Refusal for Surgery

[A Kuske]

Jurisdiction

Indiana

Hi. My brother's started going through liver failure two years ago (alcohol, he's sober now and just trying to live, knows it's his fault). Apparently this goes hand in hand with the development of hernias, actually the hernia was what helped doctors determine he also had the liver failure. Anyway no one will treat his hernia till his liver is fixed. He has been clean and sober for hour months now and is finally meeting with a transplant do in May. Still can't get a surgeon to meet or treat him. I get they are scared something will happen, but this is a much worse problem now than if they had corrected it two years ago. Advice? Not trying to get rich, I'm trying to save my brother.

 

[adjusterjack]

Still can't get a surgeon to meet or treat him. I get they are scared something will happen,

Of course they are. Hernia repair is major surgery and they are concerned that he might die on the operating table due to liver failure.

Your brother's predicament is unfortunate. But there's no malpractice going on, just caution, and they can't be blamed for that.

What is your brother's age?

 

[cbg]

Your options are to either accept the doctors' recommendations or keep looking until you find a doctor who will allow you to dictate your brother's treatment. There are no steps you can take and no laws you can invoke that will force the doctor(s) to treat your brother the way you think he should be treated.

 

[Tax Counsel]

Advice? Not trying to get rich, I'm trying to save my brother.

My advice is that you and your brother sit down with a doctor or two to go over his hernia, liver problem, and any other risk factors and if the doctor says the hernia has to wait until the liver problem is fixed, politely ask why that is.

I've had several hernias over the years and have one now. My first hernia was when I was about 6 years old, and then every decade or two after I seem to get another. The doctors have often had me wait to have surgery to fix them. The one I have now doesn't cause me much pain and I have other, bigger problems to deal with. Hernia repairs are much easier today than when I had my first one all those years ago, but it is still surgery and carries certain risks. When the patient has a failing organ that increases the risks of the hernia operation. Your brother certainly does not want the liver to fail during surgery when there isn't a replacement donated kidney waiting for him. And that is one risk he would be taking on having the hernia repair done now. I literally know how it feels to be told I have to wait for a hernia repair and sympathize with what your brother is going through. But the doctors need to take the whole picture into account and what the risks are of doing the repair now versus waiting. It sucks to be told you have to wait. I've been there. But I also appreciated my doctors' caution, too. I've had way more surgeries in my life than any one person should have (some major ones, some minor ones), and have nearly died during several of them. If it wasn't for the doctor's caution to do things in the right order I'd not be here typing this message now.

My best wishes to your brother for a successful outcome. He's lucky to have a brother who cares enough to want to help him get the care he needs.

 

[army judge]

I've had way more surgeries in my life than any one person should have (some major ones, some minor ones), and have nearly died during several of them. If it wasn't for the doctor's caution to do things in the right order I'd not be here typing this message now.

A cautious physician should be appreciated by her patients.


Assessing Surgical Risk in Those With Liver Disease
By Naveed Saleh, MD, MS Updated on January 15, 2022
Medically reviewed by Scott Sundick, MD
Print
If you have a serious liver disease, such as either alcoholic liver disease or hepatitis B or C and need surgery unrelated to the liver, things can get complicated.1 The decision to proceed with surgery in this scenario is not taken lightly. Your physicians need to consider several factors when determining your operative risk and whether you will experience serious complications or death due to surgery.

More specifically, in those whose liver function is already compromised by either acute or chronic illness, surgery may tip the scales in favor of liver decompensation, or worsening of liver disease, liver failure, and death.2 Therefore, surgery must be carefully considered if you have liver disease.

Factors that are assessed in potential surgical candidates with liver disease include the following:

acuity, cause, and severity of the liver disease
type of surgery
urgency of surgery
type of anesthesia
intraoperative drops in blood pressure
Let's take a look at the various factors that hospitalists, surgeons, hepatologists (liver specialists) and various other members of the healthcare team consider before determining whether a person with liver disease is a candidate for surgery.


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LIVER HEALTH
Assessing Surgical Risk in Those With Liver Disease
By Naveed Saleh, MD, MS Updated on January 15, 2022
Medically reviewed by Scott Sundick, MD
Print
If you have a serious liver disease, such as either alcoholic liver disease or hepatitis B or C and need surgery unrelated to the liver, things can get complicated.1 The decision to proceed with surgery in this scenario is not taken lightly. Your physicians need to consider several factors when determining your operative risk and whether you will experience serious complications or death due to surgery.

More specifically, in those whose liver function is already compromised by either acute or chronic illness, surgery may tip the scales in favor of liver decompensation, or worsening of liver disease, liver failure, and death.2 Therefore, surgery must be carefully considered if you have liver disease.

Factors that are assessed in potential surgical candidates with liver disease include the following:

acuity, cause, and severity of the liver disease
type of surgery
urgency of surgery
type of anesthesia
intraoperative drops in blood pressure
Let's take a look at the various factors that hospitalists, surgeons, hepatologists (liver specialists) and various other members of the healthcare team consider before determining whether a person with liver disease is a candidate for surgery.

liver graphic
Science Picture Co./ Getty Images
Physical Examination
How a surgical candidate looks, or one's clinical presentation before surgery is an important part of assessing surgical risk in those with liver disease.

Typically, a physician will look for the following signs and symptoms that are indicative of acute hepatitis:

nausea
jaundice
vomiting
night sweats
pruritis (itchiness)
weight loss
In people with cirrhosis, many of the following signs occur secondary to portal hypertension and indicate a poorer prognosis and suggest decompensated cirrhosis:3

increase in abdominal girth (indicative of ascites)
weight gain (indicative of ascites)
memory changes (indicative of hepatic encephalopathy)
recent gastrointestinal bleeding (indicative of variceal bleeding)
changes in sleep-wake cycle
jaundice (yellowing of the eyes, skin, and other mucous membranes)
Many people with cirrhosis experience changes in sleep patterns. These changes have classically been attributed to hepatic encephalopathy and impaired hepatic melatonin metabolism; however, we have yet to elucidate the exact pathophysiology of these sleep disturbances.

The Severity of Liver Disease
People with acute hepatitis or decompensated cirrhosis, as well as acute liver failure, shouldn't undergo surgery. This makes sense because you don't want the patient to have severely impaired liver functioning at the time of surgery.1 In general, the presence of cirrhosis adversely influences surgical outcomes. Better candidates for surgery include people with chronic hepatitis and without decompensated liver function.

With respect to elective surgery, cirrhosis and acute hepatitis are definite reasons to avoid surgery. If you have serious liver disease, you should avoid surgery when possible.

Three different evidence-based scoring methods are used to make the process of determining whether a person with liver disease is a good candidate for surgery: the Child-Pugh score, the Model for End-Stage Liver Disease (MELD) score and measurement of hepatic venous pressure gradient (HVPG).4 Of note, the HVPG is used only at big academic medical centers and isn't available everywhere. Nevertheless, it is remarkably good at predicting prognosis or clinical outcomes.

Hepatic Blood Flow
Probably the most serious thing that can happen during surgery in those with liver disease is decreased flow of oxygenated blood to the liver. This decreased blood flow leads to hepatic ischemia and necrosis (death of liver cells), which can lead to liver decompensation or failure, as well as the release of inflammatory mediators that can trigger the failure of multiple organs.5

Typically, arteries provide oxygenated blood to organs. However, in the liver, the supply of oxygenated blood comes from both the hepatic artery and portal vein. In fact, the portal vein supplies most of the oxygenated blood in the majority of people.

During surgery, blood pressure and cardiac output drops. These drops reduce the flow of oxygenated blood to the liver. Typically, