We live in a society with an average life expectancy of more than 80 years. Our families are smaller and so death comes as a relatively infrequent event for most individuals. When sudden and unexpected, particularly when associated with routine surgery, the reaction is to find out what went wrong and who was to blame. How could this happen to us, our family, my spouse?
For the surgeon, the problem is very personal. The surgeon performs the procedure and carries ultimate responsibility for the outcome.
Surgery is an imperfect science. Every operation carries some risk of death. If the patient has other diseases, such as diabetes or heart disease, the risk increases. The patient may further add to their risk by being a smoker or obese. Many patients seem to combine all imaginable risk factors yet still want surgery performed.
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The surgeon can refuse such requests and ensure they only operate on the fittest patients: their results will be excellent. Or they can take the high-risk patients and their own stress levels and anxiety will increase.
If an operation has in a fit patient a 1% risk of death but in an obese elderly smoker a 15% risk of death, it still means 85% of such high-risk patients have a satisfactory outcome. If the operation is for a cancer, this may be acceptable to the patient, doctor and family but three in 20 patients will die from that operation.
Recently a patient of mine in her 50s, who was otherwise well except for a tumour within her liver, died on the operating table from massive haemorrhage. I telephoned the husband and he came immediately to the hospital. He was stunned, angry and looking for a reason.
For the surgeon it was devastating and led to considerable self-recrimination. What if a different approach had been tried? Could another have done it better? Was it the wrong decision in the first place? Subsequent meetings with the extended family did little to placate their grief or doubts.
It is interesting that society feels it can unburden itself onto surgeons with little understanding of the devastating effects such an outcome has on the surgeon themselves. Death in an emergency situation is no less tragic for the family but much more acceptable.
Despite surgeons informing patients and families of the 1-2% risk of death for much routine surgery, few believe it should happen to their family member.
Surgeons need to be convinced the operation is necessary and patients must accept death as a possible outcome, something that seems to occur so rarely in our society today.
*Guy Maddern is professor of surgery at the University of Adelaide. St Anywhere is fictitious, but the events and issues are real.