When Patients Choose to Give Up Treatment#
Omnivore#
This article is from WeChat official account: Medical World (ID: yixuejiezazhi), author: Wang Xing (Department of Thoracic Surgery, Shanghai First People's Hospital), editor: Huang Siyu, editor: Zhao Jing, header image from: Visual China
This article tells the story of a doctor facing the dilemma of a patient giving up surgery, as well as the doctor's and family's struggle and decision-making. Through this story, the author reflects on the true meaning of informed choice.
• 💔 The dilemma of patients giving up surgery and the doctor's struggle
• 💼 Doctors consider patients and strive to provide the best treatment plan
• 🏥 The importance of professional habits and medical ethics
Early in the morning, before the 7:00 ward rounds, a family member came in and said that the elderly person did not want to undergo surgery and wanted to go home.
The elderly person is from Fuyang, Anhui, seventy years old, without children or grandchildren, and is a "five-guarantee household". He was brought to the hospital by his niece. He usually has difficulties in food and clothing. Under the dual consumption of poverty and illness, his weight has dropped to 68 catties. This condition is also a bit special. It is not lung cancer, but a special fungal infection called pulmonary aspergilloma, which means that the fungus has eroded the lungs and bronchi, and the person coughs up blood every day. He said that he has been taking antibiotics for the past few days and has not been coughing up blood much, so he wants to go home and does not want further treatment. It is not suitable for surgery at the end of the year.
Dr. Fu is his attending doctor and said, "This condition requires surgery. Although he is not coughing up blood now, the fungus is still inside him and cannot be controlled by medication. It will slowly erode and form cavities again. There is still a chance if we do the surgery now, but if we wait and want to do the surgery later, there will be no chance."
At that time, I thought that this surgery would take four to five hours, and there was not much blood available for transfusion. The patient was very sick, and to be honest, the risk was quite high.
I saw the family, the patient, and the doctor caught in a dilemma. If the surgery is not performed, the patient will not die within six months, but it is difficult to say whether he can hold on for a year. However, if the surgery is performed, it will face great risks. I have done this kind of surgery before, and the lungs damaged by the fungus will stick together like a lump of overnight dumplings, and any touch will cause a bloody disaster. This is what the saying goes, "If you don't do the surgery, it's waiting for death; if you do the surgery, it's seeking death."
The family's concern is, as a niece, who will pay for the surgery and who will make the decision? If something goes wrong, can I escape responsibility? Which option can I easily withdraw from?
The doctor's concern is, if the patient who originally did not want surgery undergoes surgery, what if they cannot afford the cost? If the doctor persuades the patient to undergo surgery and something goes wrong and the patient dies, how can it be explained?
At this moment, the meaning of informed choice is completely lost, because not only can the patient and the family not truly understand the development and outcome of the disease after not undergoing surgery, but the doctor also cannot prove to the patient that they are truly doing it for their own good.
Seemingly trapped, Dr. Fu looked at the patient's niece with his persistent and gentle eyes, without evading or being arrogant, without saying anything beautiful, just saying, "I think it should be done, and it's worth doing." I think the niece was touched at that moment, probably feeling that there was no need to ask anyone or search for information when faced with such a look. The doctor had already said everything, knowing that his family had no money but still wanted to treat him, it was definitely not for the money.
Then let's do it, please, doctor.
I also went to the operating room to help. I saw the patient lying on the bed, intubated and anesthetized, with a urinary catheter inserted, lying flat. The veins under the skin were clearly visible, and a thin layer of skin covered the ribs. When I touched it, it felt like a washboard, very much like a person who was about to reach the end. The nurse went to call the master to turn the patient over, the resident went to wash his hands, and Dr. Fu couldn't stay idle. He covered the patient with a blanket and called the logistics department, "The room is too cold, turn up the air conditioning, the patient will freeze."
When the chest was opened, the lungs were indeed stuck together, and the lungs had to be separated before the lobes could be removed. The director came over and said that he hadn't performed this kind of surgery for a long time, it was difficult, and it was scary. The process of separating the lungs was full of dangers. On one side, we had to worry about burning the underlying aorta, and on the other side, we had to be careful of the subclavian artery below the clavicle. While shouting, "This is not a joke," the director counted the accident cases he had heard and seen before—one patient became a vegetative state, and one patient died on the spot.
