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Annals of Surgery Journal Club
Interactive resource for surgery residents and surgeons to discuss and critically evaluate articles published in Annals of Surgery selected by a monthly guest expert who will review an article each month, offer questions and respond to reader's comments.
Monday, December 03, 2012
December Journal Club
Moderator: Dr. Peter Angelos
Article: The Role of Surgeon Error in Withdrawal of Postoperative Life Support Schwarze, Margaret L.; Redmann, Andrew J.; Brasel, Karen J.; Alexander, G. CalebAnnals of Surgery. 256(1):10-15, July 2012.
Summary: In the July issue of Annals of Surgery, Dr Schwarze and colleagues have reported on an important study of how likely surgeons are to go along with patient and/or family requests to withdraw life support after the patient has survived a high-risk operation and the role that surgeon error plays in this decision.  Through the use of vignettes that alter specific aspects of the cases presented to the surgeons in the study, the authors have explored the influence on the surgeon’s postoperative decision making whether the case was an emergency or elective and whether surgeon error played any role in the outcome of the operation. Although the authors report several results, 3 in particular are highlighted because of the implications they have for the surgeon–patient relationship and therefore to the practice of surgery.

First, the study showed that despite the importance of respect for patient autonomy in contemporary surgery, 63% of the vascular surgeons, cardiac surgeons, and neurosurgeons who responded to the survey would not honor a request to withdraw life-supporting treatment.  Second, the authors found that in contrast to elective cases, in emergency cases, surgeons are more likely to accede to patient and family requests to withdraw life-sustaining treatments.  Third, and most importantly, the authors found that if surgeon error was thought to have contributed to the patient’s poor clinical outcome, surgeons were less likely to go along with patient and family requests to end life-sustaining treatments.



1.  Why do you believe that surgeons are more likely to go along with requests to withdraw life-sustaining treatments when the operation was an emergency rather than when performed electively?

2.  Is it appropriate that such a low percentage of surgeons go along with  patient/family requests to withdraw life support after the patient has survived surgery?  Please explain.

3.  What is the explanation for why, in cases of surgeon error, surgeons are less likely to go along with requests to withdraw life-sustaining treatment? 

4.  Do you believe that surgeons’ choices about whether to go along with requests to withdraw life-sustaining treatments after surgery are primarily motivated by self-interest (that is avoiding blame or lawsuits) or by the belief that they are acting in the patient’s best interests? 


Please feel free to comment on any or all of the questions above. We look forward to hearing from you, the Annals readers.



About the Author

Dr. David T Efron
Dr. Efron is an Associate Professor of Surgery, Anesthesiology & Critical Care Medicine and Emergency Medicine at the Johns Hopkins School of Medicine. He is the Director of Trauma and Chief of the Division of Acute Care Surgery (encompassing Trauma, Emergency Surgery and Surgical Critical Care) in The Johns Hopkins Hospital Department of Surgery. He is currently the Vice-Chair of the Maryland State Committee on Trauma. Dr. Efron’s current research interests are within the realm of regulation of inflammatory mediators of septic and post-injury states, particularly focusing on the role that statins play in this milieu. Dr. Efron carries additional interest in traumatic injury from interpersonal violence, measures of violence intensity, and trauma recidivism with an eye to prevention strategies.

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