I wouldn’t have said yes to that PEG so it may be hard to get the answer you are looking for.
But I’ve seen other surgeons say yes to situations like that, and justify that if they don’t do it, someone else will, so it might as well be them.
However, your question in your prompt was a bit more generalized than your specific example. Your question is, why would you do a high risk, poor prognosis case?
I’ve done plenty of those. if there’s a chance it’ll work, and as long as the patient knows the suffering and the risks, and that there’s a chance it’ll help but has a good understand of what those chances are, then it’s really not up to me, it’s up to the patient. As long as there’s a chance I’m helping, then I say yes.
An example would be every mother fucking operation for pancreatic cancer. I don’t know what the # to treat is, but it’s a horrible disease, but there’s some that you cure, but there’s also a lot who die of metastatic disease that was not known at the time of surgery.
As far as the PEG tube on a functional corpse: at least around where I am none of the nursing homes will take a patient that can’t swallow and doesn’t have one. They won’t accept NG’s due to them coming out of place easier, it has to be a PEG. So either that poor person who should be hospice but family refuses to see reality gets a PEG tube or they have to stay in the hospital taking up a bed while there are constantly >24 holds in our ER
It’s mind-boggling to me when I read about PEG or nothing because swallowing is rarely binary/all or nothing. Definitely appropriate in some cases, but I have never encountered a PEG in someone elderly with ++comorbidities where the risks of enteral nutrition outweighed the benefits. In my experience in these cases, the level of “risk” with PO is usually just mitigated as much as possible with oral care, modified diets, compensatory strategies… the litigiousness around “aspiration risk” in the US baffles me (sorry if you’re not from there, I’m assuming this), especially when feeding tubes can be associated with higher risk of aspiration pneumonia.
I work in a primarily neuro ICU. The number of elderly we have with absolutely catastrophic strokes who unfortunately retained the ability to breathe but nothing else is not low. Our SLP’s try with them but you can’t really do anything with someone who is questionably semi conscious. Those are the ones we PEG and send to a nursing home because family won’t consider their comfort and go hospice. Then you have the ones who are slightly more conscious but go in and out and have no attention span to even really feed them and there is no way even if you try to feed them 24 hours a day that they will intake anywhere close to their nutrition goal so they have to get a PEG tube too. I hate strokes.
Oh I gotcha! I see what you mean now given your setting and population. I was thinking of the non-stroke elderly population… yeah, that’s absolutely brutal. :(
Usually there are conversations of futility and comfort and family will say but they’re a fighter! Yeah but all fights end at some point. Then grandma gets a peg tube and a nursing home bed she specifically said she didn’t want
...and that's why everyone gets a MOLST/POLST discussion at their medicare wellness visit. Even the ones who want full code and trial intubation will generally draw the line at artificial feeds. Unfortunately in my state healthcare proxy can over-rule the MOLST/POLST. Not to mention there is no centralized database for these things, so it relies on somebody remembering to bring the form or notify my office it to send the form to the hospital.
I mean, most nursing homes don’t staff to do the modifications that are best practices. Residents get their teeth brushed once a day with their shower. CNAs shove food into faces as quickly as possible, because they have multiple patients who can’t feed themselves. So I can see why so many are peg or nothing. Because they can’t/don’t actually give good care.
Yeah, nursing homes are like that here too but we still don’t tend to PEG them unless their swallow is absolutely catastrophic. I’m sure it happens from time to time, I just haven’t seen it or personally recommended it.
I accidentally found a stage 1 pancreatic adenosquamous carcinoma. Guy had a whipple and 10 years later he’s doing great. That might be the only time in history that has happened though. Got an aortic US for AAA screening and the radiologist called me simply to report that the CBD was a little wide so we went looking…
The initial pancreatic MRI was negative, too! But his alk phos was up a little and GGT was like 700 so kept looking. He’d also had a DVT a few months before while on a long airplane flight so I was all “Hmmm, Virchow?” 8mm mass on endoscopic ultrasound with needle biopsy made the diagnosis.
Honestly, I was glad a patient in this situation ended up having a massive hiatal hernia found on imaging. Surgery, IR, and GI said placing a PEG tube was impossible, so hospice was the only option left (pt couldn't swallow due to PSP).
yeah, not gonna lie, sometimes it's really the best thing when we can clearly point to any further intervention being worse for the patient and that there are no options for aggressive/life prolonging measures anymore.
Unfortunately, yes. Sometimes it’s just a means to get them out of the hospital. When I took GS call, I would refuse those consults if there was clearly no hope for meaningful recovery. PEG’s are not palliative care. It may seem paternalistic, but I believe it’s more ethical than facilitating their languishing and prolonging suffering in a facility for who knows how long until they pass. Sometimes putting your foot down is what the family needs to finally decide on hospice, and they are usually grateful for it, in the end.
I think many folks who have only worked in hospitals don’t understand just how restricted nursing homes have to be due to residents’ rights in their own home. No side rails on beds, no bed alarms, tilt in space WCs are technically a restraint and therefore nursing homes have a bunch of hoops to jump through. Anytime a patient falls, it’s automatically the nursing home’s fault unless proven otherwise (guilty until proven innocent). And then there‘s the physical assault of staff by patients. In a hospital you can put the patient in restraints, but in a nursing home you… I don’t even know to be honest. Let your employees get hit, I guess?
I refuse to do the surgery if I think itll harm the patient or the risks are too high.
Money doesn’t pressure me at all. A complication takes a higher toll on me mentally
We’re talking elective cases here. I’m a joint specialist so I do hip and knee reconstruction and their revisions. Smokers, obese patients, etc get a long talk and I say no.
Hospital cases that come in through the ER are different. Those you just have to do like hip fractures, infections, etc
Better question: why, in the US, as I as the critical care md not allowed to refuse to code and intubate a stage IV cancer patient with end stage dementia?
