To the Editor:—
Cases such as that of Kent et al. 1expose the flaws and relevance of today’s widely used risk stratification systems and also show the fallacy of our and the surgical specialties’ exclusive focus on perioperative morbidity and mortality.
The fact that this 97-yr-old patient’s predicted mortality was scored at only greater than 65%, despite the absolute clinical predictability of what happened, indicates that clinicians still need to use their intuition and good judgment to pick up where these scoring systems fail. More importantly, if the specialties are to consider a context of care that is applicable to all patients, from the beginning to the end of life, our interventions should be aimed at maximizing functional quality of life, not simply getting the patient through the immediate perioperative period. Therefore, as part of the preoperative evaluation and discussions with critically ill patients and their families, it must be communicated that surviving the operation is the easy part, and the postoperative period is likely to be far more trying, even highly unpleasant, for the patient and the family. As critical care physicians and anesthesiologists, we spend an inordinate amount of time discussing this frankly with family members, sometimes very graphically, in order to do whatever is necessary to get the message across.
In his 1999 Rovenstine Lecture “What We (Physicians) Can Do versus What We Should Do for the Patient,”2Dr. Hug noted that we have eliminated the “anesthesia barrier” to operating on sick patients, but that does not mean that everybody has to have an operation before they die. We have and should act on influence and responsibilities equal to that of the surgeon in delineating risks and burdens of surgery, anesthesia, and postoperative recovery and critical illness.
*Mercy Medical Center, Springfield, Massachusetts. leos@cox.net
