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Peking University Cancer Hospital, China
Title: Should considerations in patient dignity affect our surgical decisions?
Biography

Professor Gu Jin is an eminent surgeon and is currently Professor of colorectal Surgery Department of Beijing Cancer Hospital, Peking University Cancer Hospital. He is also Chairman of the Chinese Society of Oncology (Chinese Medical Association). He graduated with a medical degree from Beijing Medical University, after which he went on to complete further training as a Visiting Scholar at Les Hôpitaux Universitaires de Strasbourg, France and then at the Columbia School of Physicians and Surgeons, US. Prior to assuming his present appointment, he held the position of Attending Physician before being promoted to Professor and Deputy Director of the Department of Surgery, Beijing Medical University, China. He has published more than 71 papers in reputed journals.

Abstract

A surgeon makes a decision primarily based on whether a patient has indications or contraindications for surgery, which at the core, questions whether the patient benefits from surgery [1]. However, a surgeon often encounters a number of non-biomedical factors that affect the decision-making. The following case involves the dignity of a patient and the dilemma that a surgeon faces when the dignity contradicts surgical principles, as well as clinical guidelines and norms. The patient was a 32-year-old male. Two years ago, he had abdominal perineal resection (APR) and sigmoid colostomy for rectal cancer in another hospital, as well as physician recommended adjuvant chemotherapy. One year after surgery, a prominent lesion appeared at the stoma. When he came to our hospital in April 2016, the tumor had already invaded most of the lower abdomen wall, which had an ulcerated and infected surface, and the colostomy bag could not be fitted properly. It was suspected that the patient had metastatic lesions in the lungs as well, but this could not be confirmed. The patient was otherwise in good physical condition and strongly requested surgery. The patient explained that the lesion had prevented him from contact with people, even his family, which made him feel that he had no dignity, and this caused him immense pain (Figure 1). However, based on principles of oncological surgery, extensive local resection is not beneficial to the patient if there are suspicions of distant metastases. It was the patient’s last words that helped me make my decision: “I can’t even hug my daughter. What’s the point of living? Doctor, only you can restore my dignity!” I had repeated communication with the patient and his family, clearly explaining to them the indications, complications, and risks of the surgery. There were also differing opinions in the discussions within our department. In the end, I decided to proceed with the surgery for the sake of his dignity. The surgery was a success, and the patient recovered well (Figure 1). The patient returned home two weeks after surgery. He hugged his 4-year-old daughter, who had until then, refused to be affectionate with him. However, liver metastases appeared 4 months after the surgery and he received further treatment. This was the first time in the 30 years since I became a surgeon that I performed surgery for the dignity of the patient, even if it meant going against the current clinical guidelines. Cancers at stoma sites are rare, and only 20 cases have been reported in the literature to date. Even among these 20 reports, most are only case reports [2] [3]. Primarily from the perspective of surgical technology, there is no problem with tumor resection in this case. It is also possible to complete reconstructive surgery. Our surgery would have a huge physical impact on the patient, not to mention the suspected distant metastases. Given these reasons, should this surgery be performed. This is a new issue that surgeons may encounter: It is incontrovertible for a surgeon to base the decision of surgery on the surgical principles and clinical guidelines. However, what should the surgeon do when faced with non-biomedical factors, involving medical ethics, patient’s dignity, and social factors? Firstly, from an ethical and humanistic perspective, the patient in this case felt, through his relationship with his family and especially his daughter, that the disease debased his dignity as a human being. In particular, it was difficult for him to fulfill his role as a father, because he was unable to express his love for his daughter. A hug from a daughter was a very precious thing for this father at the current stage in his life. Especially in a country such as China with ancient roots, family values are very different from that of the West. The feelings Chinese parents have towards their children, especially regarding the care of the only child, are singularly inimitable. Therefore, the surgeon, in the role as a caretaker, should help the patient regain his dignity. It is in line with human rationale and sentiment for a surgeon to consider the patient’s main needs, in combination with his quality of life and clinical condition, as well as having an extensive discussion with the patient and the family, then coming to the conclusion of “surgery for the sake of the patient’s dignity,” in order to help him regain courage and confidence in life. Secondly, for a surgeon, the decision to perform surgery for the sake of the patient’s dignity is not included in the usual surgical principles. Strictly speaking, for patients with colon cancer, who are suspected of having distant metastases, oncologists may also question extensive resection of locally recurrent tumors and extensive reconstruction. Currently, there are no clinical guidelines or related regulations to recommend surgery with the patient’s dignity as consideration. Moreover, the definition of “dignity” is, in fact, relatively difficult to define. Third, a surgery for the sake of patient dignity will be questioned by the healthcare system. In China’s healthcare system, any surgery outside the scope of healthcare regulation is considered as an “off-label” surgery, and there is a risk of payment denial by the healthcare system. Therefore, surgeons should decide with caution to perform such controversial surgery for the sake of patient dignity, which is outside current regulations in the healthcare system. Before deciding to perform an “off-label” surgery for the sake of patient dignity, the surgeon should first consider the patient’s subjective needs and should have thorough communication with the patient and the family, as well as perform a multidisciplinary comprehensive assessment and have an effective communication with the health insurance agencies preoperatively. Given the current social context of China, a developing country where the healthcare system is far from perfect, it is necessary and more appropriate for the patients, the family, the attending surgeon, and health insurance agencies to negotiate for a good solution. A surgical decision-making mechanism incorporating multiple social factors such as patient dignity still has a long way to go. Classic surgical decision-making literatures and textbooks all have inarguably and clearly described the procedures, steps, basis, and even evidences for surgical decision- making [4] [5]. However, if we take a closer look, we will find that those decision-making processes seldom consider non-biomedical humanity factors such as sociology, ethics, or dignity. Humanistic qualities of surgeons directly affect psychological feelings of treated patients and even the therapeutic effects [6]. Enhancing the education and cultivation of surgeons for humanistic qualities is also an important part in our surgical decision-making. In addition to rigorously following clinical norms and guidelines in surgical decision-making, a surgeon should also consider many other patient factors, including their social psychology, dignity, ethnics, religions, and laws. Putting all of these together truly reflect the people-oriented character of modern medicine and the connotation of saving people’s lives. 1. Sacks GD, Dawes AJ, Ettner SL, et al. Surgeon perception of risk and benefit in the decision to operate. Ann Surg 2016; 264(6): 896-903. 2. Maeda C, Hidaka E, Shimada M, et al. Transverse colon cancer occurring at a colostomy site 35 years after colostomy: a case report. World Journal of Surgical Oncology 2015; 13(6):171. 3. Shibuya T, Uchiyama K, Kokuma M, et al. Metachronous adenocarcinoma occurring at a colostomy site after abdominoperineal resection for rectal carcinoma. J Gastroenterol 2002; 37:387–390. 4. Clive RG, Quick JBR, Simon JF, et al. Problems, diagnosis and management 5th Edition 2013; 10-16. 5. Courtney M, Townsend Jr, Mark E. Sabiston textbook of surgery: the biological basis of modern surgical practice, 19th edition 2012: 211-239. 6. Welling RE, Boberg JT. Professionalism: lifelong commitment for surgeons. Arch Surg 2003; 138(3): 262- 264.

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