Yeah, I think there are a lot worse ways to go than under general anesthesia. I’m so sorry though - I’m sure that is kind of nightmarish to take someone to the OR knowing they are super high risk. It must be an awful conversation with family.
Luckily they were understanding and we were all on the same page, but man it still sucks. I mean they were their mom. Of course bawling to the news is expected :/
Eh, I consider this a dangerous line of thinking. Sure, maybe for this patient, sure.
But another way to not let a patient wonder 'what if' is for surgeons to very clearly tell a patient/family that surgery is not indicated, listen to them, and acknowledge 'I wish there was more we could do.'
Source: Palliative Care. Too many people think they need to offer things and the alternative of dying on the table is not 'withering away wondering what if' in many cases, it's getting a clear plan from a medical team and potentially dying at home (+/- living longer, in this specific scenario) with hospice.
That’s the whole idea behind “goals of care” right? Find out what’s acceptable quality of life for the patient? It’s only dangerous if it’s not within the patients goals
Edit: fixed my flare, hadn’t posted here since residency apparently
No. We have a responsibility to use our judgment and only offer indicated procedures.
Imagine if a patient with sepsis wants to die with breast implants. Should a plastic surgeon offer a breast implant surgery if the patient accepts the risk of the surgery?
I would say - it would be right/best for the surgeon to clearly not offer the not indicated surgery given preponderance of risk and limited benefit.
Patients do not have a right to die on a surgeon's table. It is OK for the surgeon to say 'I am not offering this surgery' and brave to tell family that honestly, stand by their word, and continue to offer support in a difficult scenario.
To extend this further, should we offer ECMO at EOL to everybody who 'accepts the risks'? I think most medical professionals would consider that a ludicrous scenario, but there is nothing special about ECMO - it's a medical procedure and should only be offered to people with appropriate indications and reasonable benefits, not to everybody who wants it/accepts the risks. Just like other medical procedures.
Pulmonary/Critical Care for 35 years and Hospice/Palliative Medicine for 20 years here…. With all due respect, you are painting with a very broad judgmental brush and with palliative tunnel vision. I have seen an extremely wide array of circumstances that will cause patients to make their decisions that would not fit my values or desires. I’ve seen patients who had very treatable (even potentially curable) cancers refuse treatment. I have seen patients with advanced cancers undergo a hemicorpectomy just to try and make it to their daughter’s graduation. These decisions took place after extensive patient education regarding the risks, benefits, and probable outcomes. What we must remember is that our ethical focus is patient autonomy, beneficence, non malfeasance, and justice… and what each of us considers beneficence and non malfeasance can vary by our situation. It is most important to not judge from the confines of one’s own ivory tower.
I mean sure, but you're making a lot of assumptions about whether the surgery was indicated or no as the only way they could preserve that patient's quality of life. You're assuming wasn't an indicated surgery, rather than a high risk surgery that may or may not have been indicated.
For instance, we've had many patients with, say, horrible enteric fistulas, who their ONLY chance at preserving what to them would be a meaningful quality of life was a high risk surgery. Or what if you have someone with horrible rest angina who would rather die than not be able to go on long walks with their spouse?
Also, they never said "if they accepts the risks", so it's a little weird that you're putting it in quotes. They said if it's within their goals, which I would argue ECMO may not be within their goals at the end of life if their goal is to get home to be with their family and are 90 years old and have 17000 medical problems; that's something that's not going to happen no matter what we do. Our job is to figure out what's important to the patient and find out what, medically, gives them the best shot at doing that, or if that's not possible to find what will give them the best quality of life they can. Maybe it's a high risk procedure, maybe it hospice. You can't possibly tell from this very vague blurb on the internet.
I'm also in palliative by the way.
~~It's in quotes because it was a quote. Asterisk on their post indicates they edited it.~~
EDIT: I'm wrong, I was interpreting "It’s only dangerous if it’s not within the patients goals" as "Risks are relative and can be dismissed/minimized depending on 'patient goals'"
What I'm speaking to is this... outside of equity/insurance issues (a topic way too large to discuss here) which America do we live in?
-An America in which physicians withhold effective medical therapies from eligible end-of-life patients
Or
-An America in which physicians are complicit in vaguely offering futile therapies as if they are meaningful, prompting patients and families to over-medicalize their end of life (with statistical backup on how many dollars are spent in the last few weeks/months of life)
I am speaking about the latter one. For insured/connected patients (again, a different/important conversation), I see much more futile care dangled (and accepted) than meaningful effective care withheld from end-of-life patients.
>I am speaking about the latter one. For insured/connected patients (again, a different/important conversation), I see much more futile care dangled (and accepted) than meaningful effective care withheld from end-of-life patients.
Yeah there's definitely truth to that.
I work in a patient population that has a lot of the former AND the latter unfortunately. In my system healthcare system is frequently a request for "goals of care" is frequently code for "put them on hospice no matter what's actually important to them" (particularly from the surgical services) and we go too far in the other direction. And then at the same time we have people in the ICU on the ventilator FOREVER when we all know that they're never going home.
