions myself. (see: http://ohiosurgery.blogspot.com/2009/06/microcosm.html) But this case isn’t the appropriate forum for that. This wasn’t an elective knee replacement on an ambulatory 55 yo male. It wasn’t an MRI ordered for back pain. It wasn’t a needless EGD on a lady with known GERD who had been scoped twice in the past 12 months already. It wasn’t a 95 yo lady on a vent in the ICU. This case was about the endgame decision making on a relatively young, mentally fit patient who had very little chance either way. It was a judgement call. Doctors still have to make those from time to time, you know. We’re not always going to be right. But we try to learn from our actions, regardless of the final outcomes. it’s the only way to get better…
Apparently empathy only applies to supreme court justices. I, for one, am glad you went through with it.
Richard-
I would encourage you to actually read the original post and my subsequent replies in this forum.
As an internist and (former) nephrologist, I have a couple of questions.
You say the patient had no primary care physician, but he must have had a nephrologist who for the most part acts as PCP for these patients. Was s/he contacted and did s/he have input?
Second, you say the patient looked fantastic, and yet the degree of atherosclerotic disease you describe had to have been everywhere in his vascular system–not just in his bowel. Did he have any cardiac disease or peripheral vascular disease.
Finally, a couple of observations. I know how difficult it is to withhold a treatment that you think has only a very small chance of succeeding, if it is the patient’s only chance at survival. But if you know that this patient will not survive surgery–and in this case, that’s a very realistic assessment–it is ethical to present surgery even as an option? Here you are, operating on a hypotensive, possibly septic diaysis patient who likely has severe CAD on top of it. Horrible disease, horrible surgical risk.
I guess my experience with such cases is that the surgeon throws up his/her hands, and the nephrologist is left to explain to the family and patient how the endgame works out. It is really, really difficult.
BTW, I’m surprised he was uninsured. How did that happen? IIRC all ESRD patients are eligible for Medicare within 3 months of starting on dialysis.
I pulled the chart, to review the details. (This case was from 2 years ago.) The patient presented with acute renal failure, but wasn’t on chronic dialysis. (I change things when I write about cases, for obvious reasons). He didn’t see a regular doctor. He smoked a ton but didn’t take any medicines regularly.
Everything else is pretty accurate. The CT showed a bleak picture. As a 1st year attending, you could make a strong argument that perhaps I was overly aggressive. But I wasn’t entirely convinced at the time. Most patients with this degree of infarcted bowel show up on three pressors and look like pure hell. This guy didn’t. And again, I discharged another guy to a rehab facility a few weeks ago who had presented with portal venous gas from an infarcted cecum.
In retrospect, given what I’ve learned over the past few years, I probably would have done things differently. Call it ethics, call it experience. These aren’t easy cases. There’s no algorith in the textbooks for a lot of the complicated patients we see. I welcome the criticism though—otherwise I wouldnt blog about it…
Butheye–Teplying to your most recent comment–
Thank you for taking this thread so seriously.
I cross-posted your original post because I thought that, as you say in this comment,”These aren’t easy cases. There’s no algorith in the textbooks for a lot of the complicated patients we see.”
I’m not a physician, but I know just enough from having talked to many doctors, and having read books like Gawande’s “Complications: A Surgeon’s Notes ON An Imperfect Science” that
in real life, medicine is much, more more ambiguous than most laymen assume,
As a result, a great many of the choices doctors msut make lie in the very grey areas of medical evidence –and medical ethics.
For what it’s worth, I’m not convinced that the decision you made a few years ago wss any better than the decision that you, as a more experienced surgeon, would make today.
My guess is that, by virtue of being younger, and less experienced, you were more confident back then (and not as keenly aware of the uncertainties). So a certain bravado carried you along toward the decisons.
But, if I or my husband were your patient, I would be happy with what you did.
Normally, I am on the side of “doing less” and reining in healthcare spending, but in individual cases, I think that what you did might well serve “the greater good”–not to mention sparing the patient from a more painful and much more anxiouus death.
It’s pretty clear that you told him that he didnt’ have much of a chance, and he wated to “go for it”. Right or wrong, that was his choice. There wasn’t enough time (weeks) to ease him into accepting the fact that he was dying.
But I don’t have a real answer to the conundrum you faced. I don’t think there is a a clean, clear, final answer.
I just thought your post would inspire some real thought–which it did.
Thank you for the post — which challenged us–and congratulations on being a thoughtful doctor, both then and now.
Great find, Maggie. I wish I had found the post first. Comments that follow certainly show a lot of passion on the topic.
In my blog, I examine the question of whether a health insurer should ‘pay’ for surgery like this based on common interpretations of ‘medical necessity.’ As a former Medical Director, I think the answer is ultimately yes.
http://diseasemanagementcareblog.blogspot.com/2009/06/health-insurance-medical-necessity-of.html
Ahhh, very interesting. So the renal failure could have been due to the hypotension OR here is a guy with underlying, chronic renal dysfunction due to bilateral renal artery stenosis, in turn caused by a profound burden of atherosclerosis. Or it’s a combination of both. I vote for both. IIRC poorly perfused kidneys are especially sensitive to a further reduction in BP.
Bottom line: that abnormal creatinine is “the tip of the iceberg” so to speak: a clue to the patient’s overall medical condition and prognosis.
I hear what you’re saying about his overall projection of stamina and strength, however. Gut impressions are so important. He must have been one tough cookie.
I think your situation as a surgeon would have really different if he had had a regular physician. You might not have been in such a tough spot.
I’m glad he did the surgery because the patient asked him to AND diagnostic tests aren’t always reliable. I was practially begging doctors to cut my husband open when they kept telling me he was “fine.” I’m not sure why anybody would criticize Buckeye Surgeon…would you critics rathar that doctors keep their knowledge to themselves and not tell you what your options are, no matter how hopeless? Wouldn’t you rathar be informed so you can make your own decision?