Last year, I anaesthetised a woman for a diagnostic procedure. This is hardly a groundbreaking way to start an article about risk, but she had been highlighted to me because of her multiple co-morbidities. She had a surgical condition – an intra-abdominal cyst – that caused her constant pain every day, affecting her ability to walk, to eat and to perform even her basic activities, making her entirely reliant on her daughter. She had been turned down for surgery due to her other risk factors by the anaesthetic pre-assessment clinic and the multi-disciplinary team (MDT) looking after her, yet she continued to live with constant pain and distress. After a short discussion with her and her daughter, it became obvious that she did not want to spend the rest of her life in agony and would be very happy to take the additional risk of surgery for the benefit of not being in constant pain.
Every day, every hour we work in medicine we are assessing risk. Every decision to go ahead with surgery is a risk assessment and discussion with our patient. Usually the decision is straightforward, the patient has a surgical condition, an operation will relieve it and the risk of complications from the operation or the anaesthetic is low.
When do we get this decision wrong? The most obvious is when the intervention for that particular individual is futile, for instance the housebound man scheduled for major surgery, such as an aneurysm repair, where the likelihood of a successful outcome that improves his length and quality of life is far outstripped by the likelihood of further disability, institutionalisation and an earlier death.
However, I think we can also get these decisions wrong the other way, where we deny our patients a procedure that may improve their quality of life because of their other disease processes. A few years ago, my surgeon presented a patient to me with a highly symptomatic, enormous hiatus hernia and reflux oesophagitis. She was in constant pain, unable to eat, short of breath from the pressure of her stomach on her lungs and unable to lie flat. She also had several other co-morbidities, including a tight aortic stenosis – a condition feared by anaesthetists because of the catastrophic effects it can have on the circulation under anaesthesia.
After discussion with her, her daughter and cardiologist it became clear that we would have to proceed with her hiatus hernia repair as performing a valve replacement beforehand would not be possible. She was also very clear that she could not continue living as she was, she would rather die. She made a good recovery and had her valve replaced a few weeks later. As far as I know she is still alive today and doing well. She was also very keen that I discuss her in an article such as this one and she will be delighted you’re reading about her condition.
I think we often fail our patients, particularly denying them operations that are not life-saving, so not seen as “necessary”, but where the quality of life for this person can be improved markedly by surgery. Often these patients don’t even get referred to us – I was discussing this with a geriatrician friend of mine who mentioned one of her patients, housebound with heart failure, but whose main source of distress was faecal incontinence. No one had considered that this could be treated surgically, just assuming that he wouldn’t be fit enough for an anaesthetic. Yes, it would be a risk, but I think it would be a risk many patients would be happy to take for the improved independence, not being subjected to the humiliation of his carers having to clean him up several times every day.
Thanks to technology, modern pharmaceuticals and excellent training, anaesthesia is now so safe that most of the population really don’t appreciate that every anaesthetic does carry a risk (or that anaesthetists are doctors for that matter). We also have good, comprehensive guidelines on preparing our patients for an anaesthetic and when it’s “safe” to go ahead with elective, routine surgery, particularly when the purpose is not to save life, but improve the quality of our patient’s life.
We try our very best to reduce risk, but I think, at times, this is at the expense of our patients, protecting ourselves rather than benefitting our patient. We need to be aware of the risk of what we’re doing, minimising it where we can, but we mustn’t be risk averse.
.png)
.jpg){kind=logo}