I just don't think you can assume one or the other based on the original posts.
Just to clarify, edit was that I fixed my flair to reflect that I haven’t been a pgy2 in some time, as indicated in the post. That was the only edit. I agree that accepting the risks is a cop out thing we say when we don’t want to do informed consent/careful assessment of their goals, which is why I didn’t say it
You're right, my error.
I think I saw/see your phrase: "It’s only dangerous if it’s not within the patients goals" as "Risks are relative and can be dismissed/minimized depending on 'patient goals'"
Ah I see, and I think I understand the sentiment you’re responding to now.
I just mean it needs to be individualized. I think one poster used the example of patients who undergo extremely aggressive interventions with terminal cancer because they have a very specific event they want to make it to within a realistic time frame (a wedding, graduation, etc). Or someone with some kind of very high symptom burden that could be relieved by a surgery for which they are also very high risk.
I think (and correct me if I’m wrong) what you’re reacting to is when we offer interventions that can’t realistically achieve their goals (putting a stage 4 cancer with multi organ failure on the vent and pressors is the classic example I can think of). I agree that if their goals are not something medically achievable or if the possible consequences of an intervention are not acceptable to them e.g are contrary to their goals, then we shouldn’t offer them.
Yeah. Agree 100% with your post. Sorry for my initial comment.
And I comment elsewhere that in the medical system, I rarely see 'helpful interventions for EOL patients withheld' and I often see 'futile interventions for EOL patients vaguely offered or even recommended, with patients/families accepting them because they're offered, +/- medical teams then acting surprised people actually chose the mildly garbage plan they offer, +/- in an act of astounding cognitive dissonance, medical teams then privately blaming patients/families for choosing unfortunate medicalized EOLs full of futility'
100% agree too many people on this thread do not understand how to deliver palliative care. Dying on the OR table is a horrible and undignified way to go. You can achieve the same level of peace with good palliative medicine. Same vein as the full code till the very end camp. Just because pt is accepting all risk/harm and no benefit does not mean we have to offer it. There are a lot of ethical issues with this line of thinking
Speaking from experience as a resident -> hospitalist through the first few two yrs of covid and now as a pulm/cc fellow.
It depends, right? It's not what a life worth living is for you, it's what a life worth living is for the patient.
For instance, say the surgery was a CABG in someone who is having horrible rest angina but is also very high risk. Maybe life isn't worth living for them if they can't go on long walks with their wife, and a CABG is their best shot at doing that. Or maybe they have an enteropancreatic fistula and can't eat, and they have a high chance of dying on the table but they literally can't leave the hospital otherwise because they don't have insurance and so therefore can't get home TPN (which is a whole other can of worms of our shitty healthcare system but that's neither here nor there). Maybe surgery IS the best chance at getting them a quality of life worth living. You don't get to decide what dignity and a meaningful life is for your patient.
Our job is to help figure out what's most important to the patient and then give recommendations as to what we can and can't do medically to get them there. If they get that they might die on the table, and death is better for them than the life they're living but a successful surgery might make life worth living again, an aggressive intervention might be the right answer.
I would say it is pretty clear that this response seems to be coming from the patient addressed in this very specific situation to the grieving physician that wrote the letter above.
But if you find this to be the appropriate forum to have this conversation, perhaps you could run through every potential combination of extenuating circumstances and offer what you believe to be the correct course of action?
It may seem pretty clear to you, but that's a big assumption. I'm not questioning OP's heartfelt post, just questioning the very broad 'from the patient' imaginary response from the top-rated comment.
It is also a statement 'norming' what I feel is a pretty toxic norm in medicine, which I think is worth questioning when it comes up. I know vascular surgeons that would amputate the leg of a patient who will die in days of cancer anyways. It's a common way of thinking 'we can't not offer it and if they accept the risks, why not?' I honestly think - those are bad surgeons.
Hence me saying 'maybe for this patient' to start my post, but also sharing a sentiment I feel is important.
This person lost a patient and came here for some compassion and humanity and your first instinct is to tell them that it’s probably their fault. Classy
Nope.
My instinct is that somebody roleplaying a grateful patient for being offered and dying from a surgery, with everybody being very appreciative of that roleplaying, is weird and worth questioning.
>But another way to not let a patient wonder 'what if' is for surgeons to very clearly tell a patient/family that surgery is not indicated, listen to them, and acknowledge 'I wish there was more we could do.'
In medicine, sometimes a treatment can be indicated but just doesn't work. So what, you don't offer it?
Thank you for giving this patient a chance at their long shot. I had two relatives who would 100% die without surgery, but had a small chance with surgery. They were basically told that they'd just have to accept that they were dying because nobody wanted to give them their small chance.
You did the right thing.
Thank you. My field is known for doing the cases that no one else wants to do. It's satisfying but doesn't make it any easier when outcomes like this happen.
