Wednesday, July 11, 2018

No surgical procedure carries zero risk of death: Every consent should mention it

Although advances in surgical techniques, training, anesthesia, instruments, diagnostic equipment have greatly reduces the mortality associated with a surgery, every surgery carries a risk of death.

Death associated with anesthetic procedures is 1-4 deaths per 10,000 anesthesias. The in-hospital mortality rates for hip fractures range from 1-10%. In patients undergoing cardiac bypass surgery, mortality is 2-5% for all patients and about 1% for the lowest-risk elective patients. As per the American College of Surgeons, one of 1,000 patients die during a cholecystectomy. Mortality in hysterectomy from 0.6 to 1.6 per 1000 procedures. Post-appendectomy mortality rate at 30 days is reported to be 2.1 per 1000. 

Several factors affect the risk of death. These may be related to the surgical procedure itself, anesthesia, drugs, age of the patient, general condition of the patient, medical history of the patient (comorbidities), the type of surgery, experience of the surgeon performing the surgery. Factors like what day of the week the surgery is done or time of surgery, whether night time or during the day also influence the risk of death. Evidence has shown that patients who undergo surgery over the weekend or at night have a greater likelihood of dying after the surgery. 

Patients undergoing surgery can be categorized as low risk patients whose estimated risk of death is less than 1% and high risk patients, whose estimated risk of death is more than 1%.

No surgery therefore can be said to be risk-free. There is always a risk of death in every surgical procedure, even in a minor surgery.

Patients today are more informed and when they consult a surgeon for an elective surgery, they are also well-prepared with list of related questions addressing their concerns including the chances of death with the proposed procedure.

The doctor is bound to inform the patient and the family about the risk of death with the surgery (along with other relevant information), even if the patient is low-risk. This enables patients to make informed decision about whether they should avoid the surgery or choose to undergo the procedure, whether the benefits of the surgery are worth the risks.

The Montgomery judgement of the UK Supreme Court precisely addressed this aspect of informed consent, when it ruled that the doctor has a duty to ensure that the patient is aware of any material risks involved in any recommended treatment, and of any reasonable alternative or variant treatments”. Material risk is the risk which a reasonable person would consider significant or a risk which a doctor knows (or should reasonably know) that the patient would consider it to be significant. The judgement further said, the therapeutic exceptionis not intended to enable doctors to prevent their patients from taking an informed decision. Rather, it is the doctors responsibility to explain to her patient why she considers that one of the available treatment options is medically preferable to the others, having taken care to ensure that her patient is aware of the considerations for and against each of them.”

Dr KK Aggarwal
Padma Shri AwardeeVice President CMAAO
Group Editor-in-Chief IJCP Publications
President Heart Care Foundation of India
Immediate Past National President IMA

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