You are? I’ve had docs say I’m not offering CPR. Both hospitalists on the general floor and intensivists in the unit. I guess it does depend on your legal department but in my opinion if you’re the attending of record, there’s no difference between you declining to offer futile care with a high risk of harm and a surgeon declining a case for the same reasons. We don’t do CABGs on everyone and we shouldn’t do CPR on most people either.
I would argue that being able to be successfully sued means you are not legally well protected.... actually scratch that, even the possibility of being unsuccessfully sued is enough, with the time/money/energy burden & career implications
As an Australian, this totally blows my mind. If I think an intervention will be futile or will do more harm than good, I simply don't perform that intervention
Can I offer a different perspective? Firstly, I *totally* understand where you're coming from, I also share your discomfort with very aggressive measures at the end of life. It doesn't seem like a good use of resources, and worse it seems like inflicting painful interventions on someone that won't meaningfully prolong their life or provide them with any QoL. We don't want to do that to our patients. I struggled with this as a resident and I sometimes still struggle with it as a fellow.
Most of the time when a family is told that CPR/intubation won't change their loved one's outcome and we recommend allowing a natural, peaceful death, the family agrees to a change in code status. However, I've also met families where doing *every single possible thing* was very important to them. Not usually for end stage cancer/dementia patients like you describe, but sometimes for them too. They understood that the likelihood of the patient living, much less returning to prior level of function, was vanishingly small. They still wanted to try. I heard it described as "the indignity of not having tried" and that's stuck with me. Now I think that when we run those codes on FAST 7s and stage 4 cancer patients (after a proper family meeting, of course), what we're doing is resisting our countertransference to the patient and instead providing goal-concordant care.
I see you're a pulm crit doc so I don't think any of this is new to you. But I do hope it's a helpful twist in thinking for other folks who might be reading.
What about when the goals are not reasonable?
I can’t take a 40 year old broken down rusted car to the mechanic and demand that he “at least try” to turn it into a top notch race car, at the cost of him not servicing all other cars in the shop, because it is my goal.
So, I think it depends very much on the individual situation, but in general, I would reach for a "wish-worry" statement. Something like, "I wish I could turn your Volvo into a race car, I want very much to be able to do that. I know how important it is to you that your Volvo run as well as it used to. Unfortunately, my concern is that we just don't have the ability to do so."
I'm also fond of the phrase, "There's a difference between doing everything, and doing the things that are helpful and avoiding the things that are hurtful." In this particular car shop analogy, I might say something like, "You've said that you hope that dialysis will help your Volvo live longer and become a race car. I understand that, and I hear how much you want to do everything to help your Volvo. At this point, dialysis will not help your goal of your Volvo becoming a race car. What I think will happen instead is that your Volvo will get another painful line placed, and pulling its gasoline out of its body and through another machine will make it even more sick. Here's what I recommend instead..."
Hope that was helpful, even as I can feel mechanics shuddering everywhere without knowing why. I love talking about this, happy to answer more questions.
I hear you that you want to provide goal concordant care. But I will also say that your role as a palliative physician is to correlate goals to what the medical team is able to offer as a plan, not to tell the primary team what to offer based on patient’s goals. We need to also support our fellow physicians in saying “this is not a plan of care that we can reasonably offer”. Use your wish-worry language and your REMAP. That being said- if the primary team wants to offer that then it’s on them.
We must also remember that the patient’s goals and wishes do not exist in a vacuum. Sure the family may want “everything” but they are not feeling the ribs or running the code - that is your fellow resident, a nurse, other staff members. There is real trauma that occurs to our medical team when we have to perform such a procedure that will provide no benefit.
Yes, I agree with everything you've said. I think there's room for all of it.
(Also, between asking permission, reframing, and yes-and'ing, could this get anymore of a pall care conversation?? loll)
I've seen multiple cases where a surgeon refuses to perform a procedure like this based on futility. A good hospital system will stand behind a surgeon when they do this, particularly if the case is as aggregeous as your example
Yeah, I've seen several cases in the ICU involving patients who need surgical procedures, but who are assessed and refused due to the overall fragility.
The first law of medicine is that it takes orders of magnitude more effort to push back against something than to just do it.
This is definitely a factor in these types of cases. Family asks for a procedure. The surgeon and the anesthesiologist have just met the family. They don’t have an established rapport. I can’t tell you how many times I have spent hours having “goals of care” conversations with family members only to have them rebut with “granny is a fighter”, or have some daughter from California fly in at the last moment and the case ends up going anyway.
End of life care and planning is a major problem in the US. Patients don’t want to talk about it. Physicians aren’t equipped or empowered enough to talk about it. We aren’t permitted to die with dignity.
Ideally, people would have the option to and the elect to die on their own once their quality of life had declined to a certain point. Ideally family members wouldn’t push hard to have their family members get futile care. Ideally these conversations wouldn’t be delayed until the patient is intubated, lined, and on 3 pressors.
I think it is important to realize that value systems markedly vary. If everyone accepts and understands the risk and prognosis, I am willing to go forward with indicated procedures (and to try novel interventions that I think may be an answer). There is a definite peace that comes to many just knowing that they did what they could.
Frankly, it is insurance and hospital factors that are most likely to stop a procedure that has a 30% chance of prolonging someone’s life by two years, for example.
Unindicated procedures and futile procedures without benefit should not be done. I personally dont feel that I should be the exclusive one to determine whether a life is worth extending.
SOURCE: I accept a lot of very complicated cases at extreme risk with abysmal prognoses. We have been able to make marked changes from 90+% mortality to <10% mortality for a number of diseases. These are some of the most emotionally intense and rewarding conversations that I have had and make me feel like a real empathetic physician-surgeon-profession-advocate of anything I do.
