Thursday, November 6, 2008

How Much is Too Much?

I attended a conference recently in which a talk was given entitled, "Partnering with Patients to Improve Patient Safety." In principle I applauded the thesis of this talk: that we should strive to foster enough of a sense of empowerment in patients such that they feel they have a strong voice in their care, can question treatment decisions and reasons behind them, and can advocate for themselves. I agree. The more a patient talks to me, and the more attentively I listen, the better care I can provide for him or her. I strongly believe that.

The talk did not, however, address situations in which there need to be clear limits to partnering with patients. And I do think such situations exist.

For example: I always invite parents of young children into the operation for the induction of anesthesia, so they can provide comfort for their children and enjoy some degree of participation in their care, with the understanding that they will be shown to the waiting room immediately after induction. One time - not in my O.R., but in someone else's - a parent grew belligerent and insisted on remaining for the entire operation. This was seen as potentially compromising to the delivery of good care and distracting to those providing it, and security had to be called to escort the parent out. The other option would have been to wake the child up and cancel surgery.

I have declined a patient's request for her (physician) husband to be summoned into the operating room if there were "any problems" during surgery. I considered it a breach of boundary lines and a potential hindrance to the delivery of good care. While I know in some centers family members are allowed to be present during code situations, I think this should only be permitted if a liaison person is available whose sole job is to explain what is happening to the family member and to answer that family member's questions.

Finally, patients occasionally try to insist that I not intubate them for certain surgical procedures. I'm sorry, but if I feel the intubation is absolutely essential, then they have no choice. I ordinarily cannot allow much in the way of "partnering" for such a life-and-death decision. If a patient is admitted to the hospital with a DNR/DNI order and suffers an arrest, that's a different story; but if they need and agree to major surgery and I feel they need a breathing tube, in it goes.

For many, the prospect of "having no choice" in a matter is odious. But just as partnering with patients can increase patient safety, there are circumstances in which the partnership can be inimical to safe medicine. Perhaps some will think, reading this, "She's not being fair;" "She wants to be paternalistic;" "She's a control freak." I submit that these would be mistaken conclusions. A good anesthesiologist cares about his or her patient's concerns and, while being firm about the standard of care, can be flexible and adaptable over its delivery. When a woman was so anxious about getting spinal anesthesia for her C-section that she was sobbing as she walked into the operating room and asked if her partner could come and be with her during the placement of the spinal, of course I agreed. After it was placed, I asked him to step back out of the room for a moment while we prepared the surgical field, then invited him back in at the "usual" time once surgery was under way.

In general, I am in favor of a collaborative approach to treatment decisions, as I have written before. I am more than happy to abide by my patients' wishes in most matters, and usually they find me more than willing to listen to their concerns, answer questions, explain things, and change my plans according to their preferences. But of all the medical specialties, anesthesiology is one in which collaboration is occasionally not advisable or possible, for the simple reason that SAFETY IS NOT NEGOTIABLE.

Shadowfax has this great example, via Orac of Respectul Insolence, of what I mean when I say that sometimes we just CANNOT afford to "partner with" patients to make a decision:

"...This patient, despite having an acute abdomen and a CT scan showing air where it should not be (i.e., outside of the intestines, meaning that there is a perforation somewhere), refused surgery, even though surgery was the only thing that could save his life. This is about as close to a no-brainer of a situation as there is in surgery and medicine. Patient with perforated intestine and acute abdomen = operating room. If no operating room, patient with perforated intestine = dead patient. In any case, it was pretty clear that this patient was in denial. At that point, Shadowfax deployed a most interesting technique of persuasion:

'Okay sir, before you go up I've just got some paperwork to complete. Do you have a next of kin?'

'Um, yeah, my sister.'

'Great. What's her phone number? We'll be needing to call her later. Do you have a mortuary or funeral home selected, or should we just have your sister pick one?'

'Um, I don't think -'

'No problem, we'll just have her pick one. Now, in a few hours, you're not going to be able to breathe any more, and if we're going to keep you alive, we'll have to put you on life support. Do you want us to do that, or should we let you suffocate?'

'That sounds bad -- I don't want to suffocate.'