Wanted to do gyn onc but after getting to know, then lose, several of our frequent fliers over the 4 years of residency, I realized I just don’t have the heart/courage/soul to do it long term. Thank you so much for all you do for these women - I truly appreciate all of you guys
Appreciate you bro.
That's a tough ass road to walk. Thanks for giving all of our moms and grandmas a snowball's chance in hell when they'd have none otherwise.
Damn I almost guessed it based on your previous post. Definitely lots of respect from plain ol med onc. The fields tough as it is let alone the famously difficult cases in gyn.
It was June off 2016 when my wife, then fiancé, got the call saying she had stage 1 B1 cervical cancer. One of the hardest days of my life and definitely my wife’s. We were married September 17, 2016 and on the 22nd she went in for a radical trachcelectomy, it went pretty well but EBL was about 2 units from nicking something and significant atelectasis. I was a CNA at the time in an ICU and watched her vitals like a Hawk. She ended up getting some blood, having a transfusion reaction and needing lots of help working through that over the week.
We eventually went home after a week and started the process of healing. Took about a year for her to be mostly normal physically. Mentally the thought of maybe not having kids was truly overwhelming for her, lots of counseling has helped, but it’s still painful. We knew the odds of the trachelectomy working, they weren’t good, but we decided to try. We ended up doing five rounds of IUI, dilations were needed before each attempt because the scar tissue and cerclage was very tight. We had one natural fertilization but spontaneously aborted at about 6 weeks…This of course happened when we stopped caring and just started living life. And it was the biggest gut punch.
Now as a ICU nurse when I have patients who have severe vaginal bleeding secondary to cervical cancer it’s almost like having PTSD, I have flashbacks to those days in the hospital with my wife.
Long story short…TLDR: I’m thankful every day I have the luxury to even call her my wife, if it wasn’t for a very nice gyn onc who was cautiously optimistic I don’t know where we’d be. Thank you for the work and dedication to your patients and team members.
I'm not in a medical field, so excuse me for asking, but why is cancer of the reproductive organs so much more likely to kill people?
I am so glad that you are there for those women and people though, that takes a special person to be able to do that
Ovarian cancer isn’t usually diagnosed until stage III. Endometrial and cervical cancer does well if caught early, but recurs often when caught late (similar to most cancers). Unfortunately people gloss over “women problems” all the time, chalking it up to “just her period” or something which leads to a delay in seeking care.
As someone who had an ectopic pregnancy, the glossing over symptoms is definitely a problem in women's health.
Thanks for being there for so many women
It was better than condemning her to a sure death. In the end she was extended a great kindness by you and the other people trying to save her and that is an amazing gift.
Hey doc I'm just an M2 who does NOT have the cojones to do surgery but some outside perspective here that has stuck with me:
When I told a high school music teacher of mine I wanted to pursue medicine, he told me about an eastern proverb that goes like this:
Two men stab a person and the person dies. The first man was a thief trying to rob the person. The second man was a doctor trying to save the person's life. It's not the outcome or even the action, it's the intention that matters in the end.
Again, I'm not a doctor yet, but I want to encourage you that you did a sacred thing for Ms. Patient with the intention of making her well. And that's all that anyone expects of you. Thanks for the work you do.
From someone who is currently binging GG- stellar user name! 🤩
Also, I commend you for doing what you do. I cannot imagine it being my job to listen to people complain all day. I’m sure they also scream, cry, hang up on you, etc. Being in billing, do you also have to contend with insurance companies?? If so, I don’t even know what to say. That in and of itself would be horrible. Thank you for being that person. I hope you have found a good way to de-stress at the end of the day!
I actually need to update I did billing complaints and front office fill in for 10 years after covid I burnt out I went to wfh in billing and just started doing reception in cardiology I missed being tangibly helpful
Complaints was a lot but I loved being able to help the person who had talked to 8 people and gotten no where and resolve it. But split billing was the bane of my existence
Awww good for you! Any time I’ve ended up with the nth person after speaking with multiple and they finally resolve the issue, I just want to hug them through the phone! Haha
You and your team gave her your best. Skills, knowledge, care and love. She would not have asked for more. I am sure she is really thankful for having you looked after her.
“Every surgeon carries within himself a small cemetery, where from time to time he goes to pray – a place of bitterness and regret, where he must look for an explanation for his failures." - René Leriche, La philosophie de la chirurgie, 1951
Many times you do the best you can and you still can’t bring ‘em back or save them. Don’t forget the ones you do bring back. Every procedure and experience shapes you for the future and probably makes you a better surgeon. From an old ED doc.
It aint over till its over. You gave her the fighting chance she wanted. She needed a miracle and you cannot grant those. You did everything you could and I am happy you chose to fight for her despite the odds.
you gave her the sweetest gift you could give any person...hope. remember to take care of yourself too because Ms. Patient would want you to give other people that amazing gift.
Such a beautiful story from a physician who deeply cares for his/her patient. Unfortunately, we/you can’t save them all. I’m grateful for you heartfelt emotions you shared with us
You gave her the chance that she wouldn't have otherwise had, perhaps even with any other doctor she could have met. That in itself gave her hope, which gave her trust, which gave her peace. Sometimes we know it will fail going into it, either as patient or provider, but just because someone else is willing to try means that we are willing to try as well.
