The Right Choice? Modifiable risk factors and surgical decision making

In the July 26, 2018, issue of the New England Journal of Medicine, Ira L. Leeds, MD, David T. Efron, MD, FACS, and Lisa S. Lehmann, MD, raise the important issue of how to proceed when a patient has an indication for surgery and wants the surgery, but the patient has modifiable risk factors that make the likelihood of surgical complications high.¹ Specifically, the authors describe a 45-year-old woman with morbid obesity and chronic opioid dependency who presented with a large incisional hernia. The patient suffers from debilitating pain and nausea that has been attributed to her hernia. She is homebound and is seeking a third opinion on repair of the hernia. She has smoked for 30 years and continues to do so after prior unsuccessful attempts to quit. She has been turned down previously by two surgeons who reportedly felt she was too high risk. Application of an all-procedure risk calculator has shown a 38% higher than average risk of a complication with an expected length of stay 80% longer than average.

The authors appropriately place the decision making around this case in the context of a dilemma between allowing a patient to assume greater risks (and thereby respecting her autonomous choice) and giving the surgeon the opportunity to decline a riskier operation that will result in a greater expenditure of health care resources. The authors note that, by operating on such a high-risk patient, the surgeon and the hospital will likely receive lower scores on public ranking systems and even lower payments if reimbursement is related to performance-based outcomes. The potential improvement in the individual patient’s quality of life is thereby balanced against the risk of more complications and greater expenditure of health resources on this patient.

I commend the authors for raising this set of issues for consideration. As surgeons, we routinely make decisions about what operations we recommend to patients based on the risks of the operation. However, we also allow significant latitude for patients to make individual decisions about assuming greater or lesser risks. If the patient’s surgical risks could be reduced by her stopping smoking and losing weight, should the surgeon insist upon those things being done before being willing to operate on the patient? The answer to this question depends on the perspective that one takes in viewing this case. If the surgeon’s relationship with the patient is primary and the potential benefit of surgery is clearly present, then one could view the considerations of lower public ranking and added costs to society as irrelevant. However, if a surgeon views his or her role as not only advocating for their patient, but also being a steward of societal resources, then the added resources necessary to get this patient safely through the operation are critically important to consider.

In order to come to a decision for this individual patient, the authors argue in favor of greater patient education of the surgical risk so the patient can appreciate the importance of modifying the risky behaviors prior to surgery. This concept of shared decision making with patients is certainly important and should be encouraged in any surgeon-patient interaction around a possible surgical intervention. The authors also note the importance of ensuring an alignment of values between the patient and the surgeon in why the operation might be undertaken. These suggestions are excellent and undoubtedly would lead to better relationships between surgeons and patients and also likely better decisions about when to operate.

My primary concern with the authors’ suggestions occurs when the authors encourage surgical professional societies to “develop consistent practice guidelines without partiality to any particular patient.” The authors make the claim that, in a complex case in which it is difficult to decide what is best for the patient, we would benefit from having more guidelines about what modifiable risk factors should preclude surgery.

I worry that the appeal to guidelines is too often an appeal to ignore the individual aspects of a patient’s condition and the impact that the condition has on a patient’s life. Rather than saying, “What we need is more guidelines,” I would much prefer we emphasize the need for more communication between surgeons and patients about the risks of surgery and the implications of recovery on the patient’s quality of life. Although there is nothing detrimental to gathering data about the impact of modifiable risks on surgical outcomes, I am concerned that guidelines may become viewed as parameters of “good” patient care. We all know that no guideline can account for all the individual values and goals a patient may have and, thus, we ought not use guidelines to shield us from the complex individual decision making that as surgeons we should engage in with each of our patients.

 

Reference

1. Leeds IL et al. Surgical gatekeeping – modifiable risk factors and ethical decision making. N Engl J Med. 2018 Jul 26. doi:10.1056/NEJMms1802079.

Dr. Angelos is the Linda Kohler Anderson Professor of Surgery and Surgical Ethics, chief of endocrine surgery, and associate director of the MacLean Center for Clinical Medical Ethics at the University of Chicago.

