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Does your mom really need this operation?

By: Medix team

The current surgical decision making puts the surgeon in the center. Why and what can we do about it?

We would all like to believe that we are making the right choices, when sitting in a surgeon’s office and asked to agree to a certain operation for us or for a family member. Can we really make an informed decision?


For the most part, a decision is made following a discussion between the patient, his family and the surgeon himself. At times other specialists are consulted, such as cardiologists or nephrologists, however their role is more limited and focuses on clearing the patient for a procedure rather than giving input regarding alternative treatments. As a rule, a surgical consultation is the first time a surgeon will come into contact with the patient, meaning that a lack of understanding of the patient’s circumstances and preferences is inherent in this approach. The centrality of the surgeon in this process seems intuitive but in many cases the patient is lost in the fray. After all, surgeons are trained interventionists who aren’t necessarily prepared to properly present non-surgical treatment options, effectively barring patients from opting for one of these alternatives.


Yet this approach may be sub-optimal for many high-risk patients such as elderly people  facing decisions about major surgery. Studies published in the New England Journal of Medicine (NEJM) have revealed some concerning statistics. Taking a colectomy procedure as an example: 30% of nursing home patients which undergo this surgery die within three months after surgery and 40% of the survivors suffer a decline in functional status. Twelve months down the road and the reality is worse, with 50% mortality and 50% impairment among survivors.


In stark contrast to these figures, one third of elderly Americans undergo surgery during the final year of their life and three quarters of seriously ill patients state that they would opt out of life sustaining treatment if it resulted in serious cognitive or physical impairment.


So what can be done? Over the past years, the importance of a patient centered approach has been promoted by many medical journals. This approach has manifested itself in multidisciplinary teams comprised of a number of specialists who are meant to discuss the different aspect of a case and present the patient with multiple options and explanations regarding the advantages of each path. One field in which this has been widely implemented is oncology, with meetings called tumor boards becoming common practice.


The article in NEJM believes that a similar approach can and should be implemented for surgical decision making in high-risk patients. After all, many of the issues are the same; dealing with co-morbidities, multiple treatment options including “watchful waiting” and the need for taking into account the patient’s wishes and priorities with regard to quality of life.


"Evaluating recommendations, and articulating the benefits and risks to patients comprehensibly require more than a well-informed or experienced surgeon. Meetings these needs may require teamwork among physicians, nurses and non-clinicians like social workers" says the article. "Currently, such teamwork typically occurs on an ad hoc basis, if at all. But they should meet regularly to present and discuss high-risks cases. Achieving the best outcomes in the sickest and most frail patients 'takes a village'. It's difficult to create such a team through an ad hoc enterprise that begins the day of an operation and continues piecemeal from the early postoperative period until hospital discharge.  Ideally the team would have experience working together to coordinate preoperative assessment, intraoperative care, rehabilitation and recovery".


When making medical decisions, whether personally, or for your mom, there is a salient struggle to balance between curative treatments, and quality of life. This delicate balance is one that we all strive to master, so what better situation is there to start thinking critically and creatively about accepted medical practices?

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