The study, published online ahead of its appearance in the July issue of Annals of Surgery, is the first large-scale study to identify a link between surgeons’ personal responsibility for technical performance and their decisions about post-operative life-supporting treatments.
Dr. Margaret “Gretchen” Schwarze, an assistant professor of surgery at the UW School of Medicine and Public Health, surveyed 912 vascular, cardiothoracic and neurosurgeons across the country to better understand their practices regarding decisions about the withdrawal of life support. The survey presented surgeons with different scenarios where a patient suffers dire post-operative complications.
In one scenario, the problem is caused by surgeon error; in another, it is unclear what caused the complications; sometimes the operation is portrayed as an emergency and sometimes as an elective procedure.
In the scenario where patients suffer complications from technical error, only 33 percent of surgeons said they would honor their patient’s request to withdraw life support. However, that number jumps to 41 percent when the complications presented in the scenario were not explicitly the result of surgeon error. The gap was the same in the elective surgery versus emergency scenarios, where surgeons were more likely to withdraw life support after emergency surgery than after elective surgery.
“Our study strongly suggests that a surgeon’s emotions and sense of responsibility have inevitable clinical consequences for patients,” says Schwarze. “I think it protects surgeons psychologically to feel that they’ve done everything possible to save their patient.”
Surgeons also reported being influenced by their own optimism and the belief that patients can’t accurately predict their future health state. Schwarze, who is a surgeon herself, says this sense of total responsibility and accountability is a result of both surgical culture and training.
“Surgeons think, ‘I got you into this situation, and now I need to get you out of it.’ And that’s a great attitude for a surgeon to have,” she says. “I think we would all want our surgeons to feel responsible for us and to fight for us.”
The problem, Schwarze acknowledges, is when the surgeon’s patient has little hope for improvement and does not want to be kept alive by machines, but the surgeon refuses to consider palliative care options because of the “all in” attitude that comes with being a surgeon.
“Our findings call into question the degree to which non-clinical factors may unduly interfere with a patient’s ability to control his or her health care decisions,” Schwarze says. “It highlights the importance of frank discourse and consultation with other disinterested parties to help navigate what may be difficult decision-making about end-of-life care, particularly when there is disagreement between patients, their families and the treating physician.”
Co-authors of the study include:
- Andrew Redmann from the UW School of Medicine and Public Health
- Dr. Karen J. Brasel of the Medical College of Wisconsin
- Dr. G. Caleb Alexander of Johns Hopkins University School of Medicine
Dr. Schwarze’s work is supported by the Greenwall Faculty Scholars Award and the Department of Surgery in the UW School of Medicine and Public Health. An abstract of the study is available online; full copies of the study are available upon request.
University of Wisconsin School of Medicine and Public Health