Ruptured aortic aneurysm: the decision not

Transcription

1 Ann R Coll Surg Engl 1998; 80: Ruptured aortic aneurysm: the decision not to operate D F Hewin FRCS Specialist Registrar W B Campbell MS FRCP FRCS Consultant Surgeon Department of Surgery, Royal Devon and Exeter Hospital (Wonford), Exeter Key words: Abdominal aortic aneurysm, ruptured; Surgery; Decision-making Despite published criteria predicting poor survival after operation for ruptured abdominal aortic aneurysm (RAAA), little is known about the factors which influence surgeons not to operate. Questionnaires were sent to all 404 members of the Vascular Surgical Society of Great Britain and Ireland, posing questions about their practices, and factors influencing the decision not to operate (no influence; may influence; seldom operate; never operate). There were 323 responses (81%) and 97% decided not to operate on selected patients. Age over 80 years influenced 77%, and 54% seldom or never operate over age 85 years. The single most influential factor was severe neurological disease (75% seldom or never operate), while cardiac, pulmonary and renal disease influenced 22%, 28%, and 21%, respectively, to operate seldom or never (74% if two or more of these). Other factors which had some influence for most surgeons were cardiac arrest (85%), loss of consciousness (74%), prolonged hypotension (73%), and long-term nursing care (87%). By contrast, factors which influenced few surgeons were haemoglobin < 9 g/dl (30%), absence of a close relative (33%), and medicolegal considerations (22%). These data help to inform the debate about case selection for repair of RAAA. Rupture of an abdominal aortic aneurysm is generally fatal if left untreated, and even with aggressive surgery the death rate is substantial. Three similar studies in the UK showed that 31-61% of patients who ruptured aortic aneurysms did not reach hospital, and only 39-45% had operations: 35-39% of those presenting to hospital did Correspondence to: Mr W B Campbell, Consultant Surgeon, Department of Surgery, Royal Devon and Exeter Hospital (Wonford), Barrack Road, Exeter EX2 5DW not have surgical treatment (1-3). These figures testify to considerable case selection before surgery-an important issue which has seldom been examined in any detail. The failure of patients to reach hospital for surgical triage (4) is explained, to a large extent, by the fact that many die rapidly after rupture. However, 'case selection' for surgical referral also occurs because the diagnosis is missed (5-7), because primary care physicians may choose not to refer the most elderly and frail, and because some units attract patients who need to survive long journeys (8,9). Many studies have examined possible predictive factors for death after operation for ruptured abdominal aortic aneurysm (10-21) with the implicit suggestion that these might be used to select patients for surgery. However, the decision not to operate is often difficult. Even the very elderly, the desperately ill, and those with serious morbidity stand a small chance of survival (7,9), but this chance needs to be balanced against the reasonable use of resources, the potential distress and inhumanity of a lingering death on the intensive care unit, and the patient's likely quality of life in the longer term (22). Medicolegal considerations are also becoming a concern in all areas of surgery, with the risk that a thoughtful decision not to operate might later be challenged in court. The aim of this study was to document the current views and practices of vascular surgeons in the United Kingdom and Ireland in deciding against operation for patients with ruptured aneurysms. The results were intended to inform the debate on this difficult issue, and to provide a useful benchmark for any medicolegal activity in this area of practice. Methods Questionnaires were sent to all 404 members of the Vascular Surgical Society of Great Britain and Ireland. In