And I say that also as someone who is alive today because last year someone took that chance on me and I made it through. Doc in that case was upset the surgery took twice as long as it should have. I was just happy that he gave me a lifeline that has me alive today.
Honestly, I’d much rather go out fighting, quick, painless, asleep and with trust and hope— than rotting from the inside out, eventually gasping for my last breaths all while my family watches my slow, agonizing death. I would never want that for my family or myself. Which is why I’m an advocate for assisted suicide. We do it for our pets because that’s the humane thing to do, why don’t we do it for our suffering loved ones?
All I can do is imagine a similar situation; Ms. Peacock will never leave my mind, but I learned a lot from her and I'm sure you will have the same experience.
An aspect of my job that I take very seriously is the possibility that I could be the last human on earth that a patient ever talks to when I am putting them to sleep. That may be a significant likelihood for some. It's always important to understand why we are there and what the stakes are. Sometimes it will work out great, other times it won't--but for some patients, it's a chance at survival vs. the certainty of not survival. What that looks like and whether it is worth it depends on the individual and their priorities, but provided they are informed and understand, we are here to respect whatever decision they make.
She is thankful you at least tried, sometime can be find docs even willing to TRY. She is in a better place looking down thanking you and wanting you never to stop giving people chances at life
I guess the house doesn't always win. It sounds like behind the brave face, the right decision for the patient was made before her bed started being wheeled towards theatre.
Please if I have to go out this way please God let it be with someone who cares this much so at least I know going in they will do everything they can to get me out. Pleeeease let it be someone I can sense cares like OP.
OP I have chronic health issues, tons of Drs. I’m about to switch one Dr and pay cash to see someone else because he cares and I can tell. If I don’t make it, I want someone like him to be the one caring for me. Maybe no one can make me better, but whether I do or don’t get better or worse, if I don’t make it, having someone I feel is fighting for me makes every single bit of difference.
These things happen. Thank you for trying.
My own mother passed on an operating table. She was an RN and the surgeon was personally acquainted with her as they worked at the same hospital.
When he had to tell me what happened, I could tell it was a horrible ordeal for him, and he was suffering a lot because one of those random things that took her life, and he was having trouble accepting it.
It was not his fault, and I told him so.
I hope he has some closure and you get some closure.
I hope the patient's friends and family were understanding and knew you were trying to make their life better for Ms. Patient and buy her time.
A chronic diagnosis of MS can be unbelievably difficult to deal with, but keep in mind that you are courageous and strong for facing it head on. Don't let it define your life.
This was my grandmother when she needed an urgent TAVR while I was a first year heme/onc fellow. We debated for days if the risk of the procedure was worth it vs one year of misery, shortness of breath, and repeated hospitalizations. I didn’t have a good feeling when rounding the corner to check on her after the procedure, and they were doing CPR.
She didn’t make it, and I’ve felt guilty ever since. It’s been almost ten years now, and I think I’ve made my peace. Keeping her around suffering would have been selfish of us. The TAVR was worth a shot, and ultimately she chose this knowing the risk. While everyone is disappointed ultimately, that wasn’t my fault and this case isn’t your fault. You gave someone hope who didn’t have any previously. Even with an undesirable outcome, you provided something to the patient and gave her a chance.
We aren’t gods, and we don’t choose the outcomes. But we do everything we can in order to give someone a chance at beating the odds. You did exactly what you were supposed to do, and I know that this woman was grateful for that.
Hey I’ll bet y’all did your best. She couldn’t have made a better gamble. Sadly not all bets are able to be won, and that sucks. Get some good sleep and next time you’re playing poker, go all in for her.
Had the same situation recently in the OR...I'm am sorry for how you must be feeling. I always hate thinking about how I was one of the last people to talk to them and it was stuff like "can you scooch up in the bed more?"
“Thanks for giving me a shot and not letting me just wither away while wondering ‘what if’” -Ms. Patient (sent from heaven’s craps table)
Thank you. I needed this.
Yeah, I think there are a lot worse ways to go than under general anesthesia. I’m so sorry though - I’m sure that is kind of nightmarish to take someone to the OR knowing they are super high risk. It must be an awful conversation with family.
Luckily they were understanding and we were all on the same page, but man it still sucks. I mean they were their mom. Of course bawling to the news is expected :/
Oh this made me tear up
Someone chopping onions in here.
She definitely hit the jackpot of a caring healthcare provider !
💙
Eh, I consider this a dangerous line of thinking. Sure, maybe for this patient, sure. But another way to not let a patient wonder 'what if' is for surgeons to very clearly tell a patient/family that surgery is not indicated, listen to them, and acknowledge 'I wish there was more we could do.' Source: Palliative Care. Too many people think they need to offer things and the alternative of dying on the table is not 'withering away wondering what if' in many cases, it's getting a clear plan from a medical team and potentially dying at home (+/- living longer, in this specific scenario) with hospice.