'Right, then, the ventilator it is. But a few hours after that, your blood pressure is going to go really low and your heart will stop. Do you want us to pound on your chest and shock your heart to try to bring you back? It won't work, of course, but I just need to let the ICU doctor plan how to handle it when the time comes. So should we do CPR or not?'

He gave me a long look. 'You really mean it, don't you?' I said nothing, but let the long silence linger. 'You really think I need the surgery?' I nodded. He sighed, and slumped back, resigned,'Well, all right, if you really think I need it...'

The question is: Did Shadowfax go too far?

I would argue that, in this case at least, he did not. Sometimes the only way to overcome a severe case of denial is through extreme bluntness. This case, however, was fairly obvious. Without surgery, this patient was definitely going to die a very unpleasant death within a matter of hours, or at most, a couple of days."



Beach Bum said...

The one time I had to have general anesthesia, I spoke to the anesthetist at length about the fact that I am a professional singer, and that he had to be very careful with my vocal cords. He told me he would use a small tube, and be careful, and his willingness to entertain my concerns was comforting. But even so, had a situation arisen where my cords were damaged in the process, I would rather be alive with damaged cords, than dead with intact ones.

Jo said...

You are the professional here - you have studied for many years to get to where you are, and you will be able to make the best decision for the patient, something which either the patient or the relatives might not be able to do (particularly if there it no DNR order).

T. said...

Beach Bum - my daughter is a singer, so I totally understand how important it is to take good care of the larynx. I've tried to be especially careful with patients who are singers.

Jo - I totally agree, of course, but there are many who do not have this kind of trust in physicians as a group because of bad experiences with certain individuals, unfortunately. Setting limits on partnering for decision-making is especially challenging, understandably, when trust has been breached in the past.

Anonymous said...


Just curious. What if the patient specifically prohibits use of a ET tube under any circumstances in writing on the consent form. Patients have the absolute right to refuse any treatment or procedure, even if doing so is life threatening. At that point it would seem to me that your only options are to abide by their wishes or withdraw from the case.

In the past, you've also expressed your feelings regarding the suspension of DNR status during surgery. What if the patient adamantly refuses to go along with that?

T. said...

I would never go against a DNR/DNI order established by a patient.

If a patient did not want to suspend a DNR for purposes of surgery and needed resuscitation during surgery for events NOT having to do with side effects from routine anesthetic drugs, I would not perform the resuscitation.

There are certain types of surgery for which a refusal to be intubated wouldn't necessitate my withdrawing from the case because for those cases the surgeon wouldn't be willing to perform the surgery at all. In such cases refusing the intubation also means refusing the surgery.

Dragonfly said...

Patient safety versus patient satisfaction (ok, satisfaction is not quite the word but I am sleep deprived in exam mode). Sometimes the best decisions are not the easy ones.

dr_dredd said...

T: With respect to the patient sobbing about the spinal, what was she concerned about? Was she asking for a different method?

(Just curious. A friend of mine is very pregnant, and she's starting to ask me about what to expect during a delivery.)

T. said...

Dr. Dredd, as far as I recall, that particular patient was EXTREMELY anxious about EVERYTHING. The I.V. The blood pressure cuff going up repeatedly. The spinal. The C-section. The numb feeling after the spinal. EVERYTHING.

If your pregnant friend needs a C-section, any anesthesiologist worth his or her salt would insist on doing either a spinal or an epidural for her anesthetic and ONLY allow a general anesthetic as a last resort.

If she has a vaginal birth, an epidural would be an option for pain management if she would like one.

Ann of the Incredible Gift said...

Under anesthesia, I am not going to quibble about a tube for breathing. In general, I would rather not die, especially if living well is an option. An acute abdomen is definitely not the way I want to go; not after my dad described having appendicitis when he was a lad back in the 1930s. He said he would have done ANYTHING to ease the pain, even gone as far as eating nails if that would help. He survived the surgery, and went on to live for 80 years.

A sibling of my mother's was not so fortunate. She died as a tot around 1912 from might have been volvulus or intussusception, I'm guessing from my mother's descriptions. The family doctor had been by that day, and said she might live if she survived the night. Gran reported hearing a pop, the baby's suffering eased a bit and shortly after that her baby died.

Had modern surgery been available, I would have another Aunt. Bummer that it wasn't.