2 222 D F Hewin and W B Campbell all, 323 were completed and a further four were returned by surgeons who had retired-a response rate of 81%. The questionnaire is shown in Appendix 1. Results The majority of respondents worked in hospitals with either two (140) or three (80) surgeons with a vascular interest: 60 were single-handed and 35 reported four or more vascular surgeons in their hospital. Table I shows who normally operated on ruptured aneurysms; note that these responses were from individual surgeons, and most hospitals are therefore represented more than once. Further analysis of these figures by hospital was not possible because the questionnaires were entirely anonymous. Sixty-five (23%) surgeons said that they provided Table I. Responses to the question: 'Who operates on ruptured/emergency aortic aneurysms in your hospital?' Vascular surgeons only 122 (38) On call general surgeons 24 (7) On call general surgeons, involving vascular surgeon if required 121 (37) Vascular surgeons only, in rota with other hospitals 31 (10) Local surgeons, with transfer to another hospital on ad hoc basis 13 (4) Other 12 (4) continuous emergency cover on a contractual basis, while 170 (63%) did so by professional understanding (noncontractual). Of the surgeons, 308 (97%) decided not to operate on some cases of ruptured abdominal aortic aneurysm, while 11 (3%) operated on all cases. Table II shows how age influenced decisions: 22% would seldom or never operate on patients over 80 years and 54% on patients over 85 years of age. Table III shows the responses about other factors which might influence the decision not to operate. The single most influential factor was severe neurological disease-75% of surgeons would seldom or never operate on these patients. Limiting cardiac or renal disease or pulmonary dysfunction influenced 22%, 28% and 21% surgeons, respectively, to operate seldom or never, but a combination of two or more of the preceding factors did so for 74%. The percentage of respondents who said that they would seldom or never operate in the presence of other factors were 36% for cardiac arrest, 34% for patients in long-term nursing care, 26% for loss of consciousness and 17% for prolonged hypotension. Only 2% were so influenced by the absence of a spouse or close caring relative or a patient in long-term care; but 31 % and 53%, respectively, said that these factors would influence their decision. Responses to the question about immediate transfer to the operating theatre as opposed to a period of assessment were confused by a number of surgeons giving apparently contradictory answers. However, it was clear that 171 (55%) used a selective approach. One hundred and six Table II. Influence of age on the decision not to operate No influence May influence Seldom operate Never operate Over 75 years 180 (67) 89 (33) 1 (0) 0 (0) Over 80 years 69 (23) 164 (55) 66 (22) 1 (0) Over 85 years 33 (11) 107 (35) 112 (36) 55 (18) Values in parentheses are pecentages Table III. Factors influencing the decision not to operate No influence May influence Seldom operate Never operate Severe neurological disease 4 (1) 75 (24) 177 (57) 55 (18) Limiting cardiac disease 21 (7) 218 (71) 66 (21) 4 (1) Severe pulmonary disease 26 (8) 195 (63) 81 (26) 7 (2) Renal dysfunction 37 (12) 209 (68) 58 (19) 5 (2) Two or more of the above 2 (1) 74 (25) 152 (51) 69 (23) Cardiac arrest 48 (15) 151 (48) 87 (28) 26 (8) Loss of consciousness 80 (26) 151 (48) 59 (19) 22 (7) Prolonged hypotension 85 (27) 175 (56) 44 (14) 8 (3) Haemoglobin < 9g/dl 217 (70) 89 (29) 6 (2) 0 (0) Long-term care (eg nursing home) 41 (13) 165 (53) 92 (30) 11 (4) Absence of close caring relative 206 (67) 97 (31) 5 (2) 1 (0) Values in parentheses are percentages

