We live in a society with an average life expectancy of more than 80 years. Our families are smaller and so death comes as a relatively infrequent event for most individuals. When sudden and unexpected, particularly when associated with routine surgery, the reaction is to find out what went wrong and who was to blame. How could this happen to us, our family, my spouse?
For the surgeon, the problem is very personal. The surgeon performs the procedure and carries ultimate responsibility for the outcome.
Surgery is an imperfect science. Every operation carries some risk of death. If the patient has other diseases, such as diabetes or heart disease, the risk increases. The patient may further add to their risk by being a smoker or obese. Many patients seem to combine all imaginable risk factors yet still want surgery performed.
The surgeon can refuse such requests and ensure they only operate on the fittest patients: their results will be excellent. Or they can take the high-risk patients and their own stress levels and anxiety will increase.
If an operation has in a fit patient a 1% risk of death but in an obese elderly smoker a 15% risk of death, it still means 85% of such high-risk patients have a satisfactory outcome. If the operation is for a cancer, this may be acceptable to the patient, doctor and family but three in 20 patients will die from that operation.
Recently a patient of mine in her 50s, who was otherwise well except for a tumour within her liver, died on the operating table from massive haemorrhage. I telephoned the husband and he came immediately to the hospital. He was stunned, angry and looking for a reason.
For the surgeon it was devastating and led to considerable self-recrimination. What if a different approach had been tried? Could another have done it better? Was it the wrong decision in the first place? Subsequent meetings with the extended family did little to placate their grief or doubts.
It is interesting that society feels it can unburden itself onto surgeons with little understanding of the devastating effects such an outcome has on the surgeon themselves. Death in an emergency situation is no less tragic for the family but much more acceptable.
Despite surgeons informing patients and families of the 1-2% risk of death for much routine surgery, few believe it should happen to their family member.
Surgeons need to be convinced the operation is necessary and patients must accept death as a possible outcome, something that seems to occur so rarely in our society today.
*Guy Maddern is professor of surgery at the University of Adelaide. St Anywhere is fictitious, but the events and issues are real.
“It is interesting that society feels it can unburden itself onto surgeons with little understanding of the devastating effects such an outcome has on the surgeon themselves.”
It’s pretty interesting that the surgeon in question thinks the effects of the death could be more devasting on him than the family of the deceased…this is an unusual article to say the least.
It’s the culture of blame that is to ..er… blame. People are not that good at accepting responsibility for risk, especially if the risks are considerable, and entail factors that are within their control – like being an obese smoker. Where professional people such as doctors, surgeons, pediatricians, and teachers have to accept blame (and litigious blame in some instances), they leave the field in droves. Be careful who you blame for poor outcomes of risky procedures – some of these will be due to human error and negligence, but it sounds to me like Mr Madden takes his job, and his responsibility seriously enough to be distressed by the loss of a patient – isn’t that a good thing??
Jenny with all respect I think what he was pointing out is that even low risk procedures carry a risk. Nobody expects to die from an appendectomy but the truth is some do.
I think that was the Dr’s point.
I had surgery (keyhole gall bladder) for the first time at age 60 a couple of years ago and I was scared witless, never before having had a general anaesthetic. But it went fine and there were no problems at all. I think one of the reasons some people think surgery is ‘just a procedure’ is the the TV programs which depict all the procedures with successful and happy outcomes. People’s understanding is skewed by these programs. All surgery is serious, just the anaesthetic can kill you. Just ask ex PM John Howard who had a close shave recently.
I think the key point is that, as the article says, people accept that there is a 1-2% chance of a bad outcome but still don’t expect this will occur to them. This is because people are not particularly interested in why a bad outcome happened, they are interested in why it happened to them. I believe that is the main element of blame – yes, I know people die all the time but what went wrong to make it happen this time, not to the last guy or the next guy. Surgeons, and doctors in general, do need to be more choosy about selecting patients but they also need to be more personal in their communication of risk. Tell each patient directly “You might not survive this operation. Despite our best efforts, there are unexpected complications which can and do develop” If they want surgery on those terms, then they want it enough.