Think for a moment about the remarkably complex and diverse circumstances in which we neurosurgeons interact with, treat, care for and advocate for our patients. Indeed, this remarkable set of relationships defines what we are to our society. Once again, neurosurgery is unique in this regard. This uniqueness relates to the heterogeneity of diseases and conditions which fall under our purview. Consider the lack of commonality between patients with degenerative spine diseases, entrapment neuropathies, epilepsy, movement disorders, stroke, brain tumors and central nervous system trauma.
Some of our patients arrive at our hospital on death’s door, minutes away from certain death from an expanding intracranial hematoma. These crises dictate the nature of our initial interface with our patients and their family. Communication is brief, pointed and usually takes place while we are physically moving toward the OR. At the other end of the spectrum, of course, are the terrified patients who have undergone imaging studies and been told they had a threatening problem in their brain or spine. After review of the patient, the examination, and the imaging studies, our discussion with the patient is simply focused on reassurance that their condition is of no real threat to their health. Conditions, such as benign pineal cysts, small cavernous aneurysms, tiny meningiomas or arachnoid cysts, might fall into this category. Patients are uniformly grateful and relieved at the news.
Communicating Options
What do you do in this situation: asymptomatic but threatening lesions? Defining moments for us as treating physicians occur, in my view, when neurologically well patients come to us after having been found to have a potentially disastrous neurological condition. Such pathologies might include small subarachnoid aneurysms, vascular malformations of various types, colloid cysts of the third ventricle, asymptomatic Chiari malformations, etc. These are the patients that require the lion’s share of our outpatient management time. An empathetic educational period is followed by a discussion of our best knowledge of what the future holds for that patient if left untreated. Once a grasp of the natural history risks are understood by the patient and family, the conversation transitions into one of potential treatment options with their concomitant risks and possible benefits. I find that the clinical dilemma of weighing long term natural history risks in conditions that can be cured up front (but with clear time of treatment risks) to be the most challenging relationships to be encountered in the outpatient environment. Inevitably, the discussion leads to the physician being asked a critical question: “Doctor, if I was a family member of yours, what would you do?”. It is surprising how frequently that question is asked and how directly to the point it really is. We can never forget that our spectacular surgical and interventional techniques carry very clear risks of death or disability to our patients. It is easy to become seduced at a creative and novel idea to treat a complex lesion that takes on a life of its own. We must always remember to circle back to the patient’s critical question: “What would you do if I was in your family?”
When Further Intervention Is Not Possible
I will mention another dimension of our intimate relationship with our patients and their family and that concerns the moment when it becomes clear that further aggressive intervention no longer has hope of benefitting the patient. These all-too-frequent situations for us also define the necessity that each of us be equipped with great humanitarian sensitivities. How we handle these moments also defines us as a specialty. The physicians that I have been most impressed with during my training and practice years have been those who interfaced with these grieving patients and families as fellow human beings, and who internalize the dramatic sense of loss. Those are the physicians that render solace and comfort to those in dire need.
A Case in Point
I recently treated a woman who is a former nurse. Her case illustrates a number of particularly poignant and unique features of our world. She had been experiencing increasing neurological difficulties over the past several months and was found to have a giant, largely thrombotic basilar apex aneurysm with considerable flare signal in her crescent moon, gravely distorted brainstem. Her collateral potential as demonstrated by provocative testing appeared to be adequate for her to survive a Hunterian clip ligation. On the morning of surgery when I came to visit with her and her family, she was completely upbeat and said the following: “Good morning, Doc! Listen, I know the deal. I am a dead person. There is a small chance you might pull me out of this, and if so, I will be deeply grateful. If it doesn’t work, please don’t let me linger.” There really aren’t words that adequately constitute a response to such a remarkable statement. To my way of thinking, the only rational response is to sit on the patient’s bed, hold him or her and convey that we will do everything possible. This particular event crystallized my understanding of our role as the “court of last appeal” in patients with disastrous conditions.
These unique elements of how neurosurgeons relate to their diverse and complicated patients clearly defines the uniqueness of our field and how we “lead the way.” We must continue requiring the highest standards of professionalism, humanity, empathy and simple kindness in ourselves and colleagues. Our educational and performance standards are higher: And they must be! The cost of our errors and misjudgments is unacceptable.
By the way, blind luck and kindness from higher forces prevailed — she did great!
[aans_authors]
