Surgeons balk at withdrawing life support after medical errors
■ They feel responsible for their patients’ welfare and want to see them pull through after high-risk procedures, according to a new study.
Nearly two-thirds of surgeons are unwilling to honor a patient’s request to end life support after operating on that patient, and they are less willing to do so when a surgical error occurs, said a study in Annals of Surgery in July.
Researchers surveyed 912 neurosurgeons, cardiothoracic surgeons and vascular surgeons who performed an average of 10 high-risk procedures a month about how they would respond to a scenario specific to their specialty. The vignette in the survey concerns a high-risk surgery for a 75-year-old woman with emphysema and stable coronary artery disease who has an intraoperative stroke and weakness in her arm and leg upon awakening after surgery. She struggles postsurgery and is reintubated twice, and after seven days has developed pneumonia and needs ventilator care. The patient and family request withdrawal of life support, saying her future quality of life is unacceptable.
Faced with that scenario, 63% of surgeons said they would be “not at all” or “somewhat unlikely” to withdraw life support. Fifty-seven percent said they were likely to recommend that the patient and family wait 10 days to see if her condition improved, said the study (link).
Meanwhile, respondents who were told that a surgeon error occurred during the procedure were nearly twice as likely to object to withdrawing life support. The survey results highlight how surgeons’ sense of personal responsibility for their patients’ outcomes influences their decision-making about withdrawing life support, said Margaret L. Schwarze, MD, assistant professor of surgery at the University of Wisconsin School of Medicine and Public Health in Madison and lead author of the study.
“I’ve been practicing for 10 years, and I’ve seen this happen,” said Dr. Schwarze, a vascular surgeon. “It’s like, ‘Gosh, we did all this stuff to save you and now you want to quit on me?’ ”
Behind surgeons’ optimism
The three factors that had the biggest impact on surgeons’ willingness to withdraw life support were: their personal optimism regarding the patient’s future quality of life; their concern that patients could not accurately predict their future health status; and their personal feelings about the morality of withdrawing life support in the given scenario. Survey respondents did not commonly rate fear of litigation or impact on their performance metrics as important decision-making factors.
“This needs a lot more study, but this at least suggests that feeling responsible for the patient makes you want to feel optimistic about their chances of getting better,” Dr. Schwarze said. “It’s much harder to prognosticate when you feel responsible for the patient.”
Surgeons should be cognizant of how their emotional commitment to the patient may influence their clinical recommendations, she added. The study is prefaced with a quote from medical ethicist and sociologist Charles L. Bosk that illustrates the surgeon’s dilemma: “When the patient of an internist dies, his colleagues ask, ‘What happened?’ When the patient of a surgeon dies, his colleagues ask, ‘What did you do?’ ”