The real surprise – to me, at least – came more than halfway through Dr. Atul Gawande’s keynote address at the opening session of the American Society of Anesthesiologists’ annual meeting in Boston.
Much of his talk on October 21 celebrated the virtues of checklists and teamwork, topics that have turned into best-selling books for the well-known surgeon and professor of public health. “We are trained, hired, and rewarded to be cowboys, but it’s pit crews we need,” he said.
Then Dr. Gawande posed this question to the packed room: “What are the outcomes that matter?”
He answered his own question somberly. “The most unsafe operation is the operation that shouldn’t be done,” Dr. Gawande said. “Does the operation serve the patient’s goals or not?”
“We’ve all been there,” he continued. “Taking people to the operating room and wondering what we’re doing.”
Those are comments I’ve heard from anesthesiologists many times before, but I never thought I’d hear them from a surgeon.
Flogging the dead
For any of us who practice anesthesiology in a major hospital – doing cardiac, thoracic, or liver cases, for instance – there are days when all our efforts are spent on behalf of a patient whose health is unsalvageable. “Flogging the dead” is a phrase sometimes used to describe prolonged and futile care in the operating room or ICU.
Sometimes aggressive interventions are driven by a family that wants “everything” done, because in their innocence the family members have no idea how terrible and dehumanizing the process of postponing death can be.
In other circumstances, however, the decision of whether to do surgery is driven by the mission and the financial motivation of the health system to provide care. If care doesn’t occur, if the surgery isn’t done, no one gets paid.
If the anesthesiologist walked up to the bedside of an elderly, frail patient who is scheduled for a risky operation, and explained bluntly that the patient might die a prolonged and dismal death in the ICU, there would be hell to pay if the patient or the family decided to back out. The preoperative holding area, five minutes before surgery, isn’t the time or place to have that conversation. Yet that’s often when we meet our patients for the first time.
The “risk of death” is always mentioned in the informed consent documentation, but may be framed by physicians and nurses alike as a theoretical concern rather than a real possibility. The surgeon, the anesthesiologist, and the hospital are incentivized to do cases, not to step on the brakes and stop an operation. This is true even when the operation may fix a specific surgical problem but could lead to worse health, more pain, or loss of independence during the last months of life.
“Our goal is not survival at all costs”
One lesson that Dr. Gawande said he has learned from talking to patients is that people have priorities in life other than just survival. The goals will differ from person to person. If we don’t ask patients these difficult questions, Dr. Gawande said, “the care we provide may be out of alignment with their priorities.” That kind of care may cause more suffering than it alleviates.
One patient told Dr. Gawande that he would be okay with his quality of life so long as he could “eat chocolate ice cream and watch football.” That’s better than any living will in terms of clarity, Dr. Gawande said.
He advised asking a patient, “What’s your understanding of where you are in your illness? What abilities are so critical to your life that you can’t imagine living without them?” Understanding the patient’s goals and fears can help the patient, the family, and the medical team reach the best decision about a plan of care, Dr. Gawande said.
“Our goal is not survival at all costs,” Dr. Gawande asserted. “Nor is our goal a good death. The goal is for our care to match their goals. To deliver the right care, at the right time, every time.”
For this fundamental change in the culture of healthcare to occur, payment models must change too, Dr. Gawande said. “A switch from fee-for-service to fee-for-value is absolutely critical for us to work successfully as teams. We have to be part of driving the reinvention of how we’re paid.” The team’s success should be linked to an outcome that is optimal in the view of the patient and the family, even if the decision is not to do surgery.
Dr. Gawande praised the many contributions of anesthesiology to improving processes of care and promoting patient safety. But he urged the ASA to “move from safety to outcomes as your priority.”
To achieve the best outcome consistent with each patient’s goals, Dr. Gawande said, “we need to work as teams before and after they come to the hospital. We need to be willing to take part in the experiments and drive the experiments so that we are paid as teams for better outcomes.”