When the risk is too high to operate: a re-examination of surgical ‘futility’

Miss Hannah Javanmard-Emamghissi is a surgical registrar and a National Emergency Laparotomy Audit and Royal College of Surgeons of England Surgical Research Fellow. She is the surgical trainee representative for Age Anaesthesia and has a special interest in older people undergoing emergency laparotomy. She tweets @hannahjavanmard

An emergency laparotomy is one of the highest risk surgical procedures performed. Every year across the UK more than 24,000 emergency laparotomies are carried out. The decision on whether to perform an emergency laparotomy for a patient can be extremely difficult, especially if the patient’s comorbidities or functional status makes them at very high risk of mortality or adverse outcomes in the post-operative period. While the operation can be technically successful, it can result in an unacceptable quality of life for the patient, increased dependence or being unable to die in a way the patient and their family would want.

COVID-19 has highlighted to us all the importance of advance care planning. Decisions about proceeding with emergency surgery are often made in time-critical situations and, due to grave illness, clinicians may have no information regarding the patient’s wishes, and must rely on the patient’s family to guide the decision-making process.  The clinical team, together with the patient and family, may decide that an operation should not go ahead, especially in circumstances where the patient is unlikely to survive. If a patient does not survive, despite undergoing an emergency laparotomy, then some may refer to the procedure as being 'futile' in that it has not met the treatment goals of either the patient or clinical team.

There are differing views on what constitutes a ‘futile’ surgery; indeed, some believe the term should not exist. It is a difficult and uncomfortable concept and varies in its definition: a procedure that results in the death of the patient during an operation, a procedure that allows the patient to survive for only a few days or even a procedure that allows the patient to survive only for a few weeks. Others believe that ‘futility’ based on survival is too binary when there is a spectrum of post-operative outcomes and diversity in what patients might consider a ‘good’ or ‘bad’ outcome. These have to be balanced against the belief that a short survival time is irrelevant if it achieves other goals such as relieving symptoms.

With these perspectives in mind, the team at the Royal Derby Hospital decided to undertake a short survey aiming to compare views held by clinicians of different specialities and grades involved in the care of emergency laparotomy patients on the subject of ‘futile’ surgery. This will form part of a series of research projects that investigate the outcomes of high-risk patients that do and do not undergo emergency surgery. The overall project aims to generate a discussion on the concept of futility, rather than attempt to re-define it.

We are interested in a diverse range of perspectives from those involved in the care of emergency laparotomy patients - please join the conversation. The survey takes roughly 10 minutes to complete and will be open until the 12th of April.