AANS Neurosurgeon : Ethics in Practice

Volume 20, Number 1, 2011

But, He Told Me I ‘Needed’ Surgery

Mindful Communication Sets Stage for Realistic Patient Expectations

Craig Rabb, MD, and Paul J. Ford, PhD

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Doing “good” for patients goes beyond the competent execution of technical surgical skills. Surgical success determined by achievement of outcome targets is an obvious means of evaluation. However, success measured by physiological parameters alone may bear little relationship to the expectations patients had when they agreed to surgical therapy during the informed consent process. In order to fulfill the intent of informed consent, physicians must carefully consider what success means to us and what it means to patients burdened with an illness.

Physicians have an ethical obligation to communicate clearly with patients. This includes careful attention to the language used. Consider how the word “need” can be misunderstood or misused in an informed consent process. “Need” entails a professional judgment and a strong recommendation to a particular patient that the procedure under discussion is required for health. Because patients are likely to perceive “need” as a strong recommendation from the surgeon, and because of the natural vulnerability of patients in the patient-surgeon relationship, they might not fully weigh the risks and benefits associated with the proposed treatment.

The Ethics in Practice department covers challenging ethical issues in the practice of neurosurgery. To encourage neurosurgeons to think critically about the role of professional ethics in medicine, a short vignette is presented followed by discussion intended to focus on key concerns. The vignette is not intended to parallel a particular real-life scenario but rather is meant to highlight the ethically relevant considerations a neurosurgeon should explore in mediating the complex and competing interests of professional ethical duties to society and to one’s patient. The perspectives presented and conclusions reached are intended to stimulate thought and promote conversation about these complex relationships; they are neither intended to be nor do they necessarily represent positions of the AANS.

Words must be chosen judiciously when discussing elective surgeries that are aimed at improving quality of life. The following case of spinal fusions done strictly for alleviation of pain highlights important ethical challenges inherent in the language used during the informed consent process. Under what circumstances could it be ethically justifiable to describe this surgery as “needed” for a patient with this diagnosis?

Vignette
A 22-year-old woman sustained an injury at work that resulted in significant acute low back pain. Two months later she consulted a surgeon who performed discography that was interpreted as positive at L5–S1. The patient then underwent an L5–S1 instrumented posterior lumbar interbody fusion. There were no immediate postoperative complications and her hospital stay was uneventful.

Subsequently, her pain failed to improve and in fact worsened. Several months later she underwent removal of the fixation hardware, without noteworthy improvement.

A year after the first surgery, when her surgeon told her there was nothing more he could do to help her, she sought a second opinion. A CT scan of the lumbar spine demonstrated what appeared to be a healed interbody fusion. Her imaging studies indicated no other pathology. When she asked the second surgeon why she continued to suffer, he related that the literature suggests it is not uncommon for surgery for low back pain to fail. He further stated that for low back pain evidenced by a positive discogram and treated with fusion surgery the rate of improvement is in the range of 50 percent. The patient was in disbelief upon hearing this, and said, “But my doctor told me I needed surgery!”

Discussion
Deyo and colleagues argued convincingly in a 2004 article that discography and surgery, whether fusions or total disc arthroplasty, remain controversial for treating discogenic back pain. In a 2006 study Carragee and colleagues attempted to define a gold standard for discography. They compared a group of patients who underwent lumbar fusion for positive discography at a single level with a similar cohort of patients with spondylolisthesis at one motion segment and found that discography was not highly predictive in identifying lesions causing low back pain. Clearly, when recommending surgery with the goal of pain relief it is important that the patient be given appropriate expectations based on the best available information. Doing so can be a challenge when discussing an indication for surgery based on a complex test such as discography and the many issues that surround evaluation of the test’s reliability.

When surgery for pain relief is recommended, patients must have the opportunity to formulate a realistic assessment as to what the outcome will be. This is the foundation of the informed consent doctrine. For discogenic back pain, most surgeons would agree that a pain-free state and complete return to previous lifestyle are highly improbable.

In this case, what constitutes informed consent? What should a reasonable, prudent surgeon communicate to a patient about the likely outcome?

First and foremost, the surgeon should advise the patient that surgery for discogenic pain is done with the intent of improving pain and that delaying or declining surgery would not entail physical risk or lead to irreparable harm. As a result, the phrase “need surgery” should be replaced with a discussion of the likelihood of improvement in pain. Language that would have greater ethical support includes: “a surgical option that has been tried with uncertain benefit,” or “although studies have not proven benefit, in your case the surgery may provide pain relief.” Appropriate language would clearly communicate to the patient the optional nature of the procedure and the uncertainty of achieving pain relief.

Carragee and colleagues also recently described a novel tool called “minimum acceptable outcomes” for assessing outcomes in fusion surgery. Preoperatively patients were given standard questionnaires, including the Oswestry Disability Index, visual acuity scale, medication usage, and work status. They were asked to provide their own assessment of what they would consider the minimum acceptable improvement that would justify the burden and risk associated with their surgery. Patients prospectively described their own expectations of significant improvement that constituted an acceptable goal in light of the risks of undergoing such surgery. At the conclusion of the study, 43 percent of patients thought to have “discogenic pain” had met their goal, based upon the minimum acceptable outcome ratings they had established preoperatively.

This study raises the second important ethical consideration. Physicians must help patients interpret data in relation to the patients’ goals. It is never appropriate to withhold material facts that a prudent person would want to know when making a decision involving surgery. Some patients will believe they will be among the 43 percent that achieves diminished pain and some will decline surgery, but all will have had the opportunity to make the decision based on all available information and their own priorities.

Formulating language that clearly communicates with patients about the surgery at hand mirrors the preparation and precision required for the surgery itself. Before speaking a word, it is worthwhile to reflect carefully on how a particular patient is likely to comprehend the language used, especially considering the vulnerability of a person in pain. Developing an understanding between the patient and surgeon of how the surgery’s success will be measured is an important extension of the informed consent process, an ethical process that exists to ensure that surgery does a patient “good.”

Craig Rabb, MD, FAANS, is associate professor in the neurosurgery department at the University of Oklahoma Health Sciences Center, Oklahoma City, Okla. Paul J. Ford, PhD, is director of the neuroethics program at the Cleveland Clinic and associate professor at the CCF Lerner College of Medicine, Case Western Reserve University, Cleveland, Ohio. They are members of the AANS Ethics Committee. The authors reported no conflicts for disclosure.

Acknowledgement
The authors thank Patrick W. McCormick, MD, chair of the AANS Ethics Committee, for his helpful comments during development of this article.

For Further Information

  • AANS Code of Ethics
  • Carragee EJ, Cheng I: Minimum acceptable outcomes after lumbar spinal fusion. Spine J. 10:313–320, 2010
  • Carragee EJ, Lincoln T, Parmar VS, Alamin T: A gold standard evaluation of the “discogenic pain” diagnosis as determined by provocative discography. Spine 31:2115–2123, 2006
  • Deyo RA, Nachemson A, Mirza SK: Spinal-fusion surgery: the case for restraint. N Engl J Med 350:722–726, 2004
  • Ford PJ: Vulnerable brains: research ethics and neurosurgical patients. J Law Med Ethics 37:73–82, 2009