The Right Choice?

The right choice? Surgery “offered” or “recommended”?


 

The story was not unusual for a late-night surgical consultation request by the emergency department. The patient was a 32-year-old man who had presented to the emergency room with crampy abdominal pain. He initially had felt distended, but – during the 3 hours since his presentation to the hospital – the pain and distention had resolved. A CT of the abdomen and pelvis was obtained shortly after the patient arrived in the emergency department. The study showed some dilated small bowel along with a worrisome spiral pattern of the mesentery that suggested a midgut volvulus. The finding was surprising to the surgical resident examining the patient given that the patient now had a soft and nontender abdomen on exam. The white blood cell count was not elevated, and the electrolyte levels were all normal.

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

Dr. Peter Angelos

The surgical resident’s assessment was that, despite the unremarkable abdominal exam and the resolution of the patient’s pain, surgery was indicated. The resident discussed the patient’s case with the attending surgeon on call that night, and the attending agreed: The patient should have an abdominal exploration to rule out a midgut volvulus and the potential for an abdominal catastrophe.

When presented with this recommendation, the patient declined the recommended surgery. He stated that he felt fine and that this would be a bad time to have an operation and miss work. The patient ultimately left the hospital only to present 5 days later with peritonitis. When he was emergently explored on the second admission, he was found to have a significant amount of gangrenous small bowel that required resection.

The case was presented at the M and M (morbidity and mortality) conference the following week. When asked about the prior hospital admission, the resident reported that the patient had been “offered surgery,” and in the context of “shared decision making,” the patient had chosen to go home. This characterization of the interactions with the patient raised concern among several of the attending surgeons present. Was the patient only “offered” surgery, or was he strongly recommended to have surgery to avoid potentially risking his life? Was the patient’s refusal to have surgery despite the risks actually a case of “shared decision making”?

These questions are but a few of the many that can arise when language is used indiscriminately. Although, in the contemporary era of “patient-centered decision making,” it is common to think about every recommendation as an offer of alternative therapies, I worry that describing the interaction in this fashion is potentially misleading. Patients should not be offered potentially life-saving treatments – those treatments should be strongly recommended. Certainly, we must accept that patients can refuse even the most strongly recommended treatments, but a patient’s refusal to follow a strong recommendation for surgery should not be characterized as shared decision making. “Shared decision making” suggests that there are medically acceptable choices that the physician has offered the patient, from which the patient can make a choice based on his or her preferences and values. The case above is not shared decision making but one of respecting the patient’s autonomous choices even if we do not agree with the choices made.

There are undoubtedly situations in which there is a choice among reasonable medical options. When there is a such a choice to be made, as surgeons, we should help our patients understand the options so that they can make a decision that best fits with their values and goals. However, when the only choice is whether to have the recommended surgery or decline it, we have now moved beyond shared decision making. In that circumstance, we should strongly recommend what we believe is the better option while still respecting the autonomy of patients to decline our recommendation.

Shared decision making often is viewed as the pinnacle of ethical practice – that is, involving patients in the decisions to be made about their own health. Although I agree that we do want to educate our patients and encourage them to make what we consider safe medical decisions, when we recommend a safe choice and the patient declines it, we are no longer talking about shared decision making. In such circumstances, we are in the realm of respecting patients’ choices even when we disagree with those choices. Our responsibility as surgeons is to recommend what we think is safe but respect their choices whether we agree or not. We should do more than simply offer surgery when it is potentially life threatening not to have it.

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