How a family conference affects the decision for surgery

by Chris Porter, MD

“Treat your patients as you would your own loved ones,” is advice taught throughout training in health care.

Great advice.  I use it constantly.  Mr. Davis is dying of multiple organ failure in the ICU after exploratory abdominal surgery.  His siblings and children trickle in from Florida and Montana.

I’m always sorry for the last to arrive, who visits his dying brother’s bedside minutes before the family conference.  Sister and daughter have been holding Mr.  Davis’ hands for days, hearing my doubts, letting the gravity sink in, saying goodbye in their hearts.  The last arriver is the one who looks the most stunned at the family conference.  He is realizing his brother was kept alive (or kept dying) for three days, awaiting him.  This is when I tell the family what I would do if Mr. Davis were my brother.  This is emotionally difficult, but intellectually easy.

Harder is advising patients when the answers are less clear:

Mr. Jones has gallstones and seems to have had minor gallbladder attack.  I’m not certain.

“Do I need surgery, Doctor?”

“Well, if you were my brother…”

I would advise three of my siblings the same way:  “Let’s see if the pain happens again.”  All three would take my advice and go about their lives, giving rare thought to gallbladders and operations.

My other brother?  Not so much.  I keep this in mind when advising patients.  Some brothers don’t feel properly managed with simple reassurance; they feel blown off.  Some brothers comb the internet and determine that indeed the gallbladder is the problem.

Brother X, who is very goal-oriented, now has a checklist in a daily planner that reads:

1.     Get gallbaldder removed (laparoscopically, by surgeon who performs more than 100 cholecystectomies per year)
2.     Climb Mt Everest (Thomas Hornbein route)
3.     Learn violin
4.     MRI of knee
5.     Haircut
6.     Fold laundry
7.     Buy oxygen canisters (see #2)

My job is not only to identify pathology, but to identify suffering.  Brother X will suffer a great deal waiting for a gallbladder attack that may never come.

Yes, I recommend different things to different patients.  The art is identifying, in the few minutes you’ve spent with the patient, which brother he is.  If I’m on the fence, I tell the patient so, and try to coax out his/her personality and philosophy.  If the patient says:

“So I don’t necessarily need surgery?  Great, because the last thing I want is an operation,”  the patient gets reassurance.

If he says, “So the choice is wait around to die from my next gallbladder attack or have keyhole surgery? Take it out, Doc.  Can you do it today?”  That is brother X, who is on the schedule for a lap chole.

Chris Porter is a general surgeon and founder of OnSurg.com.  He blogs at On Surgery, etc.

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  • Winslow Murdoch

    This is a rational and individualistic way of approaching patient care when there is some level of uncertainty and there are risks with either approach.
    How will this conversation and individualized decision making fit when we are all part of an accountable care organization (ACO)? Will brother X be allowed to (or have the suggestion made to) personally opt out of our ACO panel?
    Will we suggest that brother X find another surgeon who is part of a competing ACO so that his assertiveness doesn’t become a liability to our ACOs bottom line now and in the future?
    Will we become “cherry pickers” of compliant non assertive patients to best compete?

  • Monique

    When my father had a stroke, the hospitalist called us (me and my two siblings) in to discuss options. My father couldn’t swallow and had developed pneumonia. One option was to hook him to a machine which would force air into his lungs. This would keep him alive for a time, but it would have to be done over and over again; it wasn’t a cure. My siblings wanted to do it. I didn’t. I asked the hospitalist what he would do if it were his Dad. My siblings snorted at this “stupid” question. The doctor didn’t. He reminded us that my Dad had signed a living will and he would follow his Dad’s instructions. The machine wasn’t used and my Dad died two days later. It was hard, but I know we did the right thing.

  • http://www.whatstherealcost.org Susan

    Winslow – regarding individualistic care and ACOs, practice standards, all that stuff MDs regard as “cookbook” medicine — the patients’ outcome has to be in the mix there somewhere. If the outcome is satisfactory, that has to count for something if care is within the range of normal practice.

    Of course, some brothers are satisfied ONLY after every conceivable thing has been done, but that’s exactly where the doctor can draw on practice standards to reassure the patient and keep the care rational (as opposed to rationing). Doctors are always saying medicine is both art and science, and surely part of the art is reading the patient, as Dr. Porter reports here.

    Me, I’m the sibling who had two acute gallbladder attacks, and spurned the operation, after going to a naturopath to find out that enteric-coated peppermint oil pills (antispasmodic) would ease future attacks. It works beautifully, I still have a functioning gallbladder and seldom had another episode because I know what brings them on and how to avert them.

    And patients definitely have a role to play here. This video captures my beliefs on being an engaged and informed patient: http://whatstherealcost.org/video.php?post=five-questions

  • Beth Havey@Boomer Highway

    Just last week I had to decide for my 95 year old mother who has dementia, that she should have surgery because she fractured her hip in two places. The doctors said surgery was necessary to deal with her pain. I made sure that the DNR was in place and worked with the anesthesiologist. Because he was doing a spinal and would have to give her fluids when her pressure dropped, he agreed to let her go if she coded during the procedure. She came through and now is dealing with exhaustion and post-surgical pain. Very hard decisions.