Informing and accompanying in the right way in the face of uncertainty whether or not to undergo a complex intervention is one of the fundamental and very difficult tasks of those who have to operate
Each profession requires you to make decisions and act competently. Fortunately, not all decisions are equally difficult in the surgeon’s work. At the beginning of the career it is the technical decision, the operating room requires tight deadlines, the outcome of a complicated operation depends on the speed and the right decision. The answer to study, for to be able during the operation to choose quickly and in the best possible way. Experience raises the bar for difficult decisions by making others more difficult than surgical ones appear with increasing responsibilities. How to help the patient in the decision in the face of risks and benefits? Excessive optimism could lead him to accept an intervention without taking into account the possible risks, on the contrary a negative view would make him give up the possibility of getting better for fear of complications.
Informed consent is a right, but what if another person’s difficult decision depends on the weight of the words? What to answer to the patient who asks about the risks in percentage terms? Unfortunately, the statistics are not so precise because there are so many variables. Serious complications or mortality, for example, are extrapolated from a large population, which can give a rough idea, but it is not the analysis of the patient’s twins: each has a different history, previous illnesses, vital and recovery capacities. There remains a margin of uncertainty, the greater the more we act on rare diseases with small numbers, complex procedures or delicate patients. If the patient wants to decide without knowing too many details what to do? Respect her desire, or be more precise with the risk of discouraging him, perhaps triggering a panic attack?
Experience helps to accompany patients in difficult decisions but you never fully learn: even with the utmost commitment, sometimes the spark does not strike, the patient closes and the dialogue is interrupted. Defeat is just around the corner even for the most experienced doctor, unfortunately we cannot please everyone and the patient can ask for a second opinion because of the difficult decision: our national health system leaves you free to choose the hospital or doctor to whom call on. The decision concerning a minor is paradoxically simplified the smaller the patient: if the interlocutors are only the parents, the doctor often has to answer the question what would he do if he were his child. Certainly not easy, but more difficult with a teenager because he already has the ability to understand even if he does not legally sign the informed consent: one more actor in the decision-making process.
How can you help him understand the consequences of the choice his parents have to make for him? Hospitalization, intervention, rehabilitation and risks must be shared to help the family make a difficult decision, trying to keep the right balance, which is irreparably broken if there is a disagreement on the choice of treatment by the parents, a reflection of a conflict. Here the difficult decision becomes impossible. In the end, the patient faced with the difficult choice whether to undergo a delicate and risky procedure is always alone and the only way to help him listen, explain and respond with competence and honesty. To the patient who gives up or is indecisive rather than fear the consequences of his choice it is useful to propose to listen to the opinion of another expert doctorwithout claiming to be the only one who can accompany him in the difficult decision.
* Director of Orthopedic Clinic 1 Rizzoli Institute of Bologna Univ
September 26, 2022 (change September 26, 2022 | 4:55 pm)
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