In the July 26, 2018, issue of the New England Journal of Medicine, Ira L. Leeds, MD, David T. Efron, MD, FACS, and Lisa S. Lehmann, MD, raise the important issue of how to proceed when a patient has an indication for surgery and wants the surgery, but the patient has modifiable risk factors that make the likelihood of surgical complications high.¹ Specifically, the authors describe a 45-year-old woman with morbid obesity and chronic opioid dependency who presented with a large incisional hernia. The patient suffers from debilitating pain and nausea that has been attributed to her hernia. She is homebound and is seeking a third opinion on repair of the hernia. She has smoked for 30 years and continues to do so after prior unsuccessful attempts to quit. She has been turned down previously by two surgeons who reportedly felt she was too high risk. Application of an all-procedure risk calculator has shown a 38% higher than average risk of a complication with an expected length of stay 80% longer than average.

The authors appropriately place the decision making around this case in the context of a dilemma between allowing a patient to assume greater risks (and thereby respecting her autonomous choice) and giving the surgeon the opportunity to decline a riskier operation that will result in a greater expenditure of health care resources. The authors note that, by operating on such a high-risk patient, the surgeon and the hospital will likely receive lower scores on public ranking systems and even lower payments if reimbursement is related to performance-based outcomes. The potential improvement in the individual patient’s quality of life is thereby balanced against the risk of more complications and greater expenditure of health resources on this patient.

I commend the authors for raising this set of issues for consideration. As surgeons, we routinely make decisions about what operations we recommend to patients based on the risks of the operation. However, we also allow significant latitude for patients to make individual decisions about assuming greater or lesser risks. If the patient’s surgical risks could be reduced by her stopping smoking and losing weight, should the surgeon insist upon those things being done before being willing to operate on the patient? The answer to this question depends on the perspective that one takes in viewing this case. If the surgeon’s relationship with the patient is primary and the potential benefit of surgery is clearly present, then one could view the considerations of lower public ranking and added costs to society as irrelevant. However, if a surgeon views his or her role as not only advocating for their patient, but also being a steward of societal resources, then the added resources necessary to get this patient safely through the operation are critically important to consider.

In order to come to a decision for this individual patient, the authors argue in favor of greater patient education of the surgical risk so the patient can appreciate the importance of modifying the risky behaviors prior to surgery. This concept of shared decision making with patients is certainly important and should be encouraged in any surgeon-patient interaction around a possible surgical intervention. The authors also note the importance of ensuring an alignment of values between the patient and the surgeon in why the operation might be undertaken. These suggestions are excellent and undoubtedly would lead to better relationships between surgeons and patients and also likely better decisions about when to operate.

My primary concern with the authors’ suggestions occurs when the authors encourage surgical professional societies to “develop consistent practice guidelines without partiality to any particular patient.” The authors make the claim that, in a complex case in which it is difficult to decide what is best for the patient, we would benefit from having more guidelines about what modifiable risk factors should preclude surgery.

I worry that the appeal to guidelines is too often an appeal to ignore the individual aspects of a patient’s condition and the impact that the condition has on a patient’s life. Rather than saying, “What we need is more guidelines,” I would much prefer we emphasize the need for more communication between surgeons and patients about the risks of surgery and the implications of recovery on the patient’s quality of life. Although there is nothing detrimental to gathering data about the impact of modifiable risks on surgical outcomes, I am concerned that guidelines may become viewed as parameters of “good” patient care. We all know that no guideline can account for all the individual values and goals a patient may have and, thus, we ought not use guidelines to shield us from the complex individual decision making that as surgeons we should engage in with each of our patients.

 

Reference

1. Leeds IL et al. Surgical gatekeeping – modifiable risk factors and ethical decision making. N Engl J Med. 2018 Jul 26. doi:10.1056/NEJMms1802079.

Dr. Angelos is the Linda Kohler Anderson Professor of Surgery and Surgical Ethics, chief of endocrine surgery, and associate director of the MacLean Center for Clinical Medical Ethics at the University of Chicago.

