RAS Issues Symposium: Reining in the scalpel

At weekly morbidity and mortality conferences, there always seems to be at least one discussion of a case involving an elderly patient who died after a heroic intervention. The resident involved is typically asked, “Doctor, what discussion of risk did you have with this patient and family?” The conversation that follows rolls forward like a song stuck on repeat.

Recent articles in the mainstream press indicate a growing public awareness that end-of-life procedures are overused.1,2 As surgeons, we know that the decision to perform surgery at the end of life is difficult, and there is no shortage of manuscripts delving into this complex topic. The very focus of debate at this year’s Resident and Associate Society Symposium challenged us to choose a side with regard to Surgery at the End of Life: For Love or Money?

I suggest that framing this discussion so that one opposes love or money hides the complexity of the issue and draws out unintended emotionality inherent within these words. From my perspective, end-of-life operations, specifically in the elderly, are overused and do little to lengthen or improve quality of life and often cause more harm than good.

Use of surgery at end of life

Kwok and colleagues found that nearly one-third of aging Americans undergo a surgical intervention during the last year of life, and the majority of these procedures occur within the last month.3 Those who underwent surgical procedures in the year prior to death had more hospital admissions, almost twice as many days in intensive care units, and spent nearly 50 percent more days in the hospital than those who did not have surgery in the year before death.

The same study found that use of surgery near the end of life varies greatly by U.S. region. Moreover, the regions where more operations were performed at the end of life had higher death rates than the regions with fewer procedures at the end of life.3 Another study found that 50 percent of patients ages 80 or older who underwent emergent colectomy died within six months of the procedure.4

Patient expectations

Atul Gawande, MD, MPH, FACS, recently noted that technology can sustain bodies beyond coherence.2 Complicating the matter is that end-of-life wishes, when expressed, are variable. A study in the Journal of the American Medical Association confirmed such variability, but did find that saying goodbye, maintaining dignity, and having good pain control were consistently among the top-rated desires for people foreseeing their imminent death. Notably absent from the list is a desire for an incoherent existence in an intensive care unit after surgery.5

I recall a case involving an octogenarian who was struggling on a ventilator after surgery. When finally given pencil and paper, she demanded the tube be removed so she could have a Diet Coke. Her wishes were granted, and she died on the car ride home, her final wish in hand. The Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments found that many patients die prolonged, painful deaths while receiving unwanted, invasive care.6 This study confirms that end-of-life procedures may cause undue harm and lead to unwarranted costs.

Images of death on television further complicate this issue by depicting miraculous surgical saves. This skewed view may also contribute to excessive interventions at the end of life. Perhaps this is part of the reason surgeons are often faced with making last-minute decisions for patients and families suddenly blindsided by impending death. But physicians also appear too optimistic. A Harvard study revealed that 63 percent of physicians overestimate survival time of their terminally ill patients by a factor of 5.3.7 Dr. Gawande recently presented a possible explanation for this optimism when he recognized the personal difficulties physicians face in coming to terms with patients’ prognoses.2

A quest to be better

As surgeons, we need more data to help guide the decision to operate near the end of life. One such data-gathering mechanism is The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP®). NSQIP originated in the Department of Veterans Affairs (VA) and was created in response to concerns about high postoperative complications and deaths at VA hospitals. NSQIP collected prospective data from 1991–2001 and used outcomes tracking to reduce 30-day death rates and complications by 27 percent and 45 percent, respectively. The average hospital length-of-stay decreased by 50 percent.8 These measures decreased patient suffering, deaths, and costs.

Subsequently, the ACS took responsibility for bringing the program into private sector hospitals. If all U.S. hospitals participated in ACS NSQIP, such collected data could be used to decrease surgical overuse at the end of life. While surgeons aim to evaluate their outcomes with methods such as morbidity and mortality conferences, these conversations are flawed with the 20/20 retrospective vision that hindsight provides. We must embrace outcomes data analysis not as punitive but as a way to improve the appropriate use of surgery at the end of life.

Although we need prospective data, we must also remember that the patient is an individual, not just a statistic plucked from a study. In addressing the individual, we must be mindful not only of our decisions to operate, but also our decisions in managing complications when they arise. And we must subdue our egos when confronted with a problem out of our realm of expertise so that we may call on colleagues for advice.

It starts with a conversation

We must be willing to engage in conversations in which we responsibly address end-of-life realities without destroying all hope. A recent article in The New York Times noted that more than half of people polled would tell their physicians to stop treatment if they were in pain with no expectation of improvement.9 By identifying our patients’ wishes, we can help them get what they want before death’s surprise, be it a family conversation or a Diet Coke. Upholding these wishes can provide hope in the face of death.

The patient’s withering grasp begs of us to do something. But perhaps “something” is to allow the patient the dignity to breathe out his or her last words rather than be silenced by the knife. By engaging in honest, early discussions, advocating for patient wishes, combined with better research, we can control the reins of surgery so that it is not an overused tool, but a perfected craft that provides enhanced life with more love and less money.


References

  1. Rabin R. Doctor panels recommend fewer tests for patients. The New York Times. April 4, 2012: A:10.Available at: http://www.nytimes.com/2012/04/04/health/doctor-panels-urge-fewer-routine-tests.html. Accessed September 5, 2012.
  2. Gawande A. Letting go: What should medicine do when it can’t save your life? The New Yorker. August 2, 2010. Available at http://www.newyorker.com/reporting/2010/08/02/100802fa_fact_gawande. Accessed September 5, 2012.
  3. Kwok A, Semel M, Lipsitz S, Bader A, Barnato A, Gawande A, Jha A. The intensity and variation of surgical care at the end of life: A retrospective cohort study. Lancet. 2011;378(9800):1408-1413. [E-pub 2011 Oct 5.]
  4. Kurian A, Suryadevara S, Ramaraju D, Gallagher S, Hofmann M, Kim S, Zebley M, Fassler S. In-hospital and 6-month mortality rates after open elective vs open emergent colectomy in patients older than 80 years. Dis Colon Rectum. 2011;54(4):467-471.
  5. Steinhauser K, Christakis N, Clipp E, McNeilly M, McIntyre L, Tulsky J. Factors considered important at the end of life by patients, family, physicians, and other care providers. JAMA. 2000;284(19):2476-2482.
  6. A controlled trial to improve care for seriously ill hospitalized patients. The Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT). The SUPPORT Principal Investigators. JAMA. 1995;274(20):1591-1598.
  7. Christakis N, Lamont E. Extent and determinants of error in doctors’ prognoses in terminally ill patients: Prospective cohort study. BMJ. 2000;320(7233):469-473.
  8. Wascher R. Surgery, NSQIP, complications, and death. Men’s Daily News. October 4, 2009. Available at: http://mensnewsdaily.com/2009/10/04/surgery-nsqip-complications-death/. Accessed September 5, 2012.
  9. Jacoby S. Taking responsibility for death. The New York Times. March 30, 2012. Available at: http://www.nytimes.com/2012/03/31/opinion/taking-responsibility-for-death.html?_r=1&src=tp&smid=fb-share. Accessed September 5, 2012.

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