[HSF] (no subject)
Ani Anyanwu
anianyanwu at hotmail.com
Sun May 13 09:59:13 EDT 2007
Murtaza
Roughly how I go about assessing risks-benefit balance.
Benefit
1) First does the patient have symptoms? If so do these significantly impact on his quality of life? If there are no symptoms or there is little impact on quality of life (QoL) then surgery cannot improve him (unless surgery can prolong life or prevent future loss of quality of life).
2) If the patient does have symptoms, are these due to a correctable lesion that one can reasonably expect to correct with surgery? For example if Hal's patients symptoms are primarily due to the cardiomyopathy then no form of conventional surgery can correct that. Unless there is a symptom caused by a lesion which is 'curable' then the benefit is questionable. E.g. doing an anaortic OPCAB in Hal's patient where the 3VD is clearly not an active principal cause of symptoms.
3) if patient does not have symptoms which impact on QoL or ones which can be ascribed to surgically correctable lesions then surgery cannot by definition make patient feel better. in this scenario surgery may have benefit if it prevents death or serious disability or if there are secondary gains (e.g. employment, safe performance of surgery). In Hals case the question would then be if surgery will impact on life expectancy. Generally one needs the literature to answer this question but it would be difficult to find a study of patients with low EF, triple valve disease 3VD, however there are several studies on patients with myopathy and valve disease and most such (younger) patients would be referred for transplantation because of poor results with conventional surgery.
If one cannot ascertain specific benefit of surgery then it stops here and surgery is not indicated. if there is potential benefit one must ascertain the risk.
Risk
1) Risk of operative death - Can use euroSCORE etc or surgeons own data. Hal probably has a much better track record getting such patients through that euroSCORE predicts so best to see his own experience. Even so one must look at mortality beyond 30 days as many will succumb in first six months.
2) Morbidity - these include stroke risk and there are a few models to predict it. However one must also consider, particularly in elderly patients, the possibility that surgery might end up in a worse QoL. Very difficult to predict what proportion of patients will end up debilitated and worse off but one must estimate.
When one estimates the risk and benefit
1) Where benefit is improved QoL, the question then is what risk is the patient (and to some degree surgeon) prepared to accept for the benefit in question. Some patients may be willing to accept 10% death just so they can continue to live independently, while another may be risk averse and prefer to have medical therapy and move in with family. Only the patient can answer this when given a true estimate of probability of achieving expected benefit and risk of death/morbidity. In health economics this is termed 'willingness to pay'. Sometimes I ask patients, what risk would you be willing to take to get better? If that equals or exceeds operative risk then we go ahead with surgery.
2) Where benefit is survival then much easier - if the risk of death and severe disability exceeds the potential survival gain then surgery is not advisable.
It is all very mathematical and as said previously, at the end of the day only the surgeon can have a feel for what is the right thing to do for the patient.
Ani
----- Original Message -----
From: murtaza chishti<about:blank>
To: OpenHeart-L at lists.hsforum.com<about:blank>
Sent: Saturday, May 12, 2007 11:39 PM
Subject: Re: [HSF] (no subject)
ani,
how would one (roughly) "calculate" risk benefit ratio in this given case?
murtaza
>From: "Ani Anyanwu" <anianyanwu at hotmail.com<about:blank>>
>Reply-To: OpenHeart-L at lists.hsforum.com<about:blank>
>To: <OpenHeart-L at lists.hsforum.com<about:blank>>
>Subject: Re: [HSF] (no subject)
>Date: Sat, 12 May 2007 14:41:43 -0400
>
>Well if he wants surgery, we are ethically obliged to screen him for
>surgery. I was at a meeting few weeks ago where Frazier said (regarding
>VADs) that he had been sued twice for not putting them in (because he
>turned patient down) but has never been sued for putting one in. If patient
>is screened for surgery two scenarios can emerge whereby the surgeon
>advises against surgery.
>
>1) Presence of an absolute contraindication to surgery - then the patient
>can be told condition is inoperable (provided most surgeons would accept
>same).
>
>2) Risk of surgery is thought to be either prohibitive or thought not to
>justify the benefit (or benefit thought not to warrant the risk). In this
>case patient should be offered a second opinion as another surgeons
>assessment of risk and benefit may be different. Otherwise we may condemn a
>patient where a colleague might be able to give them another chance to
>life. There are countless patients who have been informed that they are not
>candidates for surgery who weeks to years later undergo successful surgery,
>presumably there were other such 'rejected' patients who were not fortunate
>to survive to see another surgeon. Asking for a second opinion protects
>patients from opinionated, ill-informed or skill mis-matched physicians,
>and helps ensure the physician cannot 'play God'.
>
>I suspect your patient falls into the latter category and most will accept
>the benefit is questionable and does not justify the excessive risk.
>
>Regardless of the scenario though, the reason for rejecting surgery must be
>clearly documented and must be one that one's peers would accept and
>defend.
>
>Ani
> ----- Original Message -----
> From: Hgrmd at aol.com<mailto:Hgrmd at aol.com<about:blank>>
> To: OpenHeart-L at lists.hsforum.com<mailto:OpenHeart-L at lists.hsforum.com<about:blank>>
> Sent: Saturday, May 12, 2007 11:51 AM
> Subject: Re: [HSF] (no subject)
>
>
> Prasanna,
> His family isn't pressuring him to have surgery. He wants it, if we
>will
> offer it to him. I'm inclined not to do it.
> Hal
>
>
>
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