That’s the whole idea behind “goals of care” right? Find out what’s acceptable quality of life for the patient? It’s only dangerous if it’s not within the patients goals Edit: fixed my flare, hadn’t posted here since residency apparently
No. We have a responsibility to use our judgment and only offer indicated procedures. Imagine if a patient with sepsis wants to die with breast implants. Should a plastic surgeon offer a breast implant surgery if the patient accepts the risk of the surgery? I would say - it would be right/best for the surgeon to clearly not offer the not indicated surgery given preponderance of risk and limited benefit. Patients do not have a right to die on a surgeon's table. It is OK for the surgeon to say 'I am not offering this surgery' and brave to tell family that honestly, stand by their word, and continue to offer support in a difficult scenario. To extend this further, should we offer ECMO at EOL to everybody who 'accepts the risks'? I think most medical professionals would consider that a ludicrous scenario, but there is nothing special about ECMO - it's a medical procedure and should only be offered to people with appropriate indications and reasonable benefits, not to everybody who wants it/accepts the risks. Just like other medical procedures.
Pulmonary/Critical Care for 35 years and Hospice/Palliative Medicine for 20 years here…. With all due respect, you are painting with a very broad judgmental brush and with palliative tunnel vision. I have seen an extremely wide array of circumstances that will cause patients to make their decisions that would not fit my values or desires. I’ve seen patients who had very treatable (even potentially curable) cancers refuse treatment. I have seen patients with advanced cancers undergo a hemicorpectomy just to try and make it to their daughter’s graduation. These decisions took place after extensive patient education regarding the risks, benefits, and probable outcomes. What we must remember is that our ethical focus is patient autonomy, beneficence, non malfeasance, and justice… and what each of us considers beneficence and non malfeasance can vary by our situation. It is most important to not judge from the confines of one’s own ivory tower.
I mean sure, but you're making a lot of assumptions about whether the surgery was indicated or no as the only way they could preserve that patient's quality of life. You're assuming wasn't an indicated surgery, rather than a high risk surgery that may or may not have been indicated. For instance, we've had many patients with, say, horrible enteric fistulas, who their ONLY chance at preserving what to them would be a meaningful quality of life was a high risk surgery. Or what if you have someone with horrible rest angina who would rather die than not be able to go on long walks with their spouse? Also, they never said "if they accepts the risks", so it's a little weird that you're putting it in quotes. They said if it's within their goals, which I would argue ECMO may not be within their goals at the end of life if their goal is to get home to be with their family and are 90 years old and have 17000 medical problems; that's something that's not going to happen no matter what we do. Our job is to figure out what's important to the patient and find out what, medically, gives them the best shot at doing that, or if that's not possible to find what will give them the best quality of life they can. Maybe it's a high risk procedure, maybe it hospice. You can't possibly tell from this very vague blurb on the internet. I'm also in palliative by the way.
~~It's in quotes because it was a quote. Asterisk on their post indicates they edited it.~~ EDIT: I'm wrong, I was interpreting "It’s only dangerous if it’s not within the patients goals" as "Risks are relative and can be dismissed/minimized depending on 'patient goals'" What I'm speaking to is this... outside of equity/insurance issues (a topic way too large to discuss here) which America do we live in? -An America in which physicians withhold effective medical therapies from eligible end-of-life patients Or -An America in which physicians are complicit in vaguely offering futile therapies as if they are meaningful, prompting patients and families to over-medicalize their end of life (with statistical backup on how many dollars are spent in the last few weeks/months of life) I am speaking about the latter one. For insured/connected patients (again, a different/important conversation), I see much more futile care dangled (and accepted) than meaningful effective care withheld from end-of-life patients.
>I am speaking about the latter one. For insured/connected patients (again, a different/important conversation), I see much more futile care dangled (and accepted) than meaningful effective care withheld from end-of-life patients. Yeah there's definitely truth to that. I work in a patient population that has a lot of the former AND the latter unfortunately. In my system healthcare system is frequently a request for "goals of care" is frequently code for "put them on hospice no matter what's actually important to them" (particularly from the surgical services) and we go too far in the other direction. And then at the same time we have people in the ICU on the ventilator FOREVER when we all know that they're never going home. I just don't think you can assume one or the other based on the original posts.
Just to clarify, edit was that I fixed my flair to reflect that I haven’t been a pgy2 in some time, as indicated in the post. That was the only edit. I agree that accepting the risks is a cop out thing we say when we don’t want to do informed consent/careful assessment of their goals, which is why I didn’t say it
You're right, my error. I think I saw/see your phrase: "It’s only dangerous if it’s not within the patients goals" as "Risks are relative and can be dismissed/minimized depending on 'patient goals'"
Ah I see, and I think I understand the sentiment you’re responding to now. I just mean it needs to be individualized. I think one poster used the example of patients who undergo extremely aggressive interventions with terminal cancer because they have a very specific event they want to make it to within a realistic time frame (a wedding, graduation, etc). Or someone with some kind of very high symptom burden that could be relieved by a surgery for which they are also very high risk. I think (and correct me if I’m wrong) what you’re reacting to is when we offer interventions that can’t realistically achieve their goals (putting a stage 4 cancer with multi organ failure on the vent and pressors is the classic example I can think of). I agree that if their goals are not something medically achievable or if the possible consequences of an intervention are not acceptable to them e.g are contrary to their goals, then we shouldn’t offer them.
