Operative Error Skews Surgeons' Decision to Withdraw Support



Surgeons are more reluctant to withdraw life support if they made an error during surgery. This is especially true after an elective procedure, according to an extended analysis of a recent scenario-based survey of 2,100 surgeons who were involved in high-risk operations.

The survey included a series of questions regarding specialty-specific scenarios for 700 vascular surgeons (elective and emergent thoracoabdominal aortic aneurysm repair), 700 cardiothoracic surgeons (elective and emergent ascending aortic aneurysm repair), and 700 neurosurgeons (elective and emergent calcified right middle cerebral artery aneurysm clipping), according to Dr. Margaret L. Schwarze of the University of Wisconsin, Madison, and colleagues.

In the case of the vascular and the cardiac surgeons, the complication was the same: The "patient has weakness in left arm and leg when she awakes from anesthesia." The surgical error for the vascular surgeons was inadvertent placement of the proximal clamp so that it occluded the left carotid artery; for the cardiac surgeons, it was inadvertent dislodging of the arterial cannula. For both vascular and cardiac procedures, the non–error-caused complication resulted from unexplained intraoperative stroke.

The three specialties were chosen based on the presumption of routine high-risk operations, according to a report published online ahead of print in the Annals of Surgery (2012;256:10-15).

This analysis follows an earlier report in the Annals of Surgery by these same authors, who used these same survey data to determine that the majority of these surgeons performing high-risk operations did not discuss advanced directives with their patients, and 54% were unlikely to operate on these patients if they were aware of such directives prior to surgery (Ann. Surg. 2012;255:418-23).

Of the original 2,100 surveys that were sent out, 912 were completed and returned, with roughly equal percentages (54%-56%) for each specialty.

Multivariate analysis showed that surgeons who faced complications after emergency surgery that were not clearly the result of surgeon error were nearly twice as likely to agree to withdraw life-sustaining support, compared with surgeons evaluating elective procedures that had a complication resulting from surgeon error (odds ratio, 1.95). In addition, the odds of withdrawing life support were significantly greater among surgeons who were not optimistic about the patient’s future quality of life (OR, 1.75) and among those who were not concerned that the patients did not accurately value their future health state (OR, 1.59), compared with their counterparts, according to the authors.

"Iatrogenic complications that clearly derive from technical errors during elective procedures may pose considerable guilt and emotional burden upon surgeons," the authors speculated. "It is understandable that such factors should weigh on the surgeon. However, our findings call into question the degree to which these factors may unduly interfere with a patient’s ability to control his or her health care decisions."

In addition, "our data suggest that the commission of an error in surgical technique and prognostic optimism may present a challenge to patient autonomy. ... [This] suggests the importance of efforts to alleviate surgeons’ emotional strain while simultaneously respecting the fierce ethic of responsibility that surgeons possess for patients’ outcomes."

When a patient experiences a life-threatening complication and requests withdrawal of life-supporting therapy postoperatively, surgeons may be unlikely to do so without delay, according to the authors. "These decisions may be influenced by both the timing of surgery and whether the complication was the result of explicit technical error. In addition, these nonclinical factors may be associated with surgeons’ optimism about the patient’s postoperative quality of life," they concluded.

The authors reported that they had no financial disclosures.

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