Patient-Centered Decision-Making in Surgery And Anesthesia: Collaboration For Better Patient Care

Referrals from the surgical ward to the intensive care unit run
by anesthesiologists can sometimes give a clash between surgeons
and anesthesiologists in daily clinical practice. In patients with
severe comorbidities there may also be disagreements before
surgical procedures regarding indication for surgery. These are
clinical dilemmas in the crossroad between anesthesia and surgery,
and in the literature, it is often discussed under the term “futility
of care”.
The concept of medical futility was not discussed in the medical
literature before the 1980’ies [1], but the interest in the medical
literature has decreased in recent years [2]. It is relevant to discuss
not only for ethical reasons but also in times of cost containment.
We all want to do no harm but also to utilize health care resources
reasonably.
The area is, however, quite problematic, as there is in many
cases no clear definition or even understanding of futility. Different
stakeholders such as the patient, surgeon, anesthesiologist, and
family members may view questions of futility differently [3], and
even among physicians (intensivists) [4] and nurses [5] there is
variation. Nevertheless, the clinical problem is real as caregivers
say that provision of futile care occurs in daily clinical practice [6].
A literature review found that decisions to withhold or
withdraw a futile measure was done often after a dialogue with the
patient but also sometimes without informing the patient at all or
with just one-way information from caregiver to patient [7]. This
certainly points in the direction of an important clinical problem
where patient involvement could be improved.
Anesthetists and surgeons have the same goal and that is of
course to do no harm and to secure the best possible outcome for
the patient. There are, however, disagreements in daily clinical
practice and it typically involves one or more of these issues: 1)
Who is involved in the decision, 2) who is actually in charge if there
is disagreement, and 3) the decision by caregivers to say no to
surgery or no to referral to the intensive care unit is often based on
anticipated low quality of life for the patient if lifesaving surgery or
intensive care is performed.