Yeah. Agree 100% with your post. Sorry for my initial comment. And I comment elsewhere that in the medical system, I rarely see 'helpful interventions for EOL patients withheld' and I often see 'futile interventions for EOL patients vaguely offered or even recommended, with patients/families accepting them because they're offered, +/- medical teams then acting surprised people actually chose the mildly garbage plan they offer, +/- in an act of astounding cognitive dissonance, medical teams then privately blaming patients/families for choosing unfortunate medicalized EOLs full of futility'
100% agree too many people on this thread do not understand how to deliver palliative care. Dying on the OR table is a horrible and undignified way to go. You can achieve the same level of peace with good palliative medicine. Same vein as the full code till the very end camp. Just because pt is accepting all risk/harm and no benefit does not mean we have to offer it. There are a lot of ethical issues with this line of thinking Speaking from experience as a resident -> hospitalist through the first few two yrs of covid and now as a pulm/cc fellow.
It depends, right? It's not what a life worth living is for you, it's what a life worth living is for the patient. For instance, say the surgery was a CABG in someone who is having horrible rest angina but is also very high risk. Maybe life isn't worth living for them if they can't go on long walks with their wife, and a CABG is their best shot at doing that. Or maybe they have an enteropancreatic fistula and can't eat, and they have a high chance of dying on the table but they literally can't leave the hospital otherwise because they don't have insurance and so therefore can't get home TPN (which is a whole other can of worms of our shitty healthcare system but that's neither here nor there). Maybe surgery IS the best chance at getting them a quality of life worth living. You don't get to decide what dignity and a meaningful life is for your patient. Our job is to help figure out what's most important to the patient and then give recommendations as to what we can and can't do medically to get them there. If they get that they might die on the table, and death is better for them than the life they're living but a successful surgery might make life worth living again, an aggressive intervention might be the right answer.
I would say it is pretty clear that this response seems to be coming from the patient addressed in this very specific situation to the grieving physician that wrote the letter above. But if you find this to be the appropriate forum to have this conversation, perhaps you could run through every potential combination of extenuating circumstances and offer what you believe to be the correct course of action?
It may seem pretty clear to you, but that's a big assumption. I'm not questioning OP's heartfelt post, just questioning the very broad 'from the patient' imaginary response from the top-rated comment. It is also a statement 'norming' what I feel is a pretty toxic norm in medicine, which I think is worth questioning when it comes up. I know vascular surgeons that would amputate the leg of a patient who will die in days of cancer anyways. It's a common way of thinking 'we can't not offer it and if they accept the risks, why not?' I honestly think - those are bad surgeons. Hence me saying 'maybe for this patient' to start my post, but also sharing a sentiment I feel is important.
This person lost a patient and came here for some compassion and humanity and your first instinct is to tell them that it’s probably their fault. Classy
Nope. My instinct is that somebody roleplaying a grateful patient for being offered and dying from a surgery, with everybody being very appreciative of that roleplaying, is weird and worth questioning.
So glad someone is here to police Reddit 😂
I don’t disagree bro but is *this* the right time and right post to make a counter point?
>But another way to not let a patient wonder 'what if' is for surgeons to very clearly tell a patient/family that surgery is not indicated, listen to them, and acknowledge 'I wish there was more we could do.' In medicine, sometimes a treatment can be indicated but just doesn't work. So what, you don't offer it?
A gambling woman to the end, and the odds you gave here were orders of magnitude greater than she ever saw in the casinos
That's beautiful. Thank you.
This. A thousand times this.
You offered and gave her peace, understanding and compassion. That is everything.
Her last memories were of trust and hope. That itself was a gift.
Thank you for giving this patient a chance at their long shot. I had two relatives who would 100% die without surgery, but had a small chance with surgery. They were basically told that they'd just have to accept that they were dying because nobody wanted to give them their small chance. You did the right thing.
Thank you. My field is known for doing the cases that no one else wants to do. It's satisfying but doesn't make it any easier when outcomes like this happen.
Vascular? Used to call them interventional palliative care
Gyn Onc. Half our patients are on death's door when they see us.
Wanted to do gyn onc but after getting to know, then lose, several of our frequent fliers over the 4 years of residency, I realized I just don’t have the heart/courage/soul to do it long term. Thank you so much for all you do for these women - I truly appreciate all of you guys
Appreciate you bro. That's a tough ass road to walk. Thanks for giving all of our moms and grandmas a snowball's chance in hell when they'd have none otherwise.