In the July 26, 2018, issue of the New England Journal of Medicine, Ira L. Leeds, MD, David T. Efron, MD, FACS, and Lisa S. Lehmann, MD, raise the important issue of how to proceed when a patient has an indication for surgery and wants the surgery, but the patient has modifiable risk factors that make the likelihood of surgical complications high.¹ Specifically, the authors describe a 45-year-old woman with morbid obesity and chronic opioid dependency who presented with a large incisional hernia. The patient suffers from debilitating pain and nausea that has been attributed to her hernia. She is homebound and is seeking a third opinion on repair of the hernia. She has smoked for 30 years and continues to do so after prior unsuccessful attempts to quit. She has been turned down previously by two surgeons who reportedly felt she was too high risk. Application of an all-procedure risk calculator has shown a 38% higher than average risk of a complication with an expected length of stay 80% longer than average.

The authors appropriately place the decision making around this case in the context of a dilemma between allowing a patient to assume greater risks (and thereby respecting her autonomous choice) and giving the surgeon the opportunity to decline a riskier operation that will result in a greater expenditure of health care resources. The authors note that, by operating on such a high-risk patient, the surgeon and the hospital will likely receive lower scores on public ranking systems and even lower payments if reimbursement is related to performance-based outcomes. The potential improvement in the individual patient’s quality of life is thereby balanced against the risk of more complications and greater expenditure of health resources on this patient.

I commend the authors for raising this set of issues for consideration. As surgeons, we routinely make decisions about what operations we recommend to patients based on the risks of the operation. However, we also allow significant latitude for patients to make individual decisions about assuming greater or lesser risks. If the patient’s surgical risks could be reduced by her stopping smoking and losing weight, should the surgeon insist upon those things being done before being willing to operate on the patient? The answer to this question depends on the perspective that one takes in viewing this case. If the surgeon’s relationship with the patient is primary and the potential benefit of surgery is clearly present, then one could view the considerations of lower public ranking and added costs to society as irrelevant. However, if a surgeon views his or her role as not only advocating for their patient, but also being a steward of societal resources, then the added resources necessary to get this patient safely through the operation are critically important to consider.

In order to come to a decision for this individual patient, the authors argue in favor of greater patient education of the surgical risk so the patient can appreciate the importance of modifying the risky behaviors prior to surgery. This concept of shared decision making with patients is certainly important and should be encouraged in any surgeon-patient interaction around a possible surgical intervention. The authors also note the importance of ensuring an alignment of values between the patient and the surgeon in why the operation might be undertaken. These suggestions are excellent and undoubtedly would lead to better relationships between surgeons and patients and also likely better decisions about when to operate.

My primary concern with the authors’ suggestions occurs when the authors encourage surgical professional societies to “develop consistent practice guidelines without partiality to any particular patient.” The authors make the claim that, in a complex case in which it is difficult to decide what is best for the patient, we would benefit from having more guidelines about what modifiable risk factors should preclude surgery.

I worry that the appeal to guidelines is too often an appeal to ignore the individual aspects of a patient’s condition and the impact that the condition has on a patient’s life. Rather than saying, “What we need is more guidelines,” I would much prefer we emphasize the need for more communication between surgeons and patients about the risks of surgery and the implications of recovery on the patient’s quality of life. Although there is nothing detrimental to gathering data about the impact of modifiable risks on surgical outcomes, I am concerned that guidelines may become viewed as parameters of “good” patient care. We all know that no guideline can account for all the individual values and goals a patient may have and, thus, we ought not use guidelines to shield us from the complex individual decision making that as surgeons we should engage in with each of our patients.

 

Reference

1. Leeds IL et al. Surgical gatekeeping – modifiable risk factors and ethical decision making. N Engl J Med. 2018 Jul 26. doi:10.1056/NEJMms1802079.

Dr. Angelos is the Linda Kohler Anderson Professor of Surgery and Surgical Ethics, chief of endocrine surgery, and associate director of the MacLean Center for Clinical Medical Ethics at the University of Chicago.