Implications of the surgical buy in when discussing informed consent

Pauline Chen had a post in the New York Times recently about surgical informed consent. Informed consent is an important part of the surgeon/patient communication transaction.

Surgeon reviews the proposed operation, the rationale behind it, and the possible complications. For example— a patient comes in with biliary colic. We describe the anatomy and pathology. We aver that surgical resection will lead to cure. The operation (laparoscopic cholecystectomy) is described in detail. Potential complications are addressed (bile leak, CBD injury, bleeding, infections, cardiopulmonary morbidity, etc.) Patient is informed that although complication rates are low, there is still a statistical probability that her procedure will encounter such problems. Given all this information, patient then decides what she ultimately wants to do. Informed consent.

Dr. Chen talks about this concept called “surgical buy-in” where the patient is prepared for worst case scenarios prior to the operation. When a case goes bad, we surgeons have a tendency to implement the full court press, whereby we try anything and everything to get our patients back on course, even when the situation begins to look futile. It’s our ingrained sense of responsibility and duty to try to reverse the deterioration. But sometimes these last gasp maneuvers are not what the patient would have wanted.

There’s an article in Critical Care Medicine from March that talks about this buy in. For complex elective operations (Whipples, liver resections, transplants, rectal surgery) surgeons would negotiate with patients prior to the surgery the extent to which both the surgeon and the patient were willing to labor if things took a turn for the worse. In other words, the surgeon would say something along the lines of: “If you leak from your pancreaticojejunostomy and get septic would you be willing to be reintubated? Taken back for revision? If you were unable to be weaned, would you consider a tracheostomy? What about CPR? Is there a time limit you would restrict aggressive intervention to, i.e. if you weren’t improving by 6-8 weeks of intensive therapy, then palliative measures would be undertaken?”

It’s a great idea. As long as we restrict the protocol to those complex operations. I’d hate to put my patients through such a terrifying question and answer session prior to a lipoma excision or a breast biopsy.

Jeffrey Parks is a general surgeon who blogs at Buckeye Surgeon.

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