Physicians should carefully counsel women who are considering elective surgery that is not traditionally recommended and, ideally, jointly make the decision with them, according to an updated opinion statement of the American College of Obstetricians and Gynecologists (ACOG).
“After the physician has provided information and careful counseling, the patient and physician will often reach a mutually acceptable decision,” the authors note. “If the patient and physician cannot reach an agreement, then referral or second opinion may be appropriate.”
The statement was written by the college’s Committee on Ethics and is published in the November issue of Obstetrics & Gynecology. It replaces a previous statement on the same topic that was issued in 2008.
In drafting the updated statement, the committee aimed “to provide an ethical framework to guide physicians’ responses to patient requests for surgical treatment that is not traditionally recommended,” the committee notes.
Thus, the statement offers broad guidance for handling thorny ethical issues such as the acceptability of performing a risk-reducing oophorectomy for a middle-aged woman solely because of extreme anxiety about ovarian cancer or a cesarean delivery at term solely because of maternal request.
“Acknowledgment of the importance of patient autonomy and increased patient access to information, such as information on the Internet, has prompted more patient-generated requests for surgical interventions not traditionally recommended,” the committee notes. “Depending on the context, acceding to a request for a surgical option that is not traditionally recommended can be ethical.”
They recommend that physicians faced with patient requests for such surgeries ensure they have a good understanding of the current relevant scientific evidence and base their counseling about risks and benefits on this evidence, rather than on their own traditional approach.
“Decisions about acceding to patient requests for surgical interventions that are not traditionally recommended should be based on strong support for patients’ informed preferences and values; understood in the context of an interpretive conversation; and consistent with considerations of avoiding harm, cost-effectiveness, and effects on the health care system of expanded choice,” the committee advises.
Careful communication is critical, and shared patient–physician decision making is the goal, they further note. “Health care professionals also should understand that medical risk and benefit, although of obvious and first-order importance, do not exhaust all fully reasonable factors that may be important to the patient. Listening to patients, helping to frame what they might be thinking, and including process as well as outcome are key obligations,” they add.
“If, after careful counseling, the physician believes that the surgical option is best for this individual woman and her life circumstances, then it is ethically permissible to perform the surgery,” the committee notes. When insurance or hospital regulatory constraints make that impossible, physicians can still convey respect for the woman’s viewpoint and request and express regret that it cannot be met.
In contrast, “[i]f the physician believes, based on evidence, that performing the surgery would be detrimental to the overall health and welfare of the woman, he or she should not perform the surgery,” the committee maintains. In such cases, physicians are not ethically obliged to refer patients to a provider willing to perform the surgery, but they may opt to refer patients for a second opinion, which is likely to be concordant and may therefore be helpful for the patient.
Cheney’s New Book Documents His 35-Year Battle With CVD
Search through the archives oftheheart.org and no single patient has been mentioned more than former vice president Dick Cheney. In fact, an argument can be made that Cheney’s heart has been one of the most scrutinized in the history of the White House, with questions about the vice president’s health arising the moment he was named running mate to George W Bush in 2000.
Now, instead of reporter’s asking questions about his long and troubled history with coronary heart disease, Cheney himself is tackling the topic head-on with the publication of Heart: An American Medical Odyssey, a memoir he has written along with his cardiologist Dr Jonathan Reiner (George Washington University Hospital, DC).
The book documents Cheney’s 35-year battle with heart disease, a fight that began with his first MI in 1972 and culminated with a heart transplant in 2012. In that time, Cheney seems to have undergone it all, including five heart attacks, revascularization with CABG and coronary stents, the implantation of an implantable cardioverter defibrillator (ICD), treatment for atrial fibrillation, treatment for deep vein thrombosis, and the implantation of a left ventricular assist device (LVAD) for his failing heart.
Over the years, heartwire has documented Cheney’s extensive cardiology care. The former vice president underwent CABG surgery in 1988 and received the LVAD in 2010 when he was 69 years old because of advancing congestive heart failure. During a talk at the annual meeting of American Association for Thoracic Surgery in 2013, Cheney said the operation to implant the LVAD was a low point and the toughest surgery he’s had to date.
In an interview with USA Today, Reiner said Cheney is a unique patient. “He has the longest history of heart disease of any of my patients,” he said. “He has the most complex history in terms of how difficult his disease became, the most number of moving parts. And he happens to be Dick Cheney.”
He has the longest history of heart disease of any of my patients.
Today, with the new heart, Cheney has told multiple media outlets that he feels “fantastic.” “Now I’m to the point where — I literally, you know, feel like I have a new heart, a lot more energy than I had previously,” Cheney toldCNN‘s Dr Sanjay Gupta. “There aren’t any real physical limits on what I do. I fish, I hunt. And — I don’t ski, but that’s because of my knees, not my heart. So it’s — it’s been a miracle.”
No Special Treatment for the Rich VP
In the book, Cheney and Reiner stress that the vice president received no special treatment for his heart, but he did benefit from medical breakthroughs that occurred during each stage of his disease. In USA Today, Cheney relays an anecdote told to him by Reiner about his good fortune.
“It’s as though you got up in the morning at home and were late to work,” Cheney says, quoting his doctor. “You jump in the car and head out for the office and every single stoplight is red. And he said, ‘Cheney, when you got to it, they all turned green.’ That’s exactly what happened. When I needed an implantable defibrillator, I had it. When I needed stents, we had it. Cholesterol-lowering drugs, we had it.”
As reported previously, Cheney spent about 20 months on the waiting list for his new heart, which is slightly longer than the national average. The only special benefit that Cheney received was that steps were taken to prevent Cheney’s ICD from being “hacked by terrorists.” In replacing Cheney’s older ICD with a newer one in 2007, Reiner requested the WiFi feature that allowed the ICD to be reprogrammed wirelessly be turned off. Medtronic, the makers of Cheney’s ICD, made the request.
Just recently, the television drama Homeland ventured into such “fictional” territory when the show’s vice president William Walden was killed by terrorists in season 2 after they gained access to his ICD and deactivated it. However, the real-life risk of remotely hacking Cheney’s ICD is not possible based on today’s technology, according to experts.
In 2006, Cheney and his wife Lynne donated $2.7 million to the George Washington University Medical Faculty Associates and School of Medicine and Health Sciences. The Richard and Lynne Cheney Cardiovascular Institute was named in their honor.