J Thorac Cardiovasc Surg 2008;136:1608-1609
© 2008 The American Association for Thoracic Surgery
Reply to the Editor:
Jeffrey H. Shuhaiber, MD
Department of Cardiovascular Surgery, Children's Hospital Boston, 300 Longwood Ave, Boston, Mass
With every operation performed comes a period of time where we stand face to face with the patient or responsible informant explaining the indication for the surgical procedure we would like to conduct. The period is usually one in which the responsible surgeon needs to be aware of the potential complications weighted against the benefits aimed to be achieved in the context of his or her own skills and available capacity. Dr McKneally comments elegantly and thoughtfully on the editorial "Tribute to our Fallen Comrades"1
that the risks are collective for all; surgeon, patient and family, training resident, as well as allied staff and institution. The surgeon is the ultimate person who will take the blame and hold the fort against any risk or complication(s). The primary goal is always to do the job with outmost concern for every detail, ensuring that patient returns to his or her loved ones with the underlying problem treated. This consent period could last from minutes to hours, exploring various avenues, reflecting on past experiences, as well as involving other opinions and recruiting from other resources.
Providing consent with quantifying and qualifying estimates is risky by itself. Two broad domains that underpin the consent process are communication and perception. Communication influences how we perceive information and perception modifies our responses and so affects our communication. This process occurs in both patient and surgeon. Perceiving that the patient will be fine with a procedure we are familiar with makes us comfortable in providing risk estimates. However, when communication and/or perceptions loops remain unclosed, this can send messages altering the perception of patient and surgeon of what can or cannot be "guaranteed" or perceived "worthy of mention." These subtle issues about communication and perception vary all the time, exacerbating the risk of miscommunication, which could extend to the tragic death of the organ retrieval team, which could not have been predicted.
In the age of technology with limited time and excess knowledge, trainees are battling through the basics of cardiothoracic surgery during residency. Beside their duties, they need to know how to manage patients and obtain consent for their treatment. Surgical procedures involve more and more recent technology (eg, monitors, imaging instruments, and cellular material) in the surgical environment and beyond (eg, transportation-related services and nanotechnology). It is not uncommon to find a proportion of residents, including fellows, consenting for procedures in which they have never participated or whose process they do not fully understand. This by itself is a risk to them, their team, and their patients, especially when miscommunication can occur. Furthermore, to knowingly or unknowingly exclude the hazards of the associated technology or devices involved is of growing concern.
Similar to advances in our field, the consent process needs to advance and develop. It is also key to understand ourselves better by reflection of our knowledge of surgical management and an opportunity to learn what is up-to-date management for that particular pathologic condition. We should pay more attention to this in our practice. Of course, we cannot explain all risks, alternatives, and benefits, but we must have some understanding of known and unknown risks conveyed to the patient and to the surgical team. Such an unknown factor could extend to the tragic death of the organ retrieval team, which could not have been predicted.
I would not be surprised that we will be facing more unknown risks as we advance and introduce more technology into our field. It is our responsibility, therefore, to understand this process fully and share this with our patients. Surgical programs should share their expertise by teaching the next surgical generation aspects of patient and surgical consent to reduce its evolving limitations. Finally, we act by what we know; thus, unknowingly misinformed can be worse than not being informed at all.
References
- Shuhaiber JH. Tribute to our fallen comrades. J Thorac Cardiovasc Surg 2008;135:1197.[Free Full Text]