3 (37%) said that they always pursued a policy of immediate transfer to the operating theatre, but 43 (14%) combined this with a period of assessment. The possible medicolegal consequences of not operating never influenced this decision for 252 (78%) surgeons, and did so occasionally for 63 (20%). Only 6 (2%) were often influenced by medicolegal considerations, and no surgeon was 'always' influenced. For a situation which had become hopeless during surgery, 262 (85%) respondents would terminate the operation and anaesthetic support at that stage, while 47 (15%) would complete the grafting procedure and move the patient from theatre to avoid 'death on the operating table'. Discussion Few published series on the treatment of RAAA give details of the proportion of patients who are admitted to hospital but then have no operation. Such figures as are available document 15-39% as being denied surgery (1-3,23-25). This questionnaire has provided firm evidence to support the belief that almost all vascular surgeons practice some selection of patients for repair of RAAA. Many published series have sought to identify factors associated with death after operation for RAAA. These have included age (9,10,12,15,16,20,26), hypotension (8,12,13,16-21,27,28), myocardial ischaemia (10,12, 13,17,20,21,26), renal dysfunction (12,14,18,21,26), anaemia (15,20,21,26), cardiac arrest (10,21,27), coagulation abnormalities (10,29,30), loss of consciousness (10,26), neurological dysfunction (12), respiratory disease (18), preoperative delay (8,10), hospital size (11) and experience (31), and the absence of a vascular surgeon (11,15,18). Many of these remain controversial. Age is perhaps the best recognised and simplest criterion for withholding surgery: 77% of surgeons said that age over 80 years would influence their decision to operate, while 54% would seldom or never operate on patients over 85 years of age. The other single factor which influenced surgeons most against operation was severe neurological disease (99% were influenced and 75% would seldom or never operate). It was difficult to pose questions about multiple criteria, but responses to the single question about a combination of two or more of cardiac, pulmonary, renal and neurological disease provided clear evidence that surgeons were particularly influenced by multiple comorbidities. Recently, a set of criteria reported by Hardman et al. (26) has attracted special interest (32,33). The presence of three or more (age > 76 years, creatinine > 190 mmol/l, haemoglobin < 9 g/dl, loss of consciousness after arrival, and electrocardiographic evidence of ischaemia) have been shown to predict almost certain death. Another set of prospectively evaluated criteria has been described by Samy et al. (12,24) (age, shock, myocardial disease, cerebrovascular disease, renal disease). The questionnaire did not specifically explore these combinations of factors, Ruptured aortic aneurysm 223 but it was interesting that one of Hardman's criteria, haemoglobin level, had no influence at all on 70% of surgeons, possibly because it is seldom available when a decision about surgery is made. Another of the criteria, the creatinine level, is often not known when a shocked patient is admitted. Criteria based on laboratory tests are less likely to be used in the emergency setting than simple factors such as age, shock, cardiac arrest and loss of consciousness. Possible medicolegal consequences of denying surgery to RAAA patients was one of the stimuli for this questionnaire. Legal action has loomed in other areas of practice where decisions not to treat have been made on the basis of age alone. There are sound reasons for avoiding operation on the very elderly with RAAA, but with increasing litigation surgeons may need support for these decisions. The results of the present study demonstrate the practices and views of the majority of vascular surgeons in the UK and Ireland, and form a sound basis to defend reasonable decisions against operation for RAAA when the chances of survival or reasonable recovery are very low. Criteria also exist for predicting outcome based on operative (14,17,21,34) and postoperative (10,14,35) factors, but by this stage treatment is well advanced. When the situation is clearly hopeless, the great majority of questionnaire respondents would terminate the operation, but when the situation is less clear discontinuing treatment during or after surgery may pose a dilemma. This questionnaire has focused on the views of vascular specialists, and excludes the many general surgeons with other interests who deal with RAAA patients. Only 38% of the respondents were in hospitals where vascular surgeons dealt with all RAAAs, while a similar percentage offered support for these cases over and above their own general surgical emergency commitment. There were 14% involved in rotas with vascular surgeons in other hospitals, or with ad hoc transfer arrangements, leaving just 7% in rotas without regular vascular support for the duty general surgeon in dealing with RAAAs. Debate about which patients may reasonably be denied surgery tends to focus on hospital mortality as the final arbiter. However, duration and completeness of recovery, social function and quality of life (22) ought also to be considered, as perhaps should the question of cost-benefit (36,37). With regard to quality of life, it was interesting that relatively few surgeons were influenced by patients' social circumstances, which we regard as very important. If a patient is married, then the quality of two lives, not one, will be influenced by survival, while the trauma and risk of a RAAA operation for the very elderly person living alone, or existing in long-term care might be questioned on humanitarian or cost-effectiveness grounds. These are difficult moral issues, but they cannot be ignored. The authors would like to thank the members of the Vascular Surgical Society of Great Britain and Ireland who completed the questionnaire.

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5 Ruptured aortic aneurysm 225 Appendix 1 Questionnaire sent to members of the Vascular Surgical Society of Great Britain and Ireland 1. How many general surgeons are there in your hospital? With a vascular interest? Without a vascular interest? 2. Do the vascular surgeons (or surgeon) in your hospital provide continuous emergency cover for ruptured aortic aneurysm? As a contractual commitment Yes No By professional understanding (non-contractual) Yes No 3. Who operates on ruptured/emergency aortic ysms in your hospital? (Answer one only) aneur- Vascular surgeons only (by fixed rota) On call general surgeons On call general surgeons, but involving a vascular surgeon if required/available Vascular surgeons only, but in a rota involving other hospitals Local surgeons but with transfer to other hospitals on an ad hoc basis Other (described) 4. Do you decide NOT to operate in certain cases of ruptured aortic aneurysm? Yes No For questions 5 and 6 one of the following responses was invited for each question. * Does not influence my decision * May influence my decision * I would seldom operate * I would never operate 5. Does age influence your decision not to operate? Over 75 years Over 80 years Over 85 years 6. Which of these factors influence your decision not to operate? a) Limiting cardiac disease (angina/cardiac failure) b) Pulmonary disease with limiting dyspnoea c) Renal dysfunction (eg known creatinine > 190 mmol/l) d) Severe neurological disease (eg Parkinson's, hemiplegia, dementia) A combination of two or more of (a) to (d) above Prolonged hypotension (eg BP < 80 mmhg) Cardiac arrest during this presentation Loss of consciousness Haemoglobin < 9 g/dl Absence of spouse or close caring relative In long-term care (eg nursing home) 7. Preoperative management. Is your usual policy: Immediate transfer to theatre for emergency operation without any investigations? Selected cases Always A period of assessment (± resuscitation) to obtain more medical details/do blood tests/consider wisdom of operation? Selected cases Always 8. Do the possible medicolegal consequences of not operating influence your decision? (Answer one only) Never Occasionally Often Always 9. If, at operation, the situation becomes hopeless (eg very poor cardiac output despite therapy, and coagulopathy) would you normally (Answer one only) Complete the grafting procedure and move the patient from theatre to avoid 'death on the operating table'? Terminate the operation and anaesthetic support at that stage?