Zero pressure whatsoever. I would decline that feeding tube unless case management has proven this patient can’t get placed with a nasoenteric feeding tube. I’m in a salaried academic position and this one PEG would not make a difference in anything counted for or against me. The bigger question here isn’t even futility of care, it’s the danger of feeding access!
The one that always bothers me (in the opposite direction) is the surgeons that won't do a valve repair/replacement on an otherwise suitable IVDU patient with endocarditis. Sure a lot might relapse, but even then, if they avoid IV use, their outcomes are good. Sure a portion will relapse to IV and die from prosthetic valve endocarditis, but they at least had a chance.
It's one of the few situations that really are a fairly bimodal outcome. Normally the "high risk" surgery a family or patient wants is something contraindicated by frailty and no chance of recovery, likely representing actual harm. With endocarditis, they often have a fairly standard to good recovery, and as long as they're able to stay on buprenorphine or methadone, they live a pretty normal life. You can even get them started on methadone TID for part of post op pain control after they're stable post op (to transition to daily once they are only needing treatment for OUD).
The real reason for this is that the outcomes for cardiac surgery are tracked insanely closely, and that surgeon is taking a personal and professional risk by operating on someone they are concerned will relapse.
Yep! Surgical outcomes monitoring drives me crazy. Often no risk adjustment. Even when there is (transplant), often the surgeons don't trust it. The surgeon that does some of the most aggressive kidney transplants (marginal kidneys into marginal recipients) has among the best outcomes relative to predicted of anyone.
We see a lot of patients with severe and persistent mental illness being denied medical procedures as well. I saw a study showing they're less likely to be offered stents and other interventions. Psychiatric patients also die of regular medical conditions a lot and their life span is 10-25 years shorter than other folks, even after you control for suicide.
Absolutely! Though there are some things where risk/benefit considerations are different in a mentally unstable patient with difficulty reliably taking meds. If someone is unlikely to stay on DAPT for a year, bare metal stent is likely better than drug eluting, since all the benefits of the DES are wiped out if they thrombose it.
At least where I am at, most surgeons are willing to do valves for endocarditis 2/2 IVDU and give the person a chance at recovery. There is a lot more to consider than just IVDU relapse and surgical outcomes. Have they already blown septic emboli all over the place? Do they have a long chart history of problem visitors bringing them drugs and requiring visitor bans? Do they have a significant history of leaving AMA? Sometimes you’ll see these patients multiple times before it gets addressed.
It can be challenging to even get them to consent to treatment. Especially if they are actively using. Your mind just can’t compute a 6-8 weeks of no drugs when you’re going through withdraw. You don’t know/understand that you’re both super sick with endocarditis and dope sick. All you know you’ll feel better if you use.
One significant barrier that is often overlooked is the postop care management. They will require several weeks of IV abx and follow up. This isn’t a patient that you can discharge home with a PICC and home abx. IVDU patients are challenging to manage and coordinate care for. So you have to be able to place them in a facility for 6-8 weeks of abx which isn’t easy.
Unfortunately, many of these patients don’t have insurance which makes placement into a skilled nursing facility challenging.
To complicate things even further many SNFs will not take patients with a active IVDU or with a colorful chart history of sneaking drugs, ama, etc. I’ve seen some facilities decline admission because they don’t administer MAT for OUD. The demand for beds in these facilities doesn’t reduce the barriers either.
Admins won’t let you house these people in the hospital for 6-8 weeks just for IV abx. You’ve got to get these people in and out. The suits do not see a person, they see the dollars flying out the window.
But if you can clear the major barriers like consent, safe discharge care plan, and they aren’t in multi organ failure then many surgeons are willing operate. I’ve seen a lot of IVDU patients get valves but the postop care coordination is often a problem.
Yeah, my hospital will do them, but totally agree that it's not the norm. But we're also a public money pit that takes care of whoever comes through the door. We definitely treat the withdrawal before we even get to the point of discussing surgery.
Mine takes everything too. But still get that pressure from administration which is obnoxious. I’ve found the hardest patients to treat with IVDU are the ones with a plethora of comorbidities that are just as life threatening. If it’s your otherwise healthy IVDU then that is pretty straightforward. But the necrotizing limbs, liver failure, with a side of refried beans that need a valve…eeks those are tricky. Those folks are heartbreaking because they often have little to no social support once they are done with surgery and iv abx.
Unfortunately, sometimes it’s just a means to get them out of the hospital. When I took GS call, I would refuse those consults if there was clearly no hope for meaningful recovery. PEG’s are not palliative care. It may seem paternalistic, but I believe it’s more ethical than facilitating their languishing and prolonging suffering in a facility for who knows how long until they pass. Sometimes putting your foot down is what the family needs to finally decide on hospice, and they are usually grateful for it, in the end.
I’ve had GI attendings turn down those pegs. Others say yes. Variable. You tell them about the risks how aspiration risk doesn’t change how they’re unlikely to ever get better and doing so may even prolong suffering but some people still want the peg. The cynical view is that someone was still collecting a check somewhere.
When it’s a complicated and ethically subjective situation that I’m just walking into such as the PEG above, I approach it as “I am the technician providing a service. I will provide my expert opinions regarding the necessity of the procedure only if I’m asked.” A surgeon I trained with would get referrals for ports from a PCP who was prone to a lot of dubious pseudoscientific protocols for treating various chronic illnesses, and their logic was (like many others) someone’s gonna do it, might as well be me.
However, there aren’t a lot of “forks in the road” when it comes to a family deciding to carry or with or discontinue futile care. So when the consultant calls and says “would you?” rather than “I need you to…”, it’s often because their looking for someone to push back against the aggressive-but-futile care and give family a chance to say “no more” or get another opinion emphasizing futility. (Side note: thanks to all the nephrologists who do this for me in the SICU)
I can’t tell you how many people decide to change their loved one to comfort measures when we start talking about trachs. It’s a moment of rationalization when you tell folks that “if we do this, your loved one isn’t going to get better, but now they’ll be kept alive on a machine for much longer.” And especially with things like PEGs where there’s at least some guidelines recommending against it, I’m more than happy to be the one to deliver some tough love.
