Tuesday, September 14, 2010

Surgical Buy In

Pauline Chen had a post in the Times last week about surgical informed consent. Informed consent is an important part of the surgeon/patient communication transaction. Surgeon reviews the proposed operation, the rationale behind it, and the possible complications. For example--- a patient comes in with biliary colic. We describe the anatomy and pathology. We aver that surgical resection will lead to cure. The operation (laparoscopic cholecystectomy) is described in detail. Potential complications are addressed (bile leak, CBD injury, bleeding, infections, cardiopulmonary morbidity, etc.) Patient is informed that although complication rates are low, there is still a statistical probability that her procedure will encounter such problems. Given all this information, patient then decides what she ultimately wants to do. Informed consent.

Dr. Chen talks about this concept called "surgical buy-in" where the patient is prepared for worst case scenarios prior to the operation. When a case goes bad, we surgeons have a tendency to implement the full court press, whereby we try anything and everything to get our patients back on course, even when the situation begins to look futile. It's our ingrained sense of responsibility and duty to try to reverse the deterioration. But sometimes these last gasp maneuvers are not what the patient would have wanted.

There's an article in Critical Care Medicine from March that talks about this buy in. For complex elective operations (Whipples, liver resections, transplants, rectal surgery) surgeons would negotiate with patients prior to the surgery the extent to which both the surgeon and the patient were willing to labor if things took a turn for the worse. In other words, the surgeon would say something along the lines of: "If you leak from your pancreaticojejunostomy and get septic would you be willing to be reintubated? Taken back for revision? If you were unable to be weaned, would you consider a tracheostomy? What about CPR? Is there a time limit you would restrict aggressive intervention to, i.e. if you weren't improving by 6-8 weeks of intensive therapy, then palliative measures would be undertaken?"

It's a great idea. As long as we restrict the protocol to those complex operations. I'd hate to put my patients through such a terrifying question and answer session prior to a lipoma excision or a breast biopsy.


rlbates said...

I agree, Buckeye.

Anonymous said...

As a resident, I never saw a patient who was truly consented for an operation. I remember RYGBP patients coming in saying,"now..what surgery am I having today and what for?" I resolved to obtain informed consent as completely as possible. But, yes, at times we can carry it to the point that no one would ever consider an operation, when it absolutely is in their interest to do so. We can't be "fear mongers"

Anonymous said...

its like they said in residency,
"There are no minor Cases, only Minor Surgeons"


PS boy, bet your enjoying the pageantry of Ohio St/Ohio Week!!!!!
You can throw out the record books for that one!!!