Abstract
R
Another possible bypass patient is in his 30s and on a left ventricular assist device (LVAD). His BMI is too high for a heart transplant. For LVAD patients, thrombosis in the system is fatal, and hence, the patient is on high therapeutic anticoagulation. This patient is also on chronic antibiotics for bacterial colonization of the LVAD system. The heart failure treatment team pleaded for weight loss surgery and planned to manage the patient after surgery.
Any experienced surgical center knows that operations on the above two cases are technically feasible. It has many levels of coordination and unpredictable medical issues that are feared. Cardiac issues can happen despite advanced presurgical evaluations. Gastrointestinal bleeding has been reported in as low as 18% of patients on LVAD, and as high as 44%, before any surgery is performed.1,2 You can ask cardiologists how long an LVAD patient can stop anticoagulation treatment and you will get a range of responses, with the caveat that it is best to resume anticoagulation “as soon as possible.” Even if this patient loses weight sufficient enough to make the transplant list, there is no guarantee that a heart would be available, which means more waiting.
The question to the surgeon is: Would you perform weight loss surgery on patients with these problems? A good answer would be a qualified “yes,” provided that there is strong and comprehensive postsurgical support. The truthful answer for me is that there are too many issues out of my control and level of comfort. If the abdomen is accessible to minimally invasive techniques, we can do it. But if things go wrong, these patients have much fewer options than someone without these major medical issues.
It is best to get the input of the entire team. Get different perspectives on the patient's medical status, assess each team member's level of support, and glean all the things that the medical chart will not tell you. If these discussions are documented, even better. If your team raises red flags, it is wise to hold off surgery. But even if there is overwhelming assent, the decision for the surgeon is still not an easy one. The critics will always wonder why we proceeded with surgery knowing the risks.
In both of these cases, I had the patients come for a return visit to the office and I told them to bring anyone in their lives who wanted to have a say in the process. It was important for me to know the patient's entire social support system.
In the office, I went over the surgeries and the risks along with the rates of occurrence in the context of these medical conditions. I then asked the patient and the family to speak their minds, ask their questions, and to tell me everything and anything. I asked about their background going back as far as they wanted to. I wanted to know if they had children who depended on them because it would enter into our decisions. I asked them their understanding of why we had to meet again, even though they have all gone through the obligatory psychological evaluations, nutrition classes, and supervised diets. I asked them whether they understood the ramifications of having complications that they cannot emotionally and financially bear. I asked them about contingency plans in the event that they do not go home. I read their body movements, the unspoken cues of their family members; I listened to the silence and picked up the general vibes in the room.
This doctor's visit allowed me to weave together a unique story of the patient, who understands first-hand their own condition, but not in our typical medical jargon.
The woman mentioned above told me that she had remarried 11 years ago, and 3 years later became blind from her diabetes despite several operations to save her sight. She had tried to walk up the stairs 1 day and suddenly could not feel her legs, relegating her to the wheel chair. She would try to move with a walker, but it was obviously a struggle. Her wristwatch interrupted us announcing, “It is now 2 o'clock,” which gave me hints that she had learned to compensate with simple technology. She told me that she used to work for a government tax office and she was an “avid reader.” (I was clear with her that the surgery would not restore her eyesight). She said, “I'm kind of a prisoner in this body.” Even blind, she smiled a lot.
The LVAD gentleman was the guy who cooked for the entire family—really a person you want as your neighbor. His heart “gave out” after a viral illness. His wife was the one earning for the family. He was 4 years into his heart pump. After giving his story, he said, “Doc, my time's running out.” Our eyes welled up, but I was not going to give in that easily. I told him it was my turn to tell him what was on my mind. I told him how fearful I was that he would bleed and even die. I told him that if it was at all possible, I would prefer not to operate on him because “so many things can go wrong.” In an attempt to further deter him, I told him I had never operated on a patient on LVAD before. He responded, “No one else will even look at me. If I could live with this pump forever, I would. But that's not happening.”
Through these stories, I learned about the patients as people in the context of their medical condition, and not as conditions to operate on. When I can empathize with them, and they empathize with me, I can then say there is truly informed consent. Conversely, when there is no connection to be made, it is better for the patient and doctor to part ways.
I recall a physician in New York a few years ago championing the discipline of narratives for patients. 3 The idea is to allow the patient to tell her story, and not just discuss the laboratory or test results or the complication rates. As health care professionals, we understand the patients better if we figure out their story alongside the objective information. After all, patients rarely think in terms of their electrolytes or heart rhythms. When we understand the patients' position and motives, and the patients understand ours, the consent forms that we can pretty much recite by rote seem so unnecessary.
In this issue of the Journal, there is a clinical case of lithium toxicity following gastric bypass in a patient with severe bipolar disorder. Dr. Adam Darwich from Manchester, England, gives one of the best pharmacokinetic explanations I have yet to come across. Associate Editor, Dr. Scott Davis, offers a surgeon's perspective on what keeps him up at night when he wrestles with whether to operate on such emotionally complex patients. Between the two experts, we have a mix of the objective and the story. There is one qualitative study by Geraci et al. documenting what patients say (storying) regarding their postsurgical experiences. Qualitative studies, when they follow the COREQ criterion, 4 help us understand our patients beyond numeric data.
By the way, the LVAD patient was in the intensive care unit for 2 weeks due to bleeding once heparin started. There was no bleeding that could be embolized, just bleeding from any raw surgical surface. He would smile and wave at me every time I saw him in the unit. When he finally recovered at the end of an agonizing 2 weeks, his wife thanked me and asked if I had any regrets. Frankly, my only regret was how much he suffered. I think they felt my distraught throughout the 2 weeks.
(Note: The exact details of these two patients have been altered a bit for their privacy.)