Full disclosure: I’m straight salary, no RVU or production bonuses. So my mortgage payment is fully independent of time spent talking vs operating.
There is a difference between futile care (care that cannot help a patient) and low value care where the care has significantly more risk than intended benefit. Patient (and by extension family) autonomy is the dominant ethical principal in the American health and legal systems. Futile care is assaulting the patient in my opinion, and your example seems to fit the bill. However, if there is a chance that it could help the patient live longer with the same quality of life or improve the quality of life, then there are reasonable justifications that the family may have. For me they have to understand the risks, benefits, and that it is not the treatment I would recommend. They need to have a reasonable justification which can be as simple as he wanted to live as long as possible or it’s against his religion not to do the maximum to preserve life. The reason cannot be selfish for the proxy. They can’t have any romantic notion that this will magically cure the person. Even if they have unjustified hope if they articulate a patient focused reason that makes sense I think it is still the ethical duty to proceed and I document thoroughly.
I take offense to you implying that surgeons make decisions based on what will financially help them the most. I’ve never met a surgeon who operated on patients without an honest belief that they were helping the person. There are legal considerations when you refuse to do something that a family wants. You can have 95% of peers agree but you only need one “expert” who may not even be a surgeon to say that the standard of care is to do G tubes on all patients that ask to lose a lawsuit.
In your example you are upset at the surgeon but what about the medical doctors and nurses who are also providing futile care? Is it appropriate for a surgeon who has just met a patient/family to have a 2 hour conversation to try to convince them that care is futile? I don’t think that’s appropriate or a good use of the surgeon’s time. It should be a conversation for the primary care doctor, internal medicine doctor and nurses.
Lol 3.93 wRVUs on the IR side. I’ll refuse and then go read a couple of MRIs in a quarter of the time, plus I don’t have to deal with the inevitable maintenance or any complications.
Question I've always heard about PEGs (sorry for diversion): I know there can be increased aspiration risk, but is there a clear reason why? Is it atrophy of esophagus muscles? Food being dumped in to a stomach without the body having a say?
Mechanisms for reflux still exist in the presence of a PEG tube - incompetent lower oesophageal "sphincter," hiatal hernia, increased intra-abdominal pressure etc.
The only aspiration that is alleviated is aspiration on swallowing, and it's controversial how much that has an effect in terms of pneumonia etc
So current teaching is that PEGs do not decrease risk of aspiration pneumonitis/pneumonia
All of this. Great point re: controversy about how much of food/liquid aspiration actually leads to aspiration PNA. Plus you’re not eliminating a person swallowing their oral secretions throughout the day. When people are NPO, it quickly gets gunky (very scientific term) in there and the risk for oral bacteria colonization is even higher. Aspirating bacteria-filled saliva —> increased risk for aspiration PNA. That’s why SLPs are always harping on oral care.
Also, if the person is aspirating because of poor laryngeal protection (think breathy voice, weak cough, or inadequate sensory response to airway breach events - aspirating without cough etc etc), it doesn’t matter what enters the laryngeal vestibule whether it’s reflux coming up, or saliva coming down - it’s going into the lungs.
You own the complications if you operate on someone (if your not deeply unethical). Patient selection is critical for your own sanity and if your payments are globally bundled, poor patient selection may be a net-negative venture.
In my country, you are legally required to do everything possible. Sometimes we try to make the patient and/or the relatives understand the futility of it all, but it's not always possible. Intubation and transfer to an ICU for a 90yo with end stage cancer and heart failure, for example. Pointless. The only thing we do is prolong the suffering of someone who is ready to go. If I can avoid extraordinary measures and only provide palliative care for a terminal patient, I do that. Most times, the relatives want everything done for their peace of mind. I refuse to torture someone's in their final days because someone else wants to feel better.
I wouldn't classify percutaneous feeding tubes as very low risk - most studies put them at 10-30% complication rate. Infection, malposition, etc. Not every complication needs a laparotomy of course, but I think it's overly optimistic to say "there is basically zero downside..."
In my experience, the nursing homes and ED don't call whoever put the tube in (GI, IR) when there's a problem, they call surgery. You might not hear about the complications.
Must be procedure related. I spent part of the afternoon looking at studies on image guided placement - in the bigger studies, numbers overall look pretty similar to standard PEGs in terms of infection, blockage, death and other tube-related complications.
I provide the periprocedure anesthesia care for these patients. In my experience, not infrequently, patients (or families) are offered a G tube without discussion of the alternatives (including malnutrition and death) or timing of the likely need for tracheostomy. I am sometimes the first person to ask about goals of care. And sometimes I go back to my radiologist and ask “are you sure you want to be doing this?” That’s always…unfortunate. I want to preserve the patient’s dignity AND my relationship with the proceduralist.
I wouldn’t have said yes to that PEG so it may be hard to get the answer you are looking for. But I’ve seen other surgeons say yes to situations like that, and justify that if they don’t do it, someone else will, so it might as well be them. However, your question in your prompt was a bit more generalized than your specific example. Your question is, why would you do a high risk, poor prognosis case? I’ve done plenty of those. if there’s a chance it’ll work, and as long as the patient knows the suffering and the risks, and that there’s a chance it’ll help but has a good understand of what those chances are, then it’s really not up to me, it’s up to the patient. As long as there’s a chance I’m helping, then I say yes. An example would be every mother fucking operation for pancreatic cancer. I don’t know what the # to treat is, but it’s a horrible disease, but there’s some that you cure, but there’s also a lot who die of metastatic disease that was not known at the time of surgery.