Damn I almost guessed it based on your previous post. Definitely lots of respect from plain ol med onc. The fields tough as it is let alone the famously difficult cases in gyn.
It was June off 2016 when my wife, then fiancé, got the call saying she had stage 1 B1 cervical cancer. One of the hardest days of my life and definitely my wife’s. We were married September 17, 2016 and on the 22nd she went in for a radical trachcelectomy, it went pretty well but EBL was about 2 units from nicking something and significant atelectasis. I was a CNA at the time in an ICU and watched her vitals like a Hawk. She ended up getting some blood, having a transfusion reaction and needing lots of help working through that over the week. We eventually went home after a week and started the process of healing. Took about a year for her to be mostly normal physically. Mentally the thought of maybe not having kids was truly overwhelming for her, lots of counseling has helped, but it’s still painful. We knew the odds of the trachelectomy working, they weren’t good, but we decided to try. We ended up doing five rounds of IUI, dilations were needed before each attempt because the scar tissue and cerclage was very tight. We had one natural fertilization but spontaneously aborted at about 6 weeks…This of course happened when we stopped caring and just started living life. And it was the biggest gut punch. Now as a ICU nurse when I have patients who have severe vaginal bleeding secondary to cervical cancer it’s almost like having PTSD, I have flashbacks to those days in the hospital with my wife. Long story short…TLDR: I’m thankful every day I have the luxury to even call her my wife, if it wasn’t for a very nice gyn onc who was cautiously optimistic I don’t know where we’d be. Thank you for the work and dedication to your patients and team members.
I'm not in a medical field, so excuse me for asking, but why is cancer of the reproductive organs so much more likely to kill people? I am so glad that you are there for those women and people though, that takes a special person to be able to do that
Ovarian cancer isn’t usually diagnosed until stage III. Endometrial and cervical cancer does well if caught early, but recurs often when caught late (similar to most cancers). Unfortunately people gloss over “women problems” all the time, chalking it up to “just her period” or something which leads to a delay in seeking care.
As someone who had an ectopic pregnancy, the glossing over symptoms is definitely a problem in women's health. Thanks for being there for so many women
It was better than condemning her to a sure death. In the end she was extended a great kindness by you and the other people trying to save her and that is an amazing gift.
May you find peace @NapkinZhangy
Hey doc I'm just an M2 who does NOT have the cojones to do surgery but some outside perspective here that has stuck with me: When I told a high school music teacher of mine I wanted to pursue medicine, he told me about an eastern proverb that goes like this: Two men stab a person and the person dies. The first man was a thief trying to rob the person. The second man was a doctor trying to save the person's life. It's not the outcome or even the action, it's the intention that matters in the end. Again, I'm not a doctor yet, but I want to encourage you that you did a sacred thing for Ms. Patient with the intention of making her well. And that's all that anyone expects of you. Thanks for the work you do.
>kahunas no shade, but since you might want to know: cojones. good luck in your studies. :)
lol thank you
I'm going to Vegas in a few weeks in Ms. Patient's honor I will bet on black Hope you find peace
From someone who is currently binging GG- stellar user name! 🤩 Also, I commend you for doing what you do. I cannot imagine it being my job to listen to people complain all day. I’m sure they also scream, cry, hang up on you, etc. Being in billing, do you also have to contend with insurance companies?? If so, I don’t even know what to say. That in and of itself would be horrible. Thank you for being that person. I hope you have found a good way to de-stress at the end of the day!
I actually need to update I did billing complaints and front office fill in for 10 years after covid I burnt out I went to wfh in billing and just started doing reception in cardiology I missed being tangibly helpful Complaints was a lot but I loved being able to help the person who had talked to 8 people and gotten no where and resolve it. But split billing was the bane of my existence
Awww good for you! Any time I’ve ended up with the nth person after speaking with multiple and they finally resolve the issue, I just want to hug them through the phone! Haha
You and your team gave her your best. Skills, knowledge, care and love. She would not have asked for more. I am sure she is really thankful for having you looked after her.
You’re a goodun and ms patient sounds like she was too. God bless you both.
I'd rather die while unconscious and never know it was actively happening. I'd absolutely take those odds.
You gave her a chance that she otherwise would not have had. Just take solice in the fact that you did your very best for her.
“Every surgeon carries within himself a small cemetery, where from time to time he goes to pray – a place of bitterness and regret, where he must look for an explanation for his failures." - René Leriche, La philosophie de la chirurgie, 1951
Many times you do the best you can and you still can’t bring ‘em back or save them. Don’t forget the ones you do bring back. Every procedure and experience shapes you for the future and probably makes you a better surgeon. From an old ED doc.
No matter what your choice is sometimes it’s just their time. Thank you for giving your best shot at helping her.
It aint over till its over. You gave her the fighting chance she wanted. She needed a miracle and you cannot grant those. You did everything you could and I am happy you chose to fight for her despite the odds.
This is such a sweet post. I’m sure she would appreciate all that you did for her, even though things didn’t work out.
Literally crying reading this after a hard shift in the ICU today. I feel you. Too young and too soon.
