Dr Sheila Carey - Regional ELC - Complex decision making
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Presentation by Dr Sheila Carey - Arrowe Park Hospital at the Regional Emergency Laparotomy Collaborative - Complex decision making collaborative at Arrowe Park Hospital on 24 January 2020.
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Dr Sheila Carey - Regional ELC - Complex decision making
- 1. Dr Sheila Carey Consultant Anaesthetist, Arrowe Park Hospital NELA Lead Learning through Case Studies Informed Decision Making for Difficult Cases
- 2. Outline • Present brief history of cases • What makes decisions difficult • Important issues to consider when planning care for the more “challenging” patients • Factors that affect our decisions • Return Case Examples • An approach to making difficult decisions
- 3. Case 1 • 85 male, admitted under T&O Haemarthosis • PMH • Previous Laparoscopic- converted to open Hartmann’s procedure Bowel CA 2015 • AF, HTN • CML • Bronchiectasis • Wheeler to mobilise, Stair lift at home, Drives to shops • D3 Referred EGS • Distend abdo & vomiting and non functioning stoma • MEWS 4, AKI stage 2, CT SBO from parastomal hernia • Patient Refuses Surgery, Family Disagree
- 4. Case 2 • 71 Male • Lives alone, good social network • Admitted diffuse abdominal pain & vomiting • Known Lung Ca ( mesothelioma), considered for palliative chemotherapy ( patient not keen), seen 6/52 earlier with oncology stated despite SOBOE manages 3 flights stair to his flat. • CT scan – faecal peritonitis sigmoid perforation. Booked for surgery. • Preop review raised questions about suitability for surgery and sequalae
- 5. To operate or not.. That is the question.. • What is the patients perspective? • Opportunities for optimisation are limited • Predicting the physiological impact of surgery is difficult • Risk assessments can inform shared decision making • Collaborative approach between specialities can help find perspective and inform discussions with patients and families about options and potential outcomes
- 6. Potential Pitfalls • Emergency setting, preference patients are often not precisely defined • Conversations often traditionally framed around the structure of informed consent • Shared decision making should align patients values with treatment choices
- 7. What do patients want • Relief from suffering • Maintain quality of life • Fear of Nursing Home • Worry about having a bad death • Quality of Life is important, not prolongation of life • When the choice is Surgery or Palliation: • Live or Die • How to Die
- 9. Factors affect decision making • Surgical Judgement / Concept of Futility • Surgical Introspection • Pressures to operate • Other Surgeons, Institution, Colleagues • Patient, Family, Society / Culture • Cost of operating • Medical insult , emotional burden patient and physician • Can be easier to err on the side of operating – despite uncertainties / futility • Surgeons need to be empowered to advise against intervention when not beneficial
- 10. Presenting the options • Misunderstandings and faulty expectations need to be identified and addressed • Dispel false assumptions about treatment • Understand Values and Goals of the patient and their family • Be aware of personal biases • Required to understand benefits, risks, alternatives to surgery including option no intervention • Awareness of how such eventualities can be managed is critical to informed discussion • Ensuring transparency through discussion can facilitate instigation of ceilings of care / advanced planning
- 11. Ensure Clarity of information given • Rather than stating probability of death, describe the cascade of complications that precedes death. • Describe surgical outcomes within the context of prognosis over the longer term • PROGNOSIS AND GOALS (TREATMENT AND CHOICES)
- 12. Case 1 • 85 male, admitted under T&O Haemarthosis • PMH • Previous Laparoscopic- converted to open Hartmann’s procedure Bowel CA 2015 • AF, HTN • CML • Bronchiectasis • Wheeler to mobilise, Stair lift at home, Drives to shops • D3 Referred EGS • Distend abdo & vomiting and non functioning stoma • MEWS 4, AKI stage 2, CT SBO from parastomal hernia • Patient Refuses Surgery, Family Disagree • Discussions with patient reveal desire not to have surgery or prolong life • Made clear that refusal would end life, still refused • Daughter discussed with surgeons and she had discussion with patient, family leave • Patient tells family will have surgery, but then refuses again once left • Patient expresses desire to leave things as they are, not be a burden, and does not want surgery, • Family called in again, and decision to proceed made, Patient dies within 72 hours post op
