What are the acceptable risks of surgery?
This is a very complex question. Here’s how I would address it.
From a purely statistical standpoint, the risk of any procedure (intervention) needs two essential inputs:
- A comprehensive list of all the things that can go wrong. At least to some extent, such lists are available. The only, truly unacceptable risk is that of dying (mortality). All else is relative and a matter of perspective and expectations.
- A hard look at data for every procedure and the creation of a 4-way table: Exposure vs. non-exposure; outcome present vs. absent. This will allow us to establish odds/ risk ratios. An objective number can then be used to gauge the likelihood of any outcome from surgery. These statistics are available (though hotly debated) for many common surgical procedures. Examples include: wound infection, deep vein thrombosis, urinary infection, pneumonia, and so on.
- The moment you start hitting patients with these numbers, most often their eyes will glaze over and you will lose them. Most patients don’t want “just the facts.” You do have to discuss them, but in general, practical, down-to-earth terms and language.
- Enter, comorbidities: Fine and dandy, but these numbers are muddied by co-existing diseases that can alter (usually adversely) established risk; common examples are heart disease, high blood pressure, diabetes, obesity, age, previous illness, and so on. To make it worse, a combination of comorbidities is not merely additive in terms of risk; they multiply risk.
So, you get the picture? Even experienced surgeons can rarely explain the risks of surgical procedures completely. Knowing that surgeons, as a breed, are poor communicators, you can “do the math”.
Here’s my take.
Leaving risk aside and looking at outcomes—what the patient really needs—I would look at the issue from two standpoints.
- Will the operation completely or significantly improve the problem at hand?
- To what extent will you be able to go back to all that you did (activities of daily living-ADL) before the surgery? Be wary of unrealistic promises (Doc, can I play the violin after my surgery? Sure! Terrific, I couldn’t earlier.)
Remember: Risk is only a proportion, a probability at best, not a guarantee. Adverse outcomes, as far as the patient in concerned, either happen or don’t: 0 or 100%.