In a small study based on conversations with 20
hospital-based surgeons, Johns Hopkins researchers say they found that most
report feeling pressure to operate under severe emergency situations, even when
they believe the patients would not benefit.
Results of the study, published in the May issue of
the Journal of the American College
of Surgeons, highlight the multiple factors and complexity that underlie
decision-making, quality care and patient outcomes in life-and-death emergency
situations, the researchers say.
“Conversations and decisions about surgical interventions
and their risks are never easy, but they’re even more difficult in emergency
situations, and our study was designed to better understand — in a qualitative
way — surgeons’ thought processes during these times,” says Fabian
Johnston, MD, MHS, assistant professor of surgery at the Johns Hopkins
University School of Medicine. Few tools, he says, are available or
demonstrated to be effective in objectively measuring these kinds of decisions.
To gain a better understanding of how surgeons approach
decision-making with patients during life-or-death situations, Johnston and
co-authors conducted face-to-face interviews with 20 surgeons whose specialties
included trauma, vascular medicine and surgical oncology. All practiced at two
large academic medical centres’: The Johns Hopkins Hospital and the Medical
College of Wisconsin. The vast majority of the surgeons (18 of 20) were male
and white (16 of 20). The midrange age was 45 and the midrange number of years
in practice was nine.
In audio recorded interviews either over the phone or in
person, the researchers asked the surgeons what they thought were the most
important considerations when deciding whether to operate on a patient who has
what is likely a nonsurvivable injury or other emergent, acute medical problem
such as a ruptured abdominal aorta. Interviews consisted of presenting the
surgeons with two hypothetical case vignettes and 13 questions about what they
would decide to do and what factors would go into the decisions.
Two surgeon investigators conducted the interviews and two
other researchers analysed them using a method of listening to the interviews
for repeated ideas and elements, which were then organised into codes.
Their analyses of the conversations, the investigators say,
found that five themes emerged:
1) The importance of surgeons’ judgment,
2) The need for surgeon introspection,
3) The various pressures to operate: from the surgeons
themselves, from the patients and/or their families, from colleagues or
institutions, and from society and our culture,
4) The costs of operating — medically, financially and
5) The concept of futility and uncertainty around a decision
to operate or not.
Overall, Johnston and the team found that most surgeons
erred on the side of operating despite — or because of the uncertainty of —
perceived futility of treatment.
One participant said, “I think that we do have this, as
surgeons, ‘the cut is to cure’ situation … pride in the patient, pride in the
outcome, pride in what we do, and wanting the patients to do as well as they
Another said, “As much as we internally believe when
situations are futile and procedures shouldn’t be done, that just goes against
the grain of the pattern of practice in many parts of the hospital. So I think
in those scenarios, I can’t really say no” to operating.
Johnston says objective tools to assess risk are needed for
more confident and patient-centred decision-making, and that studies such as
the current one may help inform the development of such methods by identifying
factors of most concern to surgeons.
“The goal, ultimately, is to empower surgeons to confidently
advise against surgical intervention when the risks outweigh the benefits, and
that goal requires data and support from peers and institutions,” says
Johnston S, et al. Shared Decision-Making in Acute Surgical Illness: The
Surgeon’s Perspective. Journal of the
American College of Surgeons. May 2018, Volume 226, Issue 5,