- 13. Case 2 • 71 Male • Lives alone, good social network • Admitted diffuse abdominal pain & vomiting • Known Lung Ca ( mesothelioma), considered for palliative chemotherapy ( patient not keen), seen 6/52 earlier with oncology stated despite SOBOE managed 3 flights stair to his flat. • CT scan – faecal peritonitis sigmoid perforation. Booked for surgery. • Preop review raised questions about suitability for surgery and sequlae • More fact finding about current state of health • Downwards trajectory of health and functional status over last 12 months and acutely over the last week from cancer point of view • Wasn’t keen on palliation chemo for lung ca • Treatment options discussed and possible outcomes raised including the ceilings of care for intensive care • Patient opted for palliative treatment • Opportunities for family and friends to visit during his final days
- 14. Difficult Decision? Apparently Difficult Difficult 1) Recognise futility 2) Proper History Taking - Patient doesn’t want surgery 1) Not futile 2) Patient might want surgery Not for surgery Truly Difficult Decision Can the patient withstand the procedure physiologically (Premorbid condition, surgical insult planned / required) NO Yes Patient: Values and Goals Doctor: Is it wise? Are ceilings of care required? (inter speciality discussion) Proceed with surgery Documentation: patient centred discussion
- 15. References • Nabozny, Michael J et al. “Constructing High-stakes Surgical Decisions: It's Better to Die Trying.” Annals of surgery vol. 263,1 (2016): 64-70. • Rachel S. Morris, Jessica M. Ruck, Alison M. Conca-Cheng, Thomas J. Smith, Thomas W. Carver, Fabian M. Johnston. Shared Decision-Making in Acute Surgical Illness: The Surgeon's Perspective. Journal of the American College of Surgeons, 2018; 226 (5): 784 • https://onlinelibrary.wiley.com/toc/13652044/2020/75/S1 • Anaesthesia 2020 Special Issue Advances in perioperative care • E. C. McIlveen E. Wright `M. Shaw J. Edwards M. Vella T. Quasim S. J. Moug A prospective cohort study characterising patients declined emergency laparotomy: survival in the ‘NoLap’ population
- 16. Discussion
Editor's Notes
- To operate or not is a challenging question to answer with a number of different perspectives to consider – not least that of the patient, This clearly should be central to the whole discussion as clinicians we need to be aware of the reasons why patients hold the views they do so that we can better understand the perspective, allay their fears, address misconceptions and get to the heart of what it is truly matters to them the most Unlike in elective surgery, the opportunities for optimisation of this group is limited. This group is of largely older, frailer patients with multi co morbidity are optimisation is fairly limited when emergency surgery is required and what can be done is to acute physiology only Surgery initiates a systemic inflammatory response affecting the immune, metabolic, endocrine and cardiovascular systems. Predicting the impact on this reserve, in the presence of chronic co morbidity and often acute physiological derangement and sepsis, is a real challenge. Answering the question requires a collaborative approach between specialities and disciplines giving considering to the whole period period from contemplation to recovery, and not just the actual operation itself.
- Emergency setting, the preferences of patients not precisely defined In addition, the surgeons and anaesthetists and patient often haven’t had a pre-existing relationship that might otherwise in an elective setting given insights into preferences. Furthermore the patients preferences themselves can often change in an acute illness scenario. Conversations that are had are often framed around the structure of informed consent, which is not a great vehicle for decision making. Decisions to proceed with surgery can start a clinical trajectory that is inconsistent with a patients personal preferences. Surgery can be a burden to older frailer patients.
- Interviews that have been conducted with elderly patients who have co morbidities placing them near the end of their lives. These patients asked to state certain preferences when interviewed with regards contemplating high risk surgical decisions. They want to be sure that they get some relief from and the avoidance of suffering Want to be able to simple things like converse with relatives Ambulate Make decisions A Loss of independence is not what most people want. They Fear being a burden on relatives and fear of requiring NH care.