"If we persuade the patient to undergo surgery against their will and something goes wrong, it will be difficult to explain."
Many people have watched medical TV dramas and think that doctors communicate and cooperate during surgery on the operating table, just like those glamorous actors interpret it—"You clamp here, I'm going to deal with the most dangerous part!" In fact, the communication among doctors on the operating table is not based on words, but on tacit understanding. They cooperate like partners and play like opponents. With one movement, I know if you understand me or not. I raise my hand, you press down, I take the electric knife, you block, I clamp, you cauterize.
We also chatted, but we didn't talk about the surgery, but about the patient's life. Why is he a "five-guarantee household"? How much money can a "five-guarantee household" receive in a month? Why does he have no children or grandchildren? Does he have a spouse? The scrub nurse on the table said that it's so pitiful to not have a partner. I asked him how he can be sure that he will have a partner in the future, and he said, "Just focus on the surgery and don't talk."
When it came to poverty, the entire operating room started a money game. How much does this gun cost? How much does this suture cost? Is it cheaper to use Gun A with Line B or Gun C with Line D? Dr. Fu kept suggesting possible options, and the nurse calculated with the calculator, while the director was torn between them. Every operation seems to have a substitute, but the substitute also secretly marks the cost.
We need to save money for the patient while ensuring that nothing goes wrong.
"Use that gun, or forget it and give me a line. No, let's use that gun, take it apart!"
At that moment, I understood a saying that had been bothering me for a long time—"Good steel is used on the cutting edge." I had been thinking for a long time, why should it be used on the cutting edge? Isn't the back of the knife important? Can't the knife be smaller and still use good steel? With the increase in age and the thinning of hair, I slowly realized that the operation of the world is accompanied by the art of compromise. Doctors not only need to manage patients' reasonable expectations for recovery, but also understand their budget, and then try their best to present them with a good result within this budget range.
In fact, the dilemma of the surgery cost is something that I made myself uncomfortable with. It does not involve the doctor's income, whether openly or secretly, nor is it a helpless choice brought about by cost control through DRGs. It is simply a medical team's desire to save money for this "five-guarantee household" while not wanting him to have any problems. Only experts truly understand how to arrange combinations optimally, and the patient will never know that there is a group of people working hard to save money for him while he lies on the operating table.
What use does informed choice have at this moment? Actually, it is useless.
When the director successfully separated the lungs from the aorta and the deep subclavian artery, the coordinated movements of opening and closing, as well as the carefulness in the details, allowed the lungs to be completely removed from the body in a situation with no retreat. After we closed the chest and successfully removed the breathing tube and returned to the ward, we dared to say that everything was worth it.
The patient simply cannot understand how he can know the type of fungus, the price and advantages and disadvantages of various sutures, and the differences in stability between suturing and instrument fusion in the residual end. How can he know the outcomes of people with similar conditions?
He cannot know, and should not know, and it is impossible for him to make a seemingly rational and objective choice in a state of complete ignorance. Therefore, the so-called informed choice that we repeatedly emphasize, which seems to be procedural justice, should be correctly understood as the doctor giving the patient a treatment plan that the doctor believes is right and respecting their choice, rather than the doctor providing two seemingly comprehensive options and asking the patient to sign and agree.
I really want to tell the patient's niece that her intuition is correct. If she reviews the surveillance footage of the operating room, she will see someone casually picking up a blanket and covering the patient. Then she should be able to confirm that she has chosen the right person to trust.
For doctors, most of the time, these things are not done for others, but are a professional habit. Dr. Fu thinks it is right to do it this way, so he does it this way. A doctor's skills will gradually improve, but their character and cultivation are stable.
I asked Dr. Fu, why did you persuade him to undergo surgery? This surgery is so tiring and doesn't bring in any fees. Isn't it better to just not do it and save some trouble?
He said, when a surgeon starts to be afraid of surgery, their career is also over. What should be done should be done.
I think Dr. Fu will become, and should become, a more brilliant surgeon in the future because he dares to make choices for patients.
This article is from WeChat official account: Medical World (ID: yixuejiezazhi), author: Wang Xing (Department of Thoracic Surgery, Shanghai First People's Hospital), editor: Huang Siyu, editor: Zhao Jing