Saying “No” to Your Doctor
Have you heard of the HBO documentary, “Bleed Out?” It is a film made by Steve Burrows about the ten-year ordeal he and his family endured after their mother, Judie had hip surgery. During the operation, Judie had a near-catastrophic blood loss and suffered a brain injury as a result.
Of course, any time we consent to surgery there is a chance that there can be complications. But what happened to Judie is a classic case of when a patient needs to say, “no” to her physician. The documentary is very well done and I really recommend that you watch it. I will not go into all of the details that are so well explained in it. But there is one lesson that we all should take from it: Sometimes it is necessary to use your own best judgment when it comes to healthcare decisions.
Steve Burrows’ mother had been on Plavix, the brand name for clopidogrel which is a powerful anti-coagulant. This class of medication is intended to prevent strokes and heart attacks by inhibiting the body’s ability to form blood clots. As a result, people who take clopidogrel can be vulnerable t o excessive bleeding, especially during surgery. That is why, under most circumstances, it is recommended that people stop taking this medication 5-7 days before surgery. Of course, there are exceptions and it is necessary to have a discussion with the doctor who prescribed it for you, before deciding to stop this important medication.
If the surgery is an emergency and the patient is in danger of loosing life or limb, then that often overrides the concerns about clopidogrel. The risks/benefits have to be weighed in each case.
In Judie’s case, the surgery was not an emergency. She had an apparent re-fracture of the hip that had been operated on several months earlier. As a result, she was in terrible pain. But there is not an indication that her life was in danger. What is worse, she was hesitant to consent to the surgery because she had a general understanding that this medication may make her prone to excessive bleeding. When she spoke to the surgeon (who was a trusted family friend) about her concerns, he reassured her that he had never had any problems when operating on a patient who was taking clopidogrel. And yet, the package inserts for this medications states: “Talk with your doctor about stopping your Plavix before you have surgery. Your doctor may tell you to stop taking Plavix at least 5 days before you have surgery to avoid excessive bleeding during surgery.”
This put her in a difficult situation. She was hesitant to consent to surgery, but she had been in severe pain for some time-and her trusted surgeon was making light of the risks for bleeding. It is easy to see why she put her fears aside and relied on the physician. That choice permanently changed her life and the lives of everyone who loved her. Years of rehabilitation therapy, loss of her independence and ability to make her own decisions as well as financial ruin were the result.
I want to encourage you to learn from this family’s tragedy. If it is not an emergency and you are feeling hesitant about an aspect of your care, ask for another opinion. This can feel like you are being disrespectful to your doctor (especially one who you have known and trusted for years). But it is not disrespectful, it is a necessary and responsible thing to do. I do not fault Judie, or her family for how they handled the situation. They obviously did not see an alternative. But I want you to see you have alternatives.
If I could turn back the clock to when surgery was recommended for Judie, I would suggest that she have a private conversation with the anesthesiologist or nurse anesthetist who was going to do her case. In anesthesia, we are often very conservative in our judgment when it comes to the chances for uncontrolled bleeding in the OR. We are the people who are going to have to struggle to maintain the patient’s vital signs and prevent catastrophe if there is a bleeding issue during surgery, and so I believe that most anesthesia providers would have been concerned about proceeding with this particular surgery. I would have encouraged Judie to ask the anesthesia provider:
· What do you see as the risks to me in doing this surgery today?
· If I were your family member (mother, sister, etc.) would you recommend that I have the surgery today or wait the recommended 5-7 days?
If you are in a similar situation and the anesthesia provider avoids the questions, or if they just suggest you speak with the surgeon, I would not take that as a good sign. Remember, if there is not a threat to your life or a concern that delaying will make you disabled in some way-what is the justification for continuing with surgery on that day? If you are in a similar situation, feeling hesitant to have surgery remember to ask the surgeon these questions:
· At my age and with my health history, what are the specific risks that this surgery has for me?
· What is the risk or harm that can happen if we do not do the surgery? Or if we wait a few days?
· What is the benefit for doing the surgery today?
· If I were in your family, what would you want me to do?
Keep in mind, that regardless of the answers you receive you are not obligated to consent to have surgery just because it is recommended. It is natural to feel nervous or hesitant to have surgery. But if you feel really unsure and are not reassured by the answers you receive you can ask to speak with other professionals. Get as many answers as you can-be sure that you completely understand the risks and benefits. You are in charge of your healthcare and you should not defer to your healthcare provider’s judgment if it does not feel right to you-or if the plan does not fit with your goals and values.