Wednesday, December 7, 2011

Time Well Spent

     Increasingly, I find myself feeling more like a factory assembly-line worker than a physician. This has led to a profound sense of disillusionment to the point where I have seriously considered abandoning medicine altogether.  It seems as though many of us anesthesiologists have succumbed to functioning as cogs in a health care machine which relentlessly cranks out surgical cases at an astonishing rate, where cancelling an elective case because a patient hasn't been NPO is considered a mortal sin, and where it's not always clear that patients are actually benefiting from their procedures. As hospitals compete for "customers", there is increasing pressure to push these cases through the system, and God help us if we stand in the way.
     The notion of patients as "customers" seems especially preposterous to me because it negates the sanctity of our unique patient-physician relationship, which is the crux of the oath we took upon graduating from medical school. Surgical patients entrust us with their lives, and we are the last physicians they see before entering the operating room. They are often frightened because they fear pain or don't really understand why they are having surgery, or because they've had a previous bad surgical or anesthetic experience. Some are afraid they will die under anesthesia, and some patients actually have accurate premonitions about this. Although we frequently spend only a few minutes with our patients pre-operatively, we are nonetheless obliged to act on their behalf: we are compelled to be their advocates.
     I recently had a case where an elderly, but not terminally ill, patient was having a colonoscopy under propofol sedation. She had a "do-not-resuscitate" (DNR) order on her chart, which I proceeded to address with her in detail. I asked her what we should do if she stopped breathing under sedation, and whether she would accept temporary placement of a breathing tube. She emphatically informed me that under no circumstances would she accept a breathing tube or any type of artificial life support. Period. She had signed her consent, and she was competent to make that decision. My anesthetist's first question when I informed him that our patient had chosen to uphold her advance directives was "So, what do we do if we lose her airway?" to which I replied, "We do nothing." The GI physician and nursing staff were informed, the conversation was documented in her chart, and fortunately, she experienced no complications during her anesthetic. What's important about this scenario is that I actually took the time to explore her DNR order with her, making her aware of the fact that these orders are usually suspended intra-operatively unless otherwise specified, and giving her the opportunity to dictate which interventions, if any, she would be willing to accept.
     In talking about situations like this with my colleagues, many of whom have been in practice for decades, I am constantly amazed at how few of us actually have these discussions with our patients. Appallingly few surgeons and anesthesiologists, as well as operating room nurses and surgical staff,  seem to be aware of the fact that both the American Society of Anesthesiologists and the American College of Surgeons published guidelines in the early 1990s regarding perioperative DNR orders, and that it is incumbent upon us to investigate these orders with our patients to determine whether the DNR should be suspended, modified, or upheld during the procedure and immediate recovery period. An even more unsettling problem is the time constraints imposed on us in preparing patients for the OR. Patients who present for surgery nowadays are typically much more complicated and obese than they were 20 years ago, and are usually on a laundry list of medications. Interviewing them and reviewing their charts requires time, time which I believe both my patient and I are entitled to. Not everyone sees it this way, because in the "business" of health care, time is money, and time not being spent in the OR or procedure area isn't generating revenue. In addition, advances in modern anesthesiology have created a double-edged sword: we've made giving anesthesia to even the sickest patients so safe that "going to sleep" no longer seems like a big deal.
     I admit, I am an idealist. I am well aware of the fact that there is no perfect health care delivery system. However, I trained long and hard to become a board-certified consultant in anesthesiology, and I refuse to be relegated to the ranks of a mindless technician in the name of the almighty dollar. On days like today, when I am suffering from a serious deficiency of empowerment, and questioning why I became a doctor, I read Carl Hug's 1999 Rovenstine Lecture, entitled "Patient Values, Hippocrates, Science, and Technology: What We (Physicians) Can Do versus What We Should Do for the Patient." I am lucky enough to have shared the visiting faculty office with him during my time at Emory, and to call him my friend. In this inspiring lecture, he reminds us that we are morally obligated to act as patient advocates, and not merely as sleep technicians; that we must avoid complicity in matters of informed consent; that we have a duty to respect and uphold our patients' autonomy at all times, and that open communication with our surgeons is of paramount importance. Most importantly, he reminds us that the time we take to ensure that our patients are fully informed and well-prepared for surgery is of unquantifiable value: it is time well spent.

1. Hug, Carl C. Jr. M.D., Ph.D: Rovenstine Lecture: Patient Values, Hippocrates, Science, and Technology: What We (Physicians) Can Do versus What We Should Do for the Patient, 1999

http://journals.lww.com/anesthesiology/Fulltext/2000/08000/A_Matter_of_Life_and_Death__What_Every.36.aspx

2. American Society of Anesthesiologists: Ethical Guidelines for the Anesthetic Care of Patients with Do-Not-Resuscitate Orders or Other Directives That Limit Treatment (2008)

3. American College of Surgeons, Statement on Advance Directives by Patients: Do Not Resuscitate in the Operating Room (1994)

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