Unfortunately, I Cannot Guarantee Your Survival
14 Sep 2006
"What’s the worst thing that can happen if I agree to surgery?" a patient recently asked me. Unfortunately, the only honest answer was that "some patients die". It’s hardly the positive way to discuss surgical complications, but it does get quickly to the heart of the issue. Today, patients have every right to be informed about risk, but to do so effectively is easier said than done.
For instance, it could be cynically said that the only truly informed patient would be a brain surgeon informing another brain surgeon about potential complications. There are no ifs, ands or buts in this case.
In a similar vein I could talk to a nuclear physicist for days without ever understanding the complexities of his subject. But if he told me that by mixing A with B I’d blow myself up, I’d quickly get the message.
So what are the powder-keg issues of consent that doctors should stress to patients in 2006 that leave no room for doubt? The first is that surgical risks should never be swept under the rug. It’s impossible for surgeons or any medical practitioner to guarantee the outcome of any procedure.
One patient may survive a complicated heart operation. Another may die from an unexpected anesthetic problem while removal of an ingrown toe nail. Surgical procedures are not like mathematics where two plus two always equals four.
There’s another crucial dilemma today. Doctors must convince patients to rid themselves of unreasonable expectations. No better example of this is obstetrical delivery where women seem to have become programmed to expect a 100 per cent normal baby.
I’m convinced (but few agree with me) that bringing fathers and sometimes whole families into the delivery room started a dangerous trend. It helped to foster misconceptions about childbirth, that having a baby is such a natural process that nothing should or could go wrong. And if a less-than-perfect baby results, it’s automatically the doctor’s fault.
Today this has become such a problem that any young doctor considering a career in obstetrics should first consider getting psychiatric care. The delivery of babies has simply become a lose-lose medical/legal situation.
Many older obstetricians have heard this message loud and clear. They know the odds of law suits are so high that they’ve discontinued their obstetrical practice. It’s a symptom of the times we live in today and in the end it’s the patient who loses.
The difficulty is how to pass along the essential A’s and B’s of potential surgical pitfalls without scaring patients to half to death.
Some hospitals, particularly those in the U.S., require that patients sign a 15 page document describing a procedure in the hope of improved communication with patients. With more lawyers in the U.S. than in any other nation they hope this will keep doctors and the hospital out of court. But studies show that many patients read neither short nor long explanatory documents, or if they do, they can’t recall the content.
Video presentations are also being used to educate patients. As expected this approach has been shown to penetrate the patient’s psyche better than the written word. But patient recall is still only 50 per cent better than the written word. I suspect that video presentations of the operation may also give patients second thoughts about proceeding with surgery.
Hi-tech presentations may be part of the answer. But I doubt there’s anything better than a few moments of discussion with the doctor to make sure patients understand basic risks, such as a post-operative blood clot that could be fatal or the possibility of wound infection. And today with so many obese, diabetic, hypertensive patients, they need to be aware that these conditions increase the chance of heart attack and stroke.
How much risk a patient is willing to accept is always a personal matter. A two per cent chance of death may be acceptable. But if mixing A with B means a 20 per cent chance of lighting a lethal fuse patients may elect either non-surgical treatment or none at all.
