Friday, May 08, 2009

"Gentlemen, I Have The Pleasure Of Informing You..."

**For reasons that will become apparent to her, I would sugest LBF doesn't bother with this post. Her character isn't in it. I also know that now I've written this, she'll read on...**

The aortic aneurysm is a pathological entity to be feared. A weakening of the walls of the aorta, the body's main artery, the original big red, if you will, allows it to stretch and swell, to bulge. Think of old school Tom and Jerry cartoons where Tom stands on a hose, and the hose swells comically behind him.

Except it's less funny.

I shan't bore you with the details - you'll either know them already, or not want to. But the only curative therapy is surgical, and that carries significant risk. Some cases are felt 'inoperable', or carry such high risks as to be felt inadvisable.

Of course, the risk is that, like the hose, the aorta will eventually burst. And given enough time, it surely will. Such rupture carries with it a poor prognosis. For some, who we might consider the lucky ones, the rupture is catastrophic, and the end immediate, the spirit carried away in a rush of blood.

For others, the rupture is less dramatic, a slow leak, if you like, or the flow of claret is contained. These are the fellas who make it to hospital, the ones who might make it onto the table.


I am increasingly finding patients with anuerysms who have a "no surgery" decision in their notes. These decisions were invariably taken some time in the past, when the patient was well. I was not present when these decisions were made, so can't tell you how it was sold to the patient by the Consultant, or, increasingly, Vascular Nurse Specialist.

I don't know if this pre-emptive decision, this advanced directive, is being made more often; I just have quicker access to notes and clinic letters than ever before, so maybe that's it.

Now, I'm not a vascular surgeon, so my opinion on this is not as informed as it might be.

But, here it is...

I think it perfectly valid for patient and specialist to discuss surgical options for elective repair and decide against, either because the patient doesn't want surgery, or because surgery just isn't worth the risk. Fine; super.

But I'm uncomfortable about decisions being made to never consider emergent surgery. To my mind, that decision should be made at the time. I have never yet met a patient who didn't change their mind when it came to the sharp end. A decision that made perfect sense last year when you were pain free, is rapidly forgotten when you're in agony, and frightened. But maybe that's not the best time to make these decisions either, when the tendency is to grasp at any chance for more time.

Nonetheless, I think these case should be judged on their merit contemporaneously; the decision may still be that surgery isn't appropriate, but the harm : benefit ratio has changed dramatically, so surely we should be considering that.


I don't quite mean advanced directive in its true sense; I'm all for those. This is more that a decision has been made not to operate under any circs, and I'm not convinced the patients know what that entails... leastways all the ones I've seen barely remembered making he choice, and none thought it was such a great move once they hit the ED.

Counterpoint, I s'pose, is that none of them know what surgery entails, either. I guess it's just hard to tell 'em - your aneurysms ruptured, but you're not having surgery cos you said you didn't want it, and see the look on their faces.

Maybe I'm being selfish. Maybe it's my pain I'm trying to ease


Anonymous said...

I love the advance directive. However, a person that is of sound mind may change their mind at any time after they have written it. At least that is the way it works here in the US. The point where an advance directive comes into play for us is when that individual can no longer make their wishes known, or dementia takes over. Even then, family members still chime in regarding decisions at that point.

I think it is admirable that they had the foresight to say, "in the event this ticking time bomb begins to rear it's ugly head, I don't want heroic surgical measures". Hopefully that is a fully informed decision. But, people can always change their mind, can't they?

DrShroom said...

They don't really seem to be given the option of changing their minds, and none of them look like they knew this is waht would happen when the time bomb went pop... it just seems like they were told it would be a bad idea, and went along with it...