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Many surgeons don't discuss end-of-life care: study
(Reuters) - Many U.S. surgeons fail to discuss their patients' wishes in case a risky operation goes awry, and even more would not operate if patients limited what could be done to keep them alive, a survey found.
Such medical wishes and plans for end-of-life care, called "advance directives," outline what can and cannot be done if patients are unable to decide for themselves. The most famous examples are so-called living wills.
But the restrictions are debated among doctors, said the survey, published in the Annals of Surgery.
"(Surgeons) feel the advance directive basically ties their hands behind their back, and they're not given the tools to get them through the surgery," said Margaret Schwarze, an assistant professor at the University of Wisconsin School of Medicine and Public Health, who was one of the survey's authors.
She and her colleagues asked 912 surgeons who regularly perform risky operations 14 questions on how they discuss a patient's advance directives and whether the directives influence their decision to operate.
More than four out of every five surgeons discussed which forms of life support the patients would like to limit. But only about half asked specifically about the patient's advance directive, which can include restricting the use of feeding tubes and ventilators to keep a person alive.
"I think some surgeons just don't discuss advance directives because they think it's so irrelevant," Schwarze added.
More than half the surgeons said they would not operate if an advance directive limited what could be done to keep a patient alive after surgery.
The researchers said such instructions can also cause tension between the surgeon and the patient because it shows the patient may be unwilling to accept the therapies that come with high-risk operations.
Heart surgeons were much more likely than brain surgeons to decline an operation -- perhaps because brain surgeons may see removing life support as a reasonable decision, since their surgical complications can cause brain damage.
It's not uncommon for heart surgeons to use techniques such as CPR after an operation and restrictive instructions may get in their way, Schwarz added.
"I think it's important for patients to discuss their values and goals with surgeons before a big operation," Schwarz added in an email to Reuters Health.
"It's also incredibly important to discuss this with family members or someone who may need to make decisions."
Although the use of advance directives has increased in recent years, a study earlier this year found that U.S. laws set up too many roadblocks for many people to put them into place.
SOURCE: bit.ly/t9SVLr
(Reporting from New York by Andrew Seaman; editing by Elaine Lies)
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Another factor may be the way we as a society talk about and refer to death; rather than accepting it as the inevitable end result of life, we ‘battle’ and ‘fight’ and then when we die, it is because we (or our physician) ‘lost’ that battle. These ingrained concepts predispose us to ‘fight’ and our physicians to attempt extreme measures to ‘win’ which implies that someone did something wrong (or failed to do something) if they ‘lost’. Is it realistic to operate on a patient that may only have days to live when the best outcome is extending that by days or maybe weeks? At what point is it kinder to the patient and the family to have the hard conversation and explain that the end is near and nothing will change that that inescapable fact.
And I think it goes a bit further: If you read this study more closely, at least in this Reuters news piece, what you see is that the surgeons feel their hands are or may be tied by a paper that says “No CPR” or “DNR” (do not resuscitate) or the like. So some do not want to ask in the first place.
The surgeons are right to be confused and frustrated by Advance Directives. What they need to do their healing is to have a flexible, reasoned approach to the exigencies that come up during operations.
What is needed is someone they can consult (an authorized and informed, but more than that, reflective and caring person) and with whom they can make a decision.
And that spells just one thing: Conversation, lots of conversation before the day of the operation with a trusted person to whom you have given a broad POA. Conversation, lots of continuing conversation.
:- Doug.
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