When surgeons say “no” to surgery

When a surgical oncologist declines to perform surgery on a patient, there is almost always only one reason for it. The cancer has reached such an advanced stage that surgery will not improve the patient’s prognosis in a meaningful way – either because the surgery is too risky or will result in significant physical impairment. Therefore, there will be no foreseeable long-term benefits at the cost of short-term morbidity in an already extremely sick patient.

There are, of course, other reasons that a cancer patient may not undergo surgery for their disease. Financial barriers may preclude underfunded and uninsured patients from accessing surgical care, or patients may decide against receiving surgical treatment.

About a year ago, we found ourselves in a situation that didn’t fit with any of the aforementioned circumstances. As described in more detail in this article, we encountered a patient at a safety net hospital with a type of cancer that only can be treated surgically. The patient’s cancer stage was favorable for surgery, the patient had coverage for the surgery and the patient was amenable to the surgery. However, the tumor involved many abdominal organs and would be extremely challenging to resect, and some disagreement arose as to whether the surgery was technically feasible or not.

In the end, we were unable to offer surgery as an option. Although the possibility of transferring to a quaternary care cancer center was raised, we were unable to guarantee that funding would be approved for this surgery, and the patient ultimately declined.

Understandably, receiving this kind of news is devastating for patients. Our motivation for writing this article was to shed light on how such a decision and the process that led to it affects surgeons and brings with it distinct ethical and hospital policy implications.

In our case, the surgical team spent more than a month thinking about ways to successfully resect the tumor with minimal risk of morbidity. When it was finally determined that the hospital and surgery could not meet the patient’s postoperative needs, the lead surgeon felt conflicted for weeks by the thought that he could not offer this patient a treatment.

These negative feelings, we argue, are not merely emotional states felt in passing, but can accumulate over repeated experiences, resulting in moral distress – the feeling that one was not able to do what one thinks is the right thing to do. The resultant burnout, loss of empathy and moral injury may lead surgeons to no longer fight for their patients and try their hardest to identify creative treatment options when standards of care fall short, ultimately lessening the quality of care that patients receive.

We close out our article by suggesting that healthcare institutions should offer structured debriefing sessions. This should include all involved parties, including hospital administrators, and discuss factors, interpersonal or systemic, that prevented the desired outcome from being realized and what interventions might prevent such situations from occurring again in the future.

Clinicians can use these experiences to drive positive change. In our case, the lead surgeon, who was a newly hired orthopedic oncologist, demonstrated to the surgical chiefs at the hospital that he was dedicated to the care of his patients. After discussions with the blood bank about the higher requirement of blood products his surgeries might need, he convinced the blood bank to allot more units of blood products for future cases. All this paved the way for future patients with complicated musculoskeletal cancers to receive treatment at that hospital for the first time. Ultimately, these efforts highlight the power of perseverance and collaboration in improving patient care.

By Ryan Lam, second-year medical student, and Dr. Lorenzo de Rama Deveza, assistant professor in the Joseph Barnhart Department of Orthopedic Surgery