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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