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.