Pt autonomy\decision making

[abbaroodle]

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Question about planning surgery and pt autonomy. What do you do as a surgeon if you disagree with a patient about what he or she needs? For example, you want to do 3 things and the pt only wants 2 of them done. (Assuming that the 3rd is related but not doing it would be a reasonable option. And you already had a discussion about why you recommend the 3rd procedue as well.) Do you recommend that the pt see a different surgeon? Do you agree to do what the pt wants? Do you still feel like you can do a good job?

It seems to me in a medical field pts decide what recommendations to follow by choicing which prescriptions to fill\take, etc. But in a surgical field, pts can decide not to have surgery (or not follow other recommendations), but can they choose some of your recommendations?

 

[SocialistMD]

Question about planning surgery and pt autonomy. What do you do as a surgeon if you disagree with a patient about what he or she needs? For example, you want to do 3 things and the pt only wants 2 of them done. (Assuming that the 3rd is related but not doing it would be a reasonable option. And you already had a discussion about why you recommend the 3rd procedue as well.) Do you recommend that the pt see a different surgeon? Do you agree to do what the pt wants? Do you still feel like you can do a good job?

It seems to me in a medical field pts decide what recommendations to follow by choicing which prescriptions to fill\take, etc. But in a surgical field, pts can decide not to have surgery (or not follow other recommendations), but can they choose some of your recommendations?

The thing to remember is that, if you don't want to do what they want you to do, you don't have to. I'm struggling to think of a real-world example of your proposed scenario (in general surgery, at least), but I think that if the patient doesn't agree with what your training tells you is best for them, you can decline to operate on them. As to what one does, I think that answer will vary depending on the surgeon; some will not do anything and others will do what the patient wants.

 

[Blade28]

Your role as a surgeon (or any type of physician, for that matter) is to act as an advisor. You explain the patient's disease/illness/pathology as best you can, and present the available options for treatment (always including "do nothing"). You can inform them about each treatment option's risks, benefits and potential complications. You can even tell them which path you'd recommend they take.

But in the end, the decision is up to them. This is quite a departure from the older model where the patient just goes with whatever their doctor tells them. With this new model, all you can do is make suggestions.

So if after hearing about all the potential risks and benefits the patient still doesn't want to go with your proposed procedure (refuses to sign the informed consent form), there's nothing you can do about that. If they want to pursue a treatment modality that you don't want to offer for a medical reason, then they'll have to go to someone else.

As a quick example of the former, I've had patients refuse placement of NGTs even though they know that the potential risks of not having gastric decompression include aspiration, pneumonia and death. As for the latter, I've also had patients who want debulking surgery when it's clearly not indicated.

 

[abbaroodle]

I've definately seen pts who want their gallbladders out for vague abdominal pain. I guess if they go see enough surgeons someone will agree to take it out. But I agree with the saying that a great surgeon knows when not to operate.

As to the original question, I was actually in ortho clinic when this came up and lead to some interesting doctor-pt interactions. Basically the pt has an injury that needs to be surgically repaired. (Interfering with daily living, work, etc.) The surgeon wants to do another procedure at the same time because he thinks an anatomic abnormality\variation may have increased the chance of\caused the injury. The pt wants the injury repaired but doesnt want the second procedure because she isnt convinced it will help and is worried about increased recovery time and potential complications.

The situation is complicated a bit by the fact that its a fairly unusual injury\repair and there arent a lot of folks who are trained\prepared to deal with it. So she cant just go find someone else.

Would you as the surgeon be offended if the pt only wanted the first procedure? If you agreed to do it, do you think you could still do it well?

 

[Blade28]

Offended? No. If the patient doesn't want the particular procedure done, in the end it's their perogative.

The hardest thing about surgical training is knowing when not to operate.

 

[Winged Scapula]

I actually run into this not infrequently.

For example, I have gotten patients who will accept a sentinel node biopsy but not the axillary clearance, even if their biopsy is positive. As others have noted, I'm not offended nor will I force the patient to have an operation they don't want, BUT in addition to the standard risks, benefits and alternatives statement on the consent form I have them sign a separate consent form. This will state something along the lines of 'I understand that by refusing "procedure x" I am going against the standard of care for my disease and that this decision may hasten and/or cause disease recurrence, spread or my death."

Another example would be the patient who will accept a partial mastectomy for breast cancer but tells me up front that they will not get radiation. Since the risk of recurrence is 39-40%, I tell them I am not comfortable doing an operation with such a high rate of recurrence when it can be lessened by half. Most of the time they come around and I've yet to refuse to do the operation.

BUT...recently, I spent a lot of time with a patient, she chose breast conservation and then at her post-op visit as we were discussing radiation she acts like she's never heard of it. Mind you, not only did I spend considerable time discussing it in the office, I emailed her a copy of my presentation (at her request) which has several slides on RT, CALLED her at home to discuss it further (when I sensed she wouldn't go through with RT) and she agreed to surgery and RT. I have to suspect she manipulated and/or lied to me. So I'm not sure I will agree to BCT again in a patient I think is opposed to RT.

Finally, I've also had patients ask me to do operations which are not indicated - ie, sentinel node biopsy for low grade DCIS, cosmetic procedures. I think as long as they understand the risks and you document them, you're ok...of course, IF doing a low risk procedure.

Patients generally want you to advise them and even guide them. Obviously there are some who come in with their "shopping list" and those can be difficult to handle. The key is to know why they seem to need to control the situation, what it is they really need and want and how you can accomodate them. If doing so makes you feel uncomfortable, then you assist them in finding another surgeon.

What you cannot do is terminate the physician-patient relationship without aiding them in finding another surgeon. Sort of the EMTALA of the OR.