Thursday, October 6, 2011

Surgery at the End of Life: Reality Check


The medical segment of Twitter is abuzz today over a paper by Atul Gawande and colleagues pointing out that almost a third of elderly Medicare recipients undergo an inpatient surgical procedure in the last year of their lives. Just over 18% have such surgery in the last month and 8% in the last week of their lives. The paper was published online in the journal The Lancet.

There is a lot to think about in this paper including the fact that there are marked geographic regional variations in the amount of surgery performed.

I’d like to focus on an issue that is not discussed enough, which is futility. In response to the flurry of tweets linking to the abstract of the paper, I replied that I felt that families (and sometimes patients) refuse to accept reality.

Here’s a common scenario. An elderly patient is transferred to the emergency department of an acute care hospital in the middle of the night with what proves to be ischemic bowel on CT scan. Even if the surgeon says she has no chance of leaving the hospital alive, the family wants “everything done” for their 85 year old grandmother who has been demented and bed-ridden in a nursing home for five years. There is often an inverse relationship between the current level of involvement of the family in the patient’s life and their enthusiasm for wanting everything done. The relative who lives the farthest away is usually the most passionate advocate for intervention and “full code” status.

Unfortunately, the patient usually does not have a personal primary care physician. The nursing home doctor probably didn’t see her before she was sent to the hospital. There is no advance directive. The family never discussed the patient’s wishes when she was lucid enough to express them.

Now picture yourself as the surgeon who had the bad luck to have been on call for emergencies that night. Despite knowing that surgery would be futile, the surgeon is in a difficult spot. Some family member always says, “If there is one chance in a thousand that she can be saved, I want you to operate.” I know people think we surgeons believe we are God, but how can anyone say that some miracle will not occur and she will live? What would you do?

I have had many conversations with families in similar situations. Trust me; there is intense pressure to “do something.” I would estimate that in fewer than 10% of cases, the family eventually sees the light and lets Grandma die in peace. If the patient survives the operation, she likely will be in an intensive care unit on a ventilator for days to weeks, develop pneumonia and sepsis and die. Meanwhile, the tab is running and the eventual hospital bill will be well into six figures.

Don’t forget, even the one survivor in a thousand returns to the nursing home and is still demented and bed-ridden.

There are other types of futile procedures such as placement of feeding tubes which have never been shown to prolong life or improve quality of life in elderly demented patients. Surgical or endoscopic feeding tube placement is associated with numerous complications, both procedure-related and caused by the presence of the tube itself. The tubes fall out or become occluded leading to ambulance trips to the emergency department for replacement.

I do not have the answer. Maybe an all out effort to educate the public about this problem would work, but I doubt it.

17 comments:

Belle, with a side of courage said...

Sadly, because of recent rhetoric in this area any attempt to educate the public would likely be perceived as promoting "death panels".

No, we don't want death panels. We simply want planning for end of life to occur and we want there to be logic in how we address medical care for those who are frail and chronically ill.

Skeptical Scalpel said...

Well said. I agree.

silentounce said...

Hi, I just read your article on KevinMD about going to med school later in life and I wanted to ask your opinion on someone in a similar situation deciding to become a PA instead.

This is a link to your article: http://www.kevinmd.com/blog/2011/04/medical-school-tuition-debt-doctor.html

Anonymous said...

As a Surgical Technologist, I have often assisted on placement of feeding tubes for elderly patients so they could be admitted to a nursing home even though they were well advanced in age and in a fetal position with no awareness of their environment. When asked why we were doing this to a 108 year old female, the surgeon answered me by saying that he felt family members feel guilty for not spending time with the patient and the fact that nursing homes will not take patients who cannot feed themselves. What a shame for a person to undergo such a procedure just to lie in a bed with no visitors and wait to die. We need some compassion in circumstances such as these.

Skeptical Scalpel said...

@silentounce

It would be much less expansive than going to med school. I don't know what part of the country you are in, but I advise you to check and see what the job market for PAs is like.

@Anonymous

You echo what I was saying. There are many papers that show how futile it is to place feeding tubes in nursing home patients yet they continue to be done.

Anonymous said...

This is a very real and an all too common occurrence. As a retired physician, I feel that we have forgotten to be "doctors". The current high pressure scene and at times the unrealistic expectations of family members, makes it difficult to establish relationships with one's patients. Gone are the days when we made house visits and even had time for a cup of tea or coffee and a chat with the family. This is no longer and we as a society are all that much poorer. We have forgotten to touch our patients and hold their hands. We may not be the compassionate physicians we all profess to be. Our elderly and their families and that includes us, deserve an honest "doctor" who as described, will outline the prospects of survival; the benefits of the undertaking and whether this will prolong life or just lead to a prolonged and financially depleting miserable death.

Anonymous said...

I spent many years as a staff RN in the CVICU of a prominent academic medical center. The statement "There is often an inverse relationship between the current level of involvement of the family in the patient’s life and their enthusiasm for wanting everything done. The relative who lives the farthest away is usually the most passionate advocate for intervention and “full code” status." is so VERY TRUE!!! I often felt like what we did to elderly patients to "save their lives" was nothing short of criminal, and there were times I left work feeling like a guard in a Nazi concentration camp because of what I was obliged to inflict on my patients. On occasion, we would get pre-op patients in our unit if the medical cardiology unit was full. So many times, an elderly patient would confide in his/her nurse that he was scared of having surgery and didn't really want to have it, but the family insisted. You could pretty much bet a year's worth of mortgage payments that these patients would suffer the most devastating complications and die a very slow, painful, lingering death. Thank God my elderly mother, a retired RN, has often expressed her desire to not have extreme measures done for her.

Anonymous said...

Working for a well known hospice, I've seen that families don't want to talk about palliative care. The only thing that will help these situations is education. We provide education in our community but many doctors don't really want to talk to/learn about all that can be done with hospice.
Patients are given more attention, better care, social services and bereavement to help the patient and their families deal with the end of life. We've even offered to come to physician offices to meet with the patient and the family to discuss this option as many physicians are uncomfortable having this discussion.
Education is key.

Skeptical Scalpel said...

Great comments by both Anonymouses. Thanks.

Wanderer said...

The take-away is that we fear death. We do not accept it as a natural part of life and rage against the coming night in a futile attempt to prevail. I've seen so many families who don't understand and would rather watch their family suffer in the name of "saving their lives". Let them do CPR and feel the osteoporotic bones break under their hands, pack the tunneling decubitus ulcers and inflict the numerous insults to person and dignity we do in the name of keeping our elders alive. But they stand by and watch us do it, with no comprehension of they are asking. I'd like to think that if they did this, better, more humane options might be explored and accepted. But it us easier to maintain the status quo.

Riles_C said...

Really found this post interesting and so well spoken. I agree with previous commenters about the proximity of family is inversely related to the amount they want done.

As i'm planning to pursue EM residency, this is such a huge issue we deal with in nursing homes. If possible, i'd love to repost some sections of this post in one of my upcoming posts.

Thanks for a great blog. I really enjoy it and look forward to sharing it with my followers.

-Ryan
drryanc.blogspot.com

Skeptical Scalpel said...

You may post some sections of the blog. I would appreciate your mentioning my blog as the source. Thanks for commenting.

Skeptical Scalpel said...

Also, the current issue of JAMA has a nice article about caregivers frustrations with futility in the ICU. Here's the link http://jama.ama-assn.org/content/306/24/2694.abstract

hotflash said...

Just discovered your blog, it's great. And as a previous poster said, this statement is incredibly true.

"There is often an inverse relationship between the current level of involvement of the family in the patient’s life and their enthusiasm for wanting everything done. The relative who lives the farthest away is usually the most passionate advocate for intervention and “full code” status."

As an RN and POA for my 93 year old father, I did have to deal with a brother who came from far away, seldom saw his father, and then though Dad was "getting better". Fortunately, Dad had the presence of mind to slip in a coma soon thereafter, so that brother couldn't comment on his robust health any more.

Skeptical Scalpel said...

Hot flash,

Thanks for commenting. Sometimes the old folks take the initiative. I'm glad things worked out for you.

RobertL39 said...

If you haven't, you should read "Letting Go" by Dr. Gawande: New Yorker, August 2, 2010. He beautifully discusses the issue and gives examples of the successful application of "pre-need" discussion to bring down end-of-life ER visits and Medicare costs. Also covered is the difficulty for patients, some finding it easy to say "no, thanks" early on in their disease and then, "yes, please" when they're close to the end and there is a even a small chance for extending their life. Clearly much more "pre-need" [sorry to borrow the term from the funeral industry!] discussion and signed directives are needed.
RDL,MD

Skeptical Scalpel said...

RobertL39,

Thanks for the comment and the suggestion to read Gawande's article on the subject.

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