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Moral Distress in Neurosurgery - The New York Times

Dr. Miranda said one resident commented: “Fewer people will question you if you do surgery, so surgery is the safe answer. A lot of neurosurgeons operate on the assumption that operating on 10 people is worth saving the one out of 10 people who do well after sustaining such an injury.” Another stated: “If people understand what’s going on, they make different decisions.” Given that older, sicker patients are less likely to do well in surgery than younger ones, fully 50 percent of residents felt uncomfortable performing this relatively simple surgery (for ethical rather than technical reasons).

Dr. Buss observed that surgeons are well trained in technical aspects of neurosurgery but poorly trained in communicating with patients and families. They have virtually no training in discussing the withdrawal of life-sustaining treatments. These conversations often occur without supervision.

“Physicians,” she said, “are terrible in assessing their own communication skills,” noting that 30 percent of older adults die without the capacity to make decisions for themselves. When asked, 90 percent of patients document in advance directives their preferences to limit treatments. But physicians must ask.

This discussion resonated with me. It also provided me with a framework on which to base decision-making for future patients. Knowing that my colleagues struggle with the same doubts I do was reassuring and allowed me some needed perspective on my own decision-making and communication skills. It is crucial that we make decisions in the context of what matters to the patient and their family and that we understand as best we can their fears and hopes for the future.

With Dr. Buss’s recent talk fresh in my mind, I called and spoke to my patient’s daughter and son-in-law. Later, we all spoke with his wife. I explained that my patient had not improved much since his surgery and that, while we could remove the blood again, I was uncertain about whether he would regain independence. I had serious reservations about his future quality of life. His daughter told me that her father would not want this. He was fiercely independent and had also become the caregiver for his wife; she knew that her mother would not be able to manage the situation.

Over the course of a half-hour, it became clear to me that repeat surgery would not be in his interests and would, in fact, be a violation. We moved from this decision to discuss palliative and hospice care. His family wanted him to be comfortable and to be transferred closer to home. We all agreed that this was the best choice we could make for him at this moment.

At the end of our conversation, they thanked me for what I had done and for helping them make this choice on his behalf. Later, I consulted with the hospital’s palliative care team, which stepped in and did a masterful job of arranging for his transfer to an inpatient hospice unit at a hospital closer to the family’s home. This outcome — my patient’s death — although not what we had hoped for, felt right to all of us.

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