手术中犯错的外科医生常不愿撤除生命支持

《外科学年鉴》(Annals of Surgery)在线发表的一项研究显示，手术期间犯错的外科医生不太愿意撤除生命支持，择期手术后尤其如此(2012;256:10-15)。

在这项研究中，威斯康星大学麦迪逊分校的Margaret L. Schwarze博士及其同事对2,100名实施高危手术的外科医生进行了专业相关问卷调查。共纳入3个专业的外科医生：血管外科(择期和紧急胸腹主动脉瘤修复)、心胸外科(择期和紧急升主动脉瘤修复)和神经外科(择期和紧急钙化右脑中动脉瘤夹闭)的医生各700名。在最初发出的2,100份调查问卷中，共回收有效问卷912份，各专业的问卷回收率基本相同。

血管外科医生和心胸外科医生遇到的并发症相同：麻醉复苏后患者左臂和腿部无力。血管外科医生的常见手术错误为意外放置近端钳，以致其阻塞左颈动脉。心胸外科医生的常见手术错误为意外取出动脉导管。对于血管手术和心脏手术，非错误引起的并发症是由不明原因的术中卒中所致。

多变量分析显示，与错误导致并发症的择期手术外科医生相比，术后并发症明确不是由错误引起的紧急手术外科医生更可能同意撤除生命支持[比值比(OR) 1.95]。此外，对患者未来生活质量不乐观的外科医生(OR，1.75)及认为患者能够正确评价其未来健康状况的外科医生(OR，1.59)撤除生命支持的可能性显著大于相应对照组。

研究者推测，技术性错误引起的医源性并发症可能会使外科医生产生相当强的内疚感和精神负担。这些因素对外科医生造成影响是可以理解的，但研究者担心这些因素可能会明显削弱患者控制其医疗决策的能力。

该研究结果提示，犯外科技术性错误和对预后的乐观程度可能会影响患者自主权。因此，应努力减轻外科医生的情感压力，并同时尊重外科医生对患者预后负责的严格伦理原则。

当术后患者出现危及生命的并发症并要求撤除生命支持治疗时，外科医生不可能立即这么做。这些决策可能受手术时机和并发症是否是由明确技术性错误引起这两个因素影响。此外，这些非临床因素可能与外科医生对患者术后生活质量的乐观程度有关。

研究者声明无相关经济利益冲突。

爱思唯尔  版权所有

By: MARK S. LESNEY, Cardiology News Digital Network

Surgeons are more reluctant to withdraw life support if they made an error during surgery. This is especially true after an elective procedure, according to an extended analysis of a recent scenario-based survey of 2,100 surgeons who were involved in high-risk operations.

The survey included a series of questions regarding specialty-specific scenarios for 700 vascular surgeons (elective and emergent thoracoabdominal aortic aneurysm repair), 700 cardiothoracic surgeons (elective and emergent ascending aortic aneurysm repair), and 700 neurosurgeons (elective and emergent calcified right middle cerebral artery aneurysm clipping), according to Dr. Margaret L. Schwarze of the University of Wisconsin, Madison, and colleagues.

In the case of the vascular and the cardiac surgeons, the complication was the same: The "patient has weakness in left arm and leg when she awakes from anesthesia." The surgical error for the vascular surgeons was inadvertent placement of the proximal clamp so that it occluded the left carotid artery; for the cardiac surgeons, it was inadvertent dislodging of the arterial cannula. For both vascular and cardiac procedures, the non–error-caused complication resulted from unexplained intraoperative stroke.

The three specialties were chosen based on the presumption of routine high-risk operations, according to a report published online ahead of print in the Annals of Surgery (2012;256:10-15).

This analysis follows an earlier report in the Annals of Surgery by these same authors, who used these same survey data to determine that the majority of these surgeons performing high-risk operations did not discuss advanced directives with their patients, and 54% were unlikely to operate on these patients if they were aware of such directives prior to surgery (Ann. Surg. 2012;255:418-23).

Of the original 2,100 surveys that were sent out, 912 were completed and returned, with roughly equal percentages (54%-56%) for each specialty.

Multivariate analysis showed that surgeons who faced complications after emergency surgery that were not clearly the result of surgeon error were nearly twice as likely to agree to withdraw life-sustaining support, compared with surgeons evaluating elective procedures that had a complication resulting from surgeon error (odds ratio, 1.95). In addition, the odds of withdrawing life support were significantly greater among surgeons who were not optimistic about the patient’s future quality of life (OR, 1.75) and among those who were not concerned that the patients did not accurately value their future health state (OR, 1.59), compared with their counterparts, according to the authors.

"Iatrogenic complications that clearly derive from technical errors during elective procedures may pose considerable guilt and emotional burden upon surgeons," the authors speculated. "It is understandable that such factors should weigh on the surgeon. However, our findings call into question the degree to which these factors may unduly interfere with a patient’s ability to control his or her health care decisions."

In addition, "our data suggest that the commission of an error in surgical technique and prognostic optimism may present a challenge to patient autonomy. ... [This] suggests the importance of efforts to alleviate surgeons’ emotional strain while simultaneously respecting the fierce ethic of responsibility that surgeons possess for patients’ outcomes."

When a patient experiences a life-threatening complication and requests withdrawal of life-supporting therapy postoperatively, surgeons may be unlikely to do so without delay, according to the authors. "These decisions may be influenced by both the timing of surgery and whether the complication was the result of explicit technical error. In addition, these nonclinical factors may be associated with surgeons’ optimism about the patient’s postoperative quality of life," they concluded.

The authors reported that they had no financial disclosures.