By Andrew M. Seaman
NEW YORK (Reuters Health) - A new survey of surgeons suggests many fail to discuss their patients' wishes in case a risky operation goes awry, and even more would not operate if patients limited what could be done to keep them alive.
Such medical wishes, called advance directives, outline what can and cannot be done if patients are unable to decide for themselves, but the restrictions are debated among doctors.
"(Surgeons) feel the advance directive basically ties their hands behind their back, and they're not given the tools to get them through the surgery," said Dr. Margaret Schwarze, one of the survey's authors and an assistant professor at the University of Wisconsin School of Medicine and Public Health.
She and her colleagues asked 912 surgeons who regularly perform risky operations 14 questions on how they discuss a patient's advance directives and whether they influence their decision to operate.
The survey's results, published in the Annals of Surgery, found that more than four out of every five surgeons discussed which forms of life support the patients would like to limit. But only about one half specifically asked about the patient's advance directive, which can include restricting the use of feeding tubes and ventilators to keep a person alive.
"I think some surgeons just don't discuss advance directives because they think it's so irrelevant," said Schwarze.
Over one half of the surgeons said they would not operate if an advance directive limited what could be done to keep a patient alive after surgery.
The researchers said such instructions can also cause tension between the surgeon and the patient, because it shows the patient may be unwilling to accept the therapies that come with high-risk operations.
Compared with brain surgeons, heart surgeons were much more likely to decline an operation.
According to the researchers, brain surgeons may see removing life support as a reasonable decision, because their surgical complications can cause brain damage.
Schwarze told Reuters Health it's not uncommon for heart surgeons to use techniques like CPR after an operation, and restrictive instructions may get in the surgeon's way.
"I think it's important for patients to discuss their values and goals with surgeons before a big operation," Schwarze added in an email to Reuters Health. "It's also incredibly important to discuss this with family members or someone who may need to make decisions."
However, she added that surgeons should also address the advance directive to get rid of potential confusion.
Dr. Peter Angelos, professor and chief of endocrine surgery at the University of Chicago Medical Center, agreed that family members should be involved in the discussion.
"An advanced directive is frequently a vague general statement, but in fact, every case is going to be a very specific situation," said Angelos.
He added that family members who aren't involved in a patient's conversation with the surgeon can be at a loss after the operation.
The 900 responses were from 2,100 randomly selected heart, brain and vascular surgeons in the U.S.
The study is accompanied by an editorial, which the journal declined to make available even though the survey's results are online.
SOURCE: http://bit.ly/t9SVLr Annals of Surgery, online December 1, 2011.