They say that ‘old age does not come alone’, and ill health is one of its most common companions. Modern medicine may have successfully increased our life span, but the fruit of this success is a massive increase in age-related illness and the associated cost of end-of-life care. This brings myriad challenges for physicians and surgeons, and introduces a complex ethical dilemma to daily practice: at what point do we say ‘no’ to surgery?

 

One of the central tenets of international healthcare is the oath to ‘first do no harm’ yet any incision – no matter how small – is an assault on a patient’s body. It comes down to the professional judgement of the surgeon to decide whether the benefits outweigh the risks. As a 1999 article1 in the BMJ points out: “Good surgeons know how to operate, better ones when to operate, and the best when not to operate… It takes wisdom, experience, strength, and courage not to intervene. The minute that a surgeon cuts the skin or a physician prescribes a drug, harm is done. The benefit of a treatment will have to exceed that harm before the doctor is doing good.”

 

​“Good surgeons know how to operate, better ones when to operate, and the best when not to operate… ”BMJ article1

 

Alternative treatments

This is by no means a straight forward decision in any medical discipline, but it’s often at its most acute in patients with complex health conditions or those nearing the end of their lives. First of course, there is the question of outcomes – is surgery the best treatment option? Looking for example at spinal stenosis – one of the most common age-related back problems, affecting around 8-11% of Americans2 – surgery is often considered a last resort, to be considered after other treatment options have been exhausted. Physicians tend to take a conservative approach to begin with, prescribing anti-inflammatory drugs or injections of corticosteroids with lidocaine. Indeed, while previous research argued that this treatment was ineffective in managing pain, a retrospective case series3 published in the New England Journal of Medicine in October 2015 suggests that epidural steroid injections are highly effective in the short term, leading the Boston University research team to call for more research into non-surgical approaches.

 

Clinical momentum

Yet while surgeons may review research literature and analyse outcome statistics to inform their treatment decision, patients are more emotionally invested, often viewing surgery as a risky but necessary ‘cure’. In an article4 in General Surgery News, Dr Margaret Schwarze, assistant professor at the University of Wisconsin, Madison, referred to a ‘clinical momentum’ in which “there are forces pushing you to operate even though you think surgery is futile and that the outcome would not be acceptable to the patient.” Dr Schwarze’s point is validated by her research study5, which asked four focus groups of 37 elderly patients and two focus groups of 17 surgeons to watch a video about a chronically ill 79-year-old woman facing a choice between surgery and palliative care. Many of the senior citizens equated surgery with ‘life’ and palliative care with ‘death’, concluding that it was ‘better to die trying’. They were under the misperception that surgery would restore their health.

 

​“There are forces pushing you to operate even though you think surgery is futile and that the outcome would not be acceptable to the patient.”Dr Margaret Schwarze

 

The surgical group, by contrast, had a variety of reactions: some refused to offer surgery when they felt there was virtually no likelihood of a positive outcome; others said they would strongly bias the patient’s decision towards nonoperative strategies, while a small group believed it was their responsibility to present the options objectively and let the patient decide.

 

In some European countries such as Germany, this ethical dilemma has been removed from the equation altogether, by legislating that medical teams must objectively present all potential treatment options to the patient, leaving them to decide on the next steps.

 

Judgement call

This mixed reaction of surgeons in Schwarze study highlights the importance of professional judgement and experience, and for surgeons to make their decision on a case-by-case basis, if the decision is theirs to make. Unfortunately Schwarze’s notion of ‘clinical momentum’ may be felt most keenly among inexperienced surgeons. A 2010 study6 by the Imperial College of Medicine, London, sought to analyse decision making in emergency surgery. The methodology involved semi-structured interviews to investigate how expert surgeons decide when to operate (Phase 1), and clinical case vignettes (Phase 2) during which 22 general surgeons at various stages of their training were asked whether they would operate and their confidence in patient outcomes. Perhaps unsurprisingly, the research revealed that surgeons with fewer than five years experience were less confident about patient outcomes. Despite this, these surgeons opted to perform significantly more operations (40 +/- 4%) than their more experienced counterparts (18 +/- 2%).

 

Strained services

Poor surgical outcomes not only have potentially devastating consequences for patients and their families, but also place enormous strain on healthcare providers. A 2013 study7 in JAMA Internal Medicine found that in the critical care setting, 11% of patients were perceived as receiving futile treatment in the critical care setting, at an estimated cost of $2.6 million. In the UK, the cost burden of unnecessary surgery is a key concern for the NHS Institute for Innovation and Improvement, which seeks to transform healthcare by developing new work practices, technology and improved leadership. It reports that some procedures, such as surgery for varicose veins, are so ineffective in treating the patient’s reported symptoms they are not considered clinically useful, yet the NHS in England and Wales spends £400-600m treating chronic venous insufficiency8. The Institute has also found9 that one in four NHS patients on orthopaedic waiting list were removed without treatment, mostly because they were either unfit or unwilling to have the surgery. Its response is to stress the importance of Pre-operative Assessment and Planning to ensure the patient is fully informed about the procedure and their prognosis.

 

Of course, the financial burden of surgery runs both ways: while countries with national health services feel the strain of unnecessary elective surgeries, money can only muddy the water in the decision making process for private healthcare providers.

 

Two-way communication

While the medical profession invests heavily in new technologies, many physicians are calling for greater investment in training, to equip relatively inexperienced surgeons with the communication skills needed to better understand what ‘quality of life’ means to individual patients, and to enable them to effectively explain the risks and benefits of surgery. Dr Schwarze writes10: “To determine whether surgery is worthwhile for them, older patients need to imagine how the outcomes of surgery might be experienced within the context of their overall health. Rather than more information, patients need more interpretation about what these risks and predictors mean for them.”

 

Ultimately, apart from technical skill or innovation, the surgeons delivering the highest standards of care are those who have the experience and wisdom to really listen to what ‘health’ means to their patient.

 

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