- When choice on offer is surgery or palliation, Patients tend to see things in one of 2 ways. Whether to live or die, of How to die Those that may be keen on surgery, for some their personal beliefs may make it imperative to always choose life,: Don’t want to feel Guilt/disappoint others, Only God decides life and death , Cannot explicitly choose death that its better for them to die trying to live ( proceed with surgery), It's painless to die in the operating room, Death in surgery is okay because it is controlled by someone else(surgeon/God) or they believe that their life will somewhat be better than what is presented, Disbelief about outcomes/options, Surgeon is wrong/misinformed, Surgery might be “successful” Those that don’t have surgery will have death now or later, know that surgery can prolong death but that death can be expected – potential to involve family, be painfree and at peace.
- Surgical Judgement / Concept of Futility Surgical Introspection Pressures to operate Other Surgeons, Institution, Colleagues Patient, Family, Society / Culture Cost of operating Can be easier to err on the side of operating – despite uncertainties / futility. Often factors outside control add pressure - late consults / time pressures / even what time of the day it is ( inter speciality working / advice) Surgeons to be confidently and make patient centred decisions Need the tools to help them do this - Having skills, knowledge and wisdom can empower them to advise against an intervention when the risks outweight the benefits How the y present the options to a patient can also affect the patients perspectives on what the best course of action may be. Sometimes might offer no choice – outcome is unacceptable and will avoid buredensome tratemnt, Boased choice – surgeon feels patient not for surgery and frames it this way to the patient and family, or they can be offered a simple choice where the patient and family decide and a sugeon may suppress their own opinion. Futility represents a concept often used to justify withholding/withdrawing therapies and, at the same time, a shift in the physician's ethical obligations to patients. In this sense, one might expect that physicians would use clear criteria for determining when a therapy is futile. This is not true. Rather than being a discrete and definable entity, a therapy may be defined as futile merely when we cross the threshold of the therapies with very low efficacy. Decisions to withhold/withdraw therapy deemed as futile must follow both clinical evidence about the chance of success of a therapy and an explicit consideration of the patient's goals for therapy expressed by the patient when possible or their surrogates.
- Misunderstandings and faulty expectations need to be identified and addressed as they can influence high stakes decision making We must dispel false assumptions about treatment We must understand what the values and goals of the patient are and be aware of the personal biases we may hold that can affect our own judgements Our subjective experiences can influence our deceiosn making Clinicians should have a broad understanding of potential benefits, risks, alternatives to surgery including the option of no intervention. Discussing the option of no treatment relies on knowledge of surgical disease progression if surgery is not undertaken. And an awareness of how these eventualities can be managed is critical to an informed discussion, so that the details of expected symptoms, potential mode of death and palliative management options are included. Ensuring transparency through shared decision making discussions can facilitate instigation of appropriate ceilings of care / advanced planning.
- The decision to operate or not is complex. It is guided by objective patient characteristics and the subjective experiences of the emergency surgeon and peri‐operative team. The most common documented reasons for not operating were ‘poor fitness’ and ‘not fit enough for surgery’. In most cases the diagnosis of fitness too poor to proceed to laparotomy was not explicitly justified in the notes, Recently published finding frm the No Lap Anaesthesia 2020 In conclusion, this is the first UK study to characterise the third of patients who are eligible for emergency laparotomy but who do not proceed to surgery, of whom one‐third survive at least 30 days. Predicted survival suggested that some patients who did not proceed to surgery might have benefitted from laparotomy, while some patients who had laparotomy might have benefitted from non‐surgical interventions. Decisions to operate or not are complex. We hope that further research will improve the management of patients with acute abdomen and may inform how to best match patients to operative management or symptomatic management without surgery. Original Article A prospective cohort study characterising patients declined emergency laparotomy: survival in the ‘NoLap’ population† E. C. McIlveen E. Wright `M. Shaw J. Edwards M. Vella T. Quasim S. J. Moug