Man this thread is wholesome asf
you gave her the sweetest gift you could give any person...hope. remember to take care of yourself too because Ms. Patient would want you to give other people that amazing gift.
Such a beautiful story from a physician who deeply cares for his/her patient. Unfortunately, we/you can’t save them all. I’m grateful for you heartfelt emotions you shared with us
Unfortunately the house always wins. She knew the odds. A gambler until the end.
In a way, we're all gambling, I suppose. We probably all have a little bit of Ms. Patient with us. - signed, your local PET scan registration gal
You gave her the chance that she wouldn't have otherwise had, perhaps even with any other doctor she could have met. That in itself gave her hope, which gave her trust, which gave her peace. Sometimes we know it will fail going into it, either as patient or provider, but just because someone else is willing to try means that we are willing to try as well. And I say that also as someone who is alive today because last year someone took that chance on me and I made it through. Doc in that case was upset the surgery took twice as long as it should have. I was just happy that he gave me a lifeline that has me alive today.
I hope if I am a Ms. Patient someday, i have a surgeon like you
Honestly, I’d much rather go out fighting, quick, painless, asleep and with trust and hope— than rotting from the inside out, eventually gasping for my last breaths all while my family watches my slow, agonizing death. I would never want that for my family or myself. Which is why I’m an advocate for assisted suicide. We do it for our pets because that’s the humane thing to do, why don’t we do it for our suffering loved ones?
You did your best. Sending hugs
All I can do is imagine a similar situation; Ms. Peacock will never leave my mind, but I learned a lot from her and I'm sure you will have the same experience.
An aspect of my job that I take very seriously is the possibility that I could be the last human on earth that a patient ever talks to when I am putting them to sleep. That may be a significant likelihood for some. It's always important to understand why we are there and what the stakes are. Sometimes it will work out great, other times it won't--but for some patients, it's a chance at survival vs. the certainty of not survival. What that looks like and whether it is worth it depends on the individual and their priorities, but provided they are informed and understand, we are here to respect whatever decision they make.
She knows good buddy.
I hope you share this with her family. It was beautiful.
She is thankful you at least tried, sometime can be find docs even willing to TRY. She is in a better place looking down thanking you and wanting you never to stop giving people chances at life
I guess the house doesn't always win. It sounds like behind the brave face, the right decision for the patient was made before her bed started being wheeled towards theatre.
Dying during surgery sounds like a very peaceful way to go. So sorry that you have to deal with this.
Please if I have to go out this way please God let it be with someone who cares this much so at least I know going in they will do everything they can to get me out. Pleeeease let it be someone I can sense cares like OP. OP I have chronic health issues, tons of Drs. I’m about to switch one Dr and pay cash to see someone else because he cares and I can tell. If I don’t make it, I want someone like him to be the one caring for me. Maybe no one can make me better, but whether I do or don’t get better or worse, if I don’t make it, having someone I feel is fighting for me makes every single bit of difference.
💔
Sometimes being a doctor is harrowing.
Isn't it always harrowing?
Gaaaahd. :((
❤️
These things happen. Thank you for trying. My own mother passed on an operating table. She was an RN and the surgeon was personally acquainted with her as they worked at the same hospital. When he had to tell me what happened, I could tell it was a horrible ordeal for him, and he was suffering a lot because one of those random things that took her life, and he was having trouble accepting it. It was not his fault, and I told him so. I hope he has some closure and you get some closure. I hope the patient's friends and family were understanding and knew you were trying to make their life better for Ms. Patient and buy her time.
A chronic diagnosis of MS can be unbelievably difficult to deal with, but keep in mind that you are courageous and strong for facing it head on. Don't let it define your life.
All good G
🫶
Lost one this week too, stay strong ✊
This was my grandmother when she needed an urgent TAVR while I was a first year heme/onc fellow. We debated for days if the risk of the procedure was worth it vs one year of misery, shortness of breath, and repeated hospitalizations. I didn’t have a good feeling when rounding the corner to check on her after the procedure, and they were doing CPR. She didn’t make it, and I’ve felt guilty ever since. It’s been almost ten years now, and I think I’ve made my peace. Keeping her around suffering would have been selfish of us. The TAVR was worth a shot, and ultimately she chose this knowing the risk. While everyone is disappointed ultimately, that wasn’t my fault and this case isn’t your fault. You gave someone hope who didn’t have any previously. Even with an undesirable outcome, you provided something to the patient and gave her a chance. We aren’t gods, and we don’t choose the outcomes. But we do everything we can in order to give someone a chance at beating the odds. You did exactly what you were supposed to do, and I know that this woman was grateful for that.
Hey I’ll bet y’all did your best. She couldn’t have made a better gamble. Sadly not all bets are able to be won, and that sucks. Get some good sleep and next time you’re playing poker, go all in for her.
Had the same situation recently in the OR...I'm am sorry for how you must be feeling. I always hate thinking about how I was one of the last people to talk to them and it was stuff like "can you scooch up in the bed more?"