“Doc, do I really need this operation? What are the TRUE risks?” Improving the conversation around surgical risk using evidence-based medicine

A 70-year-old woman with peptic ulcer disease comes to the ED with sudden severe abdominal pain. She also has a history of diabetes and hypertension, both well controlled with oral medication. Her vitals at triage show low-grade tachycardia but are otherwise within normal limits. She is peritoneal on exam and an upright chest x-ray reveals free air. While labs are pending, she is made NPO and started on IV fluid resuscitation.

You are the general surgeon called to see the patient, and your history and exam corroborate the diagnosis of perforated viscus, most likely peptic ulcer, and that the patient needs to go to the operating room for an exploratory laparotomy. You explain to her what’s going on and why she needs surgery. She says, “Doc, I’m an old lady—do I really need this operation? What if I die from the surgery?”

Consider for a moment that you are this patient, or your grandmother is this patient. Which answer would be most informative and helpful in decision-making and managing expectations?

  1. “Your old age probably makes the operation more risky, but you need this surgery, and I’m pretty sure your risk of dying from the surgery is lower than your risk of dying without the surgery.”
  2. “I calculated the risk of mortality and morbidity in patients undergoing emergency laparotomy and your risk percentages are 9.1% and 45.5%, respectively.”
  3. “Advanced age is one factor that we know can make surgery more risky, but in your case, the benefits of the surgery outweigh the risks. Looking at evidence from thousands of patients just like you, who are your age, with the same medical history and bloodwork results, undergoing the same surgery, we’ve found that there’s about a 45% risk of complications, which includes things like bleeding, infection, blood clots, and needing to be on a ventilator after the surgery, and about a 9% risk of dying from these complications.”

While every patient is different and your clinical judgment (and common sense) should always prevail, it can often be helpful to employ a combination of patient-specific information with data, especially with patients going for emergency surgery, in whom establishing rapport and trust quickly is critical.

An answer like (a), delivered confidently, may help a patient feel more at ease, but is not necessarily that informative or evidence-based. Answer (b) is technically true, but oftentimes it’s nice for a patient to feel like a human and not a number. Answer (c), which acknowledges the patient’s concerns and case-specific details, combined with good data, is an effective way to start the process of informed consent.

Two important points to remember about risk estimates in surgery:

  1. Risk estimates are exactly that—estimates of risk. They are not necessarily predictive. What’s the difference? For a young healthy patient undergoing a routine laparoscopic cholecystectomy, the risk of surgical site infection, according to data from the ACS NSQIP database, is about 0.5%. But for those 0.5% of patients who get an SSI, their risk is effectively 100% (and quoting percentages to those patients is of little comfort).
  2. A high risk for complications should not preclude surgery in a patient who needs surgery and understands the risk. Our 70-year-old patient with a perforated viscus is not the perfect surgical candidate, and she has a real risk for complications, including death. But she needs an operation, and so with a patient like her, it is especially important to have the conversation about risk, and more specifically about types of complications and their severities—for example, her risk for a UTI may be higher than her risk for MI, but most would choose UTI over MI (if only it worked that way).

MDCalc’s POSSUM for Operative Morbidity and Mortality Risk not only calculates morbidity and mortality percentages, but also has all the information included in this post that can help facilitate these conversations with patients, including:

  • Pearls/Pitfalls: including that “The POSSUM should NOT dictate the decision to operate, which is a clinical decision.”
  • Why Use?: Compare the POSSUM to other similar scores like APACHE II, Surgical Apgar Score, ACS NSQIP Risk Calculator, Revised Cardiac Risk Index.
  • Facts and Figures: The complete list of all complications that were included in the derivation.
  • Evidence Appraisal: Description and analysis of the original study by Graham Copeland, updated modifications like P-POSSUM, and additional validation studies in specific types of surgery.
  • Creator Insights: Thoughts from Dr Copeland himself on using POSSUM.