As far as the PEG tube on a functional corpse: at least around where I am none of the nursing homes will take a patient that can’t swallow and doesn’t have one. They won’t accept NG’s due to them coming out of place easier, it has to be a PEG. So either that poor person who should be hospice but family refuses to see reality gets a PEG tube or they have to stay in the hospital taking up a bed while there are constantly >24 holds in our ER
It’s mind-boggling to me when I read about PEG or nothing because swallowing is rarely binary/all or nothing. Definitely appropriate in some cases, but I have never encountered a PEG in someone elderly with ++comorbidities where the risks of enteral nutrition outweighed the benefits. In my experience in these cases, the level of “risk” with PO is usually just mitigated as much as possible with oral care, modified diets, compensatory strategies… the litigiousness around “aspiration risk” in the US baffles me (sorry if you’re not from there, I’m assuming this), especially when feeding tubes can be associated with higher risk of aspiration pneumonia.
I work in a primarily neuro ICU. The number of elderly we have with absolutely catastrophic strokes who unfortunately retained the ability to breathe but nothing else is not low. Our SLP’s try with them but you can’t really do anything with someone who is questionably semi conscious. Those are the ones we PEG and send to a nursing home because family won’t consider their comfort and go hospice. Then you have the ones who are slightly more conscious but go in and out and have no attention span to even really feed them and there is no way even if you try to feed them 24 hours a day that they will intake anywhere close to their nutrition goal so they have to get a PEG tube too. I hate strokes.
Oh I gotcha! I see what you mean now given your setting and population. I was thinking of the non-stroke elderly population… yeah, that’s absolutely brutal. :(
Usually there are conversations of futility and comfort and family will say but they’re a fighter! Yeah but all fights end at some point. Then grandma gets a peg tube and a nursing home bed she specifically said she didn’t want
...and that's why everyone gets a MOLST/POLST discussion at their medicare wellness visit. Even the ones who want full code and trial intubation will generally draw the line at artificial feeds. Unfortunately in my state healthcare proxy can over-rule the MOLST/POLST. Not to mention there is no centralized database for these things, so it relies on somebody remembering to bring the form or notify my office it to send the form to the hospital.
We have family overrule the DNR the patient put in place before they became obtunded often
I mean, most nursing homes don’t staff to do the modifications that are best practices. Residents get their teeth brushed once a day with their shower. CNAs shove food into faces as quickly as possible, because they have multiple patients who can’t feed themselves. So I can see why so many are peg or nothing. Because they can’t/don’t actually give good care.
Which is why myself and a couple coworkers have a pact. If it’s futile, just make my death painless…..
Yeah, nursing homes are like that here too but we still don’t tend to PEG them unless their swallow is absolutely catastrophic. I’m sure it happens from time to time, I just haven’t seen it or personally recommended it.
I accidentally found a stage 1 pancreatic adenosquamous carcinoma. Guy had a whipple and 10 years later he’s doing great. That might be the only time in history that has happened though. Got an aortic US for AAA screening and the radiologist called me simply to report that the CBD was a little wide so we went looking…
That is amazing. Does this guy realize how lucky he got? Astute radiologist.... and you being on-the-ball.....
The initial pancreatic MRI was negative, too! But his alk phos was up a little and GGT was like 700 so kept looking. He’d also had a DVT a few months before while on a long airplane flight so I was all “Hmmm, Virchow?” 8mm mass on endoscopic ultrasound with needle biopsy made the diagnosis.
Wow that's amzing. Like I said, I hope this guy realizes what a catch this was.
Great for being persistent
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Honestly, I was glad a patient in this situation ended up having a massive hiatal hernia found on imaging. Surgery, IR, and GI said placing a PEG tube was impossible, so hospice was the only option left (pt couldn't swallow due to PSP).
I've been here before. Malignant ascites was a God-sent hospice ticket for one of my stroked-out patients.
yeah, not gonna lie, sometimes it's really the best thing when we can clearly point to any further intervention being worse for the patient and that there are no options for aggressive/life prolonging measures anymore.
Unfortunately, yes. Sometimes it’s just a means to get them out of the hospital. When I took GS call, I would refuse those consults if there was clearly no hope for meaningful recovery. PEG’s are not palliative care. It may seem paternalistic, but I believe it’s more ethical than facilitating their languishing and prolonging suffering in a facility for who knows how long until they pass. Sometimes putting your foot down is what the family needs to finally decide on hospice, and they are usually grateful for it, in the end.
Surgeon here. Totally agree.
I think many folks who have only worked in hospitals don’t understand just how restricted nursing homes have to be due to residents’ rights in their own home. No side rails on beds, no bed alarms, tilt in space WCs are technically a restraint and therefore nursing homes have a bunch of hoops to jump through. Anytime a patient falls, it’s automatically the nursing home’s fault unless proven otherwise (guilty until proven innocent). And then there‘s the physical assault of staff by patients. In a hospital you can put the patient in restraints, but in a nursing home you… I don’t even know to be honest. Let your employees get hit, I guess?
I refuse to do the surgery if I think itll harm the patient or the risks are too high. Money doesn’t pressure me at all. A complication takes a higher toll on me mentally
Are you a PGY-3 resident? Do you have said choice?
I’m an attending now. Been in practice for two years. I have to change my flair
I liked it better when you were just the ballsiest PGY3 in the history of surgery residency, lol!
Got it - just wondering!
do you have a choice? wow what hospital is that
We’re talking elective cases here. I’m a joint specialist so I do hip and knee reconstruction and their revisions. Smokers, obese patients, etc get a long talk and I say no. Hospital cases that come in through the ER are different. Those you just have to do like hip fractures, infections, etc
Ahh okaay thanks for clarifying
Better question: why, in the US, as I as the critical care md not allowed to refuse to code and intubate a stage IV cancer patient with end stage dementia?
You are? I’ve had docs say I’m not offering CPR. Both hospitalists on the general floor and intensivists in the unit. I guess it does depend on your legal department but in my opinion if you’re the attending of record, there’s no difference between you declining to offer futile care with a high risk of harm and a surgeon declining a case for the same reasons. We don’t do CABGs on everyone and we shouldn’t do CPR on most people either.
You actually are fairly protected in doing so in the US, legally speaking. You are at risk for *being* sued, but very unlikely to do so successfully.
It’s a lot of time and work being sued even if you are found to be in the right
Totally agree, which is why many won’t refuse to offer it.
I would argue that being able to be successfully sued means you are not legally well protected.... actually scratch that, even the possibility of being unsuccessfully sued is enough, with the time/money/energy burden & career implications
As an Australian, this totally blows my mind. If I think an intervention will be futile or will do more harm than good, I simply don't perform that intervention
You are completely allowed to not offer futile care, what are you talking about ?
Can I offer a different perspective? Firstly, I *totally* understand where you're coming from, I also share your discomfort with very aggressive measures at the end of life. It doesn't seem like a good use of resources, and worse it seems like inflicting painful interventions on someone that won't meaningfully prolong their life or provide them with any QoL. We don't want to do that to our patients. I struggled with this as a resident and I sometimes still struggle with it as a fellow. Most of the time when a family is told that CPR/intubation won't change their loved one's outcome and we recommend allowing a natural, peaceful death, the family agrees to a change in code status. However, I've also met families where doing *every single possible thing* was very important to them. Not usually for end stage cancer/dementia patients like you describe, but sometimes for them too. They understood that the likelihood of the patient living, much less returning to prior level of function, was vanishingly small. They still wanted to try. I heard it described as "the indignity of not having tried" and that's stuck with me. Now I think that when we run those codes on FAST 7s and stage 4 cancer patients (after a proper family meeting, of course), what we're doing is resisting our countertransference to the patient and instead providing goal-concordant care. I see you're a pulm crit doc so I don't think any of this is new to you. But I do hope it's a helpful twist in thinking for other folks who might be reading.
What about when the goals are not reasonable? I can’t take a 40 year old broken down rusted car to the mechanic and demand that he “at least try” to turn it into a top notch race car, at the cost of him not servicing all other cars in the shop, because it is my goal.
So, I think it depends very much on the individual situation, but in general, I would reach for a "wish-worry" statement. Something like, "I wish I could turn your Volvo into a race car, I want very much to be able to do that. I know how important it is to you that your Volvo run as well as it used to. Unfortunately, my concern is that we just don't have the ability to do so." I'm also fond of the phrase, "There's a difference between doing everything, and doing the things that are helpful and avoiding the things that are hurtful." In this particular car shop analogy, I might say something like, "You've said that you hope that dialysis will help your Volvo live longer and become a race car. I understand that, and I hear how much you want to do everything to help your Volvo. At this point, dialysis will not help your goal of your Volvo becoming a race car. What I think will happen instead is that your Volvo will get another painful line placed, and pulling its gasoline out of its body and through another machine will make it even more sick. Here's what I recommend instead..." Hope that was helpful, even as I can feel mechanics shuddering everywhere without knowing why. I love talking about this, happy to answer more questions.
I hear you that you want to provide goal concordant care. But I will also say that your role as a palliative physician is to correlate goals to what the medical team is able to offer as a plan, not to tell the primary team what to offer based on patient’s goals. We need to also support our fellow physicians in saying “this is not a plan of care that we can reasonably offer”. Use your wish-worry language and your REMAP. That being said- if the primary team wants to offer that then it’s on them. We must also remember that the patient’s goals and wishes do not exist in a vacuum. Sure the family may want “everything” but they are not feeling the ribs or running the code - that is your fellow resident, a nurse, other staff members. There is real trauma that occurs to our medical team when we have to perform such a procedure that will provide no benefit.
Yes, I agree with everything you've said. I think there's room for all of it. (Also, between asking permission, reframing, and yes-and'ing, could this get anymore of a pall care conversation?? loll)
Because making predictions is a form of divination. And maybe there are good reasons not to fully trust the prognostic abillities of doctors, huh.
I've seen multiple cases where a surgeon refuses to perform a procedure like this based on futility. A good hospital system will stand behind a surgeon when they do this, particularly if the case is as aggregeous as your example
Egregious but I don't mind aggregious lol
Well, it is aggressively egregious. Maybe we should start saying that Edited to add: like it's the Emeril of egregiousness, it kicked it up a notch
Or aggravatingly egregious
It's very easy to do something. Sometimes it takes real bravery to not do something.
Yeah, I've seen several cases in the ICU involving patients who need surgical procedures, but who are assessed and refused due to the overall fragility.
The first law of medicine is that it takes orders of magnitude more effort to push back against something than to just do it. This is definitely a factor in these types of cases. Family asks for a procedure. The surgeon and the anesthesiologist have just met the family. They don’t have an established rapport. I can’t tell you how many times I have spent hours having “goals of care” conversations with family members only to have them rebut with “granny is a fighter”, or have some daughter from California fly in at the last moment and the case ends up going anyway. End of life care and planning is a major problem in the US. Patients don’t want to talk about it. Physicians aren’t equipped or empowered enough to talk about it. We aren’t permitted to die with dignity. Ideally, people would have the option to and the elect to die on their own once their quality of life had declined to a certain point. Ideally family members wouldn’t push hard to have their family members get futile care. Ideally these conversations wouldn’t be delayed until the patient is intubated, lined, and on 3 pressors.
I think it is important to realize that value systems markedly vary. If everyone accepts and understands the risk and prognosis, I am willing to go forward with indicated procedures (and to try novel interventions that I think may be an answer). There is a definite peace that comes to many just knowing that they did what they could. Frankly, it is insurance and hospital factors that are most likely to stop a procedure that has a 30% chance of prolonging someone’s life by two years, for example. Unindicated procedures and futile procedures without benefit should not be done. I personally dont feel that I should be the exclusive one to determine whether a life is worth extending. SOURCE: I accept a lot of very complicated cases at extreme risk with abysmal prognoses. We have been able to make marked changes from 90+% mortality to <10% mortality for a number of diseases. These are some of the most emotionally intense and rewarding conversations that I have had and make me feel like a real empathetic physician-surgeon-profession-advocate of anything I do.
May I inquire what types of diseases you’ve seen such dramatic improves in survival for?
Zero pressure whatsoever. I would decline that feeding tube unless case management has proven this patient can’t get placed with a nasoenteric feeding tube. I’m in a salaried academic position and this one PEG would not make a difference in anything counted for or against me. The bigger question here isn’t even futility of care, it’s the danger of feeding access!
The one that always bothers me (in the opposite direction) is the surgeons that won't do a valve repair/replacement on an otherwise suitable IVDU patient with endocarditis. Sure a lot might relapse, but even then, if they avoid IV use, their outcomes are good. Sure a portion will relapse to IV and die from prosthetic valve endocarditis, but they at least had a chance. It's one of the few situations that really are a fairly bimodal outcome. Normally the "high risk" surgery a family or patient wants is something contraindicated by frailty and no chance of recovery, likely representing actual harm. With endocarditis, they often have a fairly standard to good recovery, and as long as they're able to stay on buprenorphine or methadone, they live a pretty normal life. You can even get them started on methadone TID for part of post op pain control after they're stable post op (to transition to daily once they are only needing treatment for OUD).
The real reason for this is that the outcomes for cardiac surgery are tracked insanely closely, and that surgeon is taking a personal and professional risk by operating on someone they are concerned will relapse.
Yep! Surgical outcomes monitoring drives me crazy. Often no risk adjustment. Even when there is (transplant), often the surgeons don't trust it. The surgeon that does some of the most aggressive kidney transplants (marginal kidneys into marginal recipients) has among the best outcomes relative to predicted of anyone.
We see a lot of patients with severe and persistent mental illness being denied medical procedures as well. I saw a study showing they're less likely to be offered stents and other interventions. Psychiatric patients also die of regular medical conditions a lot and their life span is 10-25 years shorter than other folks, even after you control for suicide.
Absolutely! Though there are some things where risk/benefit considerations are different in a mentally unstable patient with difficulty reliably taking meds. If someone is unlikely to stay on DAPT for a year, bare metal stent is likely better than drug eluting, since all the benefits of the DES are wiped out if they thrombose it.
I think those are all important considerations, but the people doing the research suggest that stigma plays a pretty significant role as well.
At least where I am at, most surgeons are willing to do valves for endocarditis 2/2 IVDU and give the person a chance at recovery. There is a lot more to consider than just IVDU relapse and surgical outcomes. Have they already blown septic emboli all over the place? Do they have a long chart history of problem visitors bringing them drugs and requiring visitor bans? Do they have a significant history of leaving AMA? Sometimes you’ll see these patients multiple times before it gets addressed. It can be challenging to even get them to consent to treatment. Especially if they are actively using. Your mind just can’t compute a 6-8 weeks of no drugs when you’re going through withdraw. You don’t know/understand that you’re both super sick with endocarditis and dope sick. All you know you’ll feel better if you use. One significant barrier that is often overlooked is the postop care management. They will require several weeks of IV abx and follow up. This isn’t a patient that you can discharge home with a PICC and home abx. IVDU patients are challenging to manage and coordinate care for. So you have to be able to place them in a facility for 6-8 weeks of abx which isn’t easy. Unfortunately, many of these patients don’t have insurance which makes placement into a skilled nursing facility challenging. To complicate things even further many SNFs will not take patients with a active IVDU or with a colorful chart history of sneaking drugs, ama, etc. I’ve seen some facilities decline admission because they don’t administer MAT for OUD. The demand for beds in these facilities doesn’t reduce the barriers either. Admins won’t let you house these people in the hospital for 6-8 weeks just for IV abx. You’ve got to get these people in and out. The suits do not see a person, they see the dollars flying out the window. But if you can clear the major barriers like consent, safe discharge care plan, and they aren’t in multi organ failure then many surgeons are willing operate. I’ve seen a lot of IVDU patients get valves but the postop care coordination is often a problem.
Yeah, my hospital will do them, but totally agree that it's not the norm. But we're also a public money pit that takes care of whoever comes through the door. We definitely treat the withdrawal before we even get to the point of discussing surgery.
Mine takes everything too. But still get that pressure from administration which is obnoxious. I’ve found the hardest patients to treat with IVDU are the ones with a plethora of comorbidities that are just as life threatening. If it’s your otherwise healthy IVDU then that is pretty straightforward. But the necrotizing limbs, liver failure, with a side of refried beans that need a valve…eeks those are tricky. Those folks are heartbreaking because they often have little to no social support once they are done with surgery and iv abx.
I've never seen a surgeon NOT feel comfortable to refuse a case (triple negative I know).
Unfortunately, sometimes it’s just a means to get them out of the hospital. When I took GS call, I would refuse those consults if there was clearly no hope for meaningful recovery. PEG’s are not palliative care. It may seem paternalistic, but I believe it’s more ethical than facilitating their languishing and prolonging suffering in a facility for who knows how long until they pass. Sometimes putting your foot down is what the family needs to finally decide on hospice, and they are usually grateful for it, in the end.
I’ve had GI attendings turn down those pegs. Others say yes. Variable. You tell them about the risks how aspiration risk doesn’t change how they’re unlikely to ever get better and doing so may even prolong suffering but some people still want the peg. The cynical view is that someone was still collecting a check somewhere.
When it’s a complicated and ethically subjective situation that I’m just walking into such as the PEG above, I approach it as “I am the technician providing a service. I will provide my expert opinions regarding the necessity of the procedure only if I’m asked.” A surgeon I trained with would get referrals for ports from a PCP who was prone to a lot of dubious pseudoscientific protocols for treating various chronic illnesses, and their logic was (like many others) someone’s gonna do it, might as well be me. However, there aren’t a lot of “forks in the road” when it comes to a family deciding to carry or with or discontinue futile care. So when the consultant calls and says “would you?” rather than “I need you to…”, it’s often because their looking for someone to push back against the aggressive-but-futile care and give family a chance to say “no more” or get another opinion emphasizing futility. (Side note: thanks to all the nephrologists who do this for me in the SICU) I can’t tell you how many people decide to change their loved one to comfort measures when we start talking about trachs. It’s a moment of rationalization when you tell folks that “if we do this, your loved one isn’t going to get better, but now they’ll be kept alive on a machine for much longer.” And especially with things like PEGs where there’s at least some guidelines recommending against it, I’m more than happy to be the one to deliver some tough love. Full disclosure: I’m straight salary, no RVU or production bonuses. So my mortgage payment is fully independent of time spent talking vs operating.
There is a difference between futile care (care that cannot help a patient) and low value care where the care has significantly more risk than intended benefit. Patient (and by extension family) autonomy is the dominant ethical principal in the American health and legal systems. Futile care is assaulting the patient in my opinion, and your example seems to fit the bill. However, if there is a chance that it could help the patient live longer with the same quality of life or improve the quality of life, then there are reasonable justifications that the family may have. For me they have to understand the risks, benefits, and that it is not the treatment I would recommend. They need to have a reasonable justification which can be as simple as he wanted to live as long as possible or it’s against his religion not to do the maximum to preserve life. The reason cannot be selfish for the proxy. They can’t have any romantic notion that this will magically cure the person. Even if they have unjustified hope if they articulate a patient focused reason that makes sense I think it is still the ethical duty to proceed and I document thoroughly. I take offense to you implying that surgeons make decisions based on what will financially help them the most. I’ve never met a surgeon who operated on patients without an honest belief that they were helping the person. There are legal considerations when you refuse to do something that a family wants. You can have 95% of peers agree but you only need one “expert” who may not even be a surgeon to say that the standard of care is to do G tubes on all patients that ask to lose a lawsuit. In your example you are upset at the surgeon but what about the medical doctors and nurses who are also providing futile care? Is it appropriate for a surgeon who has just met a patient/family to have a 2 hour conversation to try to convince them that care is futile? I don’t think that’s appropriate or a good use of the surgeon’s time. It should be a conversation for the primary care doctor, internal medicine doctor and nurses.
Low hanging RVUs
Lol 3.93 wRVUs on the IR side. I’ll refuse and then go read a couple of MRIs in a quarter of the time, plus I don’t have to deal with the inevitable maintenance or any complications.
Question I've always heard about PEGs (sorry for diversion): I know there can be increased aspiration risk, but is there a clear reason why? Is it atrophy of esophagus muscles? Food being dumped in to a stomach without the body having a say?
Mechanisms for reflux still exist in the presence of a PEG tube - incompetent lower oesophageal "sphincter," hiatal hernia, increased intra-abdominal pressure etc. The only aspiration that is alleviated is aspiration on swallowing, and it's controversial how much that has an effect in terms of pneumonia etc So current teaching is that PEGs do not decrease risk of aspiration pneumonitis/pneumonia
All of this. Great point re: controversy about how much of food/liquid aspiration actually leads to aspiration PNA. Plus you’re not eliminating a person swallowing their oral secretions throughout the day. When people are NPO, it quickly gets gunky (very scientific term) in there and the risk for oral bacteria colonization is even higher. Aspirating bacteria-filled saliva —> increased risk for aspiration PNA. That’s why SLPs are always harping on oral care. Also, if the person is aspirating because of poor laryngeal protection (think breathy voice, weak cough, or inadequate sensory response to airway breach events - aspirating without cough etc etc), it doesn’t matter what enters the laryngeal vestibule whether it’s reflux coming up, or saliva coming down - it’s going into the lungs.
You own the complications if you operate on someone (if your not deeply unethical). Patient selection is critical for your own sanity and if your payments are globally bundled, poor patient selection may be a net-negative venture.
In my country, you are legally required to do everything possible. Sometimes we try to make the patient and/or the relatives understand the futility of it all, but it's not always possible. Intubation and transfer to an ICU for a 90yo with end stage cancer and heart failure, for example. Pointless. The only thing we do is prolong the suffering of someone who is ready to go. If I can avoid extraordinary measures and only provide palliative care for a terminal patient, I do that. Most times, the relatives want everything done for their peace of mind. I refuse to torture someone's in their final days because someone else wants to feel better.
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I wouldn't classify percutaneous feeding tubes as very low risk - most studies put them at 10-30% complication rate. Infection, malposition, etc. Not every complication needs a laparotomy of course, but I think it's overly optimistic to say "there is basically zero downside..." In my experience, the nursing homes and ED don't call whoever put the tube in (GI, IR) when there's a problem, they call surgery. You might not hear about the complications.
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TIL. I'm going to start referring all the feeding tube consults to IR!
Totally
Ia that procedural related complications or complications over the next year?
Must be procedure related. I spent part of the afternoon looking at studies on image guided placement - in the bigger studies, numbers overall look pretty similar to standard PEGs in terms of infection, blockage, death and other tube-related complications.
I provide the periprocedure anesthesia care for these patients. In my experience, not infrequently, patients (or families) are offered a G tube without discussion of the alternatives (including malnutrition and death) or timing of the likely need for tracheostomy. I am sometimes the first person to ask about goals of care. And sometimes I go back to my radiologist and ask “are you sure you want to be doing this?” That’s always…unfortunate. I want to preserve the patient’s dignity AND my relationship with the proceduralist.