Big Surgery

Developing an Ars Moriendi for High Risk Surgical Patients

Martin McKneally

The 15th century Latin text Ars Moriendi provided guidance toward a good death. In that era there was no risk of dying intubated, unable to speak, and separated by institutional rules from family and friends. Technological advances in our century have allowed surgical teams to cross the boundary that once protected the frail elderly and irremediably ill from operative treatment and intensive care.

As advances in technology and intensive care allow us to push the surgical boundary further into the elderly population, we risk entering a zone in which life sustaining treatment becomes the last rite of passage for our patients. Those in the emergency room slip through its porous boundaries into the hospital, the operating room and the intensive care unit with little discussion of the limits of complex care that is possible in the modern era. This results in conflict and moral distress that can lead to burnout among caregivers. We are not well prepared by our training for reflective discussion on the limits to be placed on our interventions.

Public education of the populace about the Ars Moriendi has been effective in some communities. Atul Gawande describes the very low incidence of terminal intensive care in Southern Wisconsin, in contrast to jurisdictions where patients commonly die separated from their family, intubated, unable to communicate, and degraded by a medicalized last rite of passage from life (1). Agonizing conflicts develop in the intensive care setting, sometimes requiring judicial rulings on terminal sedation, transfer to hospice or the substitution of comfort care for futile efforts to cure. Intensive care nurses assigned to these rituals suffer moral anguish; they are left with the moral residue of feelings that they are not treating their patients in a way that they would wish for themselves or their family members.

In interviews and focus groups, 46 surgeons expressed profound feelings of responsibility and commitment to the survival of their patients (2). Trained in a warrior culture that pits them against death and disease, and complicit in the complications they struggle to overcome, surgeons are disabled to withdraw life sustaining treatment (LST) from the patients they committed to rescue. If complications result in irretrievable loss of function and quality of residual life, conflicts arise when intensive caregivers and family members request withdrawal of LST. A preoperative Ars Moriendi directive could help all concerned.

Surgeons in Toronto and their collaborators in Wisconsin and Boston recently completed a study of preoperative conversations about the boundaries of postoperative life-sustaining therapy in the rare instances when it becomes required (3). Because conflicts arise when families, nurses, intensivists, and surgeons confront these issues in the absence of any advance directive, we asked surgeons and their patients to allow us to record their preoperative conversations. The transcripts reveal that surgeons in all locations tended to encrypt the experience in phrases such as “it’s big surgery”, or “it’s not day surgery”. While they clearly list the risks of death and life threatening complications, when they raise the possibilities of prolonged intubation, feeding tubes, and dialysis, patients derailed the conversations, changing the topic to discussion of logistical and other issues, such as “sutures, or staples?”, or “Can my husband be in the room?”. Even though the issue of their potential mortality is more proximate, and there is time to talk about it, patients and to some extent their surgeons have difficulty confronting the ars moriendi in explicit language. We are currently extending our qualitative research with our surgeons and their patients to answer the question “How would patients and their families prefer to address LST preoperatively, rather than waiting until the emotionally charged time when decisions have to be made in a crisis mode, when the patient may be incapable of participating?”.

In a different setting, ethicist Susan Tolle, a palliative physician in Portland, Oregon, has developed a set of questions about life-sustaining treatment that are routinely asked as part of the process of admission to long term care facilities in Oregon (4). POLST (Physician Orders for LST) or similar policies have spread to 18 states and are developing in several more. It preempts many trips to the emergency room when frail elderly patients develop cough and fever, putting them at risk of slipping into the intensive care unit, the zone of often unwanted and inappropriate LST at the end of life.

When I have discussed this issue informally with the Cardiothoracic Ethics Forum, a group of surgeons who are past and present members of the ethics committees of the Society of Thoracic Surgeons and the American Association for Thoracic Surgery, some recount that they are quite explicit and directive. “I tell them that I want them to give me 30 days to get them through the procedure.” Others assume permission to initiate LST is implicit in consent. In 40 years of practice, I have found that patients and families are rarely comfortable with attempts to conflate the discussion of life saving surgery with a discussion of termination of LST should complications lead to an irretrievably degraded state. We are currently embarking on the next phase of our research: asking patients and families for advice on how best to introduce this important topic – sort of a “crowd-sourced ars moriendi”.

An extended conversation with multiple caregivers has become the standard in securing consent for organ donation from living donors. That may be a useful model for us to follow. Separating the discussion of patient and family preferences for delineating the boundaries on LST seems reasonable and less overwhelming. Anesthesiologists, who administer life sustaining interventions in the operating room and participate in or direct intensive care units, may be more appropriate agents for discussion of postoperative LST and obtaining informed consent for its conduct and limits. Intensive care nurses, who have a critical role and keen interest in reducing ambiguity about the limits of LST are also appropriate candidates.

Training and continuing education of surgeons and their operating teams can help address the ars moriendi of post-operative life sustaining treatment. I would be grateful for advice from our surgical readers on how they approach this important issue.

M.M.

1. Gawande A. Letting go. New Yorker, August 2, 2010.

2. McKneally MF, et al. Responding to trust: Surgeons’ Perspective on informed consent. World J Surg 2009; 33:1341-7.

3. Pecanac K, et al. It’s big surgery. Ann Surg 2013;00:1-6.

4. “Oregon’s path in eliciting, recording and respecting wishes across settings of care.” Susan Tolle MD, May 29, 2013 (Link to article).