Little conversations about big decisions

Margaret L. Schwarze, MD, MPP, wants you to know that surgeons are not crazy. Or, at least, they're not just acting crazy when they argue with hospitalists about providing life-sustaining treatments to very ill patients.

To better explain surgeons' perspectives on these debates, Dr. Schwarze, an assistant professor of surgery at the University of Wisconsin School of Medicine and Public Health in Madison, Wis., recently surveyed a national sample of her colleagues about how they would typically talk to a surgical patient who preoperatively requests limits on postoperative life-supporting treatment.

Almost two-thirds of the cardiothoracic, vascular, and neurosurgeons agreed on how to respond to such situations: They would create an informal contract with the patient describing agreed-upon limitations of aggressive therapy, or, if that didn't work out, they would sometimes or always refuse to operate. These survey findings were published in the January 2013 Critical Care.

The two approaches outlined can lead to issues in surgeons' communication with patients and other physicians, according to Dr. Schwarze. She recently spoke with ACP Hospitalist about potential consequences and solutions.

Q: What led you to research this topic?

A: I'm a surgeon, and I did a fellowship in clinical ethics. I was at an ethics conference and gave a talk. Afterwards one of my colleagues stood up and said, “Why is it that surgeons have such a hard time withdrawing life-supporting treatments on their postoperative patients? Is it that they are nervous about their outcomes measures, or is there something else going on?”

That question inspired me to look into this issue. Several years ago, I did a qualitative study where we interviewed some surgeons and talked to them. We had this idea that maybe if you had an advance directive before surgery, it wouldn't be so hard to withdraw life-supporting treatments afterwards if necessary. What we ended up finding was this phenomenon we describe as buy-in, that surgeons expect patients to participate in postoperative life-supporting treatments and that they think they have had a conversation with patients about this preoperatively. That was the basis for this national survey of surgeons.

Q: Are there lessons in your research for hospitalists who comanage surgical patients?

A: There's a tremendous amount of conflict between surgeons and intensivists or surgeons and hospitalists about taking care of their postoperative patients. Maybe part of why there's conflict postoperatively is because surgeons are trying to support patients' preferences about what they would want, and [physicians] who hadn't met the patient beforehand were unaware of this conversation or deal that happened preoperatively.

Sometimes people look at surgeons as these crazy, mean people who are doing this just to protect themselves. I don't think that's the usual stance of the surgeon. I think the usual stance is, “I talked to the patient before. I truly believe that this is what they thought surgery was going to be about and they wanted to fight and be aggressive after surgery.”

If anything comes out of this research, it's not for people to give surgeons a break, but to try and figure out where they're coming from, because I do think that helps de-escalate this conflict that happens postoperatively.

Q: Were you surprised by any of the survey results?

A: The thing that surprised me most is that there is clearly an association with surgeons who are concerned about their outcomes metrics [being more likely to] decline to operate on patients who have preferences for no life-supporting treatments.

That gets back to what my friend said a long time ago: Is it just about outcomes measures? It's not a huge group of people, but it is significant. That's an area that probably is going to need a lot more thought about how to preserve the good things that outcomes measures do to inspire quality and safety, but make sure that it doesn't have this horrible side effect of either not offering patients operations that they would want, or potentially keeping them alive postoperatively in a state that was not acceptable to them.

Q: Are these informal preoperative contracts an effective system for ensuring that patients get the treatment they want?

A: This survey gives a very birds' eye view, but we really don't have a sense of what these conversations are like. We're doing a project now where we're listening to surgeons talk to their patients.

My hunch is that I can see why the surgeons think they've had this conversation, but it's not at all clear to me that the patients understand that this is what's happening in the conversation. It's entirely possible that while [the surgeons] are getting informed consent, they're interpreting that as, “We talked about this. We talked about the things that could go wrong, and the things we might do if things went wrong.” I can imagine that's a very, very scary conversation for the patient. It would require the patient to chime in and say, “I might not want that,” and that would take a very sophisticated and savvy patient.

Q: Do you have any potential solutions?

A: My original solution was that every patient should just have an advance directive before surgery, and I think that is a really bad idea for about 10 different reasons now. One reason is that there are many surgeons who would refuse to operate on a patient who had an advance directive, and it's not entirely clear to me that that is in line with the patient's preferences at all. A patient who would benefit from surgery and would prefer to have surgery to reach a certain goal, to have that goal be restricted because of the presence of an advance directive seems to me very dangerous.

It seems to me advance directives are likely to set up some sort of impasse between the patient and the surgeon, when I think you could get through that with a different kind of conversation that didn't revolve around procedures and treatments and a laundry list of what you did and didn't want, and instead had a conversation more about the goals of surgery and patients' fears about surgery.

How do we get people to have those conversations without getting stuck on this impasse? This might be a really nice place for patient coaching, something as simple as a brochure that the patient could read in the office before they met with the surgeon: “You're going to have a conversation about having surgery. These may be some questions that would be important to you to talk to the surgeon about.” I suspect there are probably some other more sophisticated things.

One of the projects I have just starting out right now is to talk to patients before they're about to have a high-risk operation and get a sense of what their decisional needs are. It's entirely possible that this is just too scary a conversation to have and they're not able to do that before an operation. It's entirely possible that because the surgeon is very dominant in the surgeon-patient relationship that the dynamic is not a good setup to have this kind of conversation. It's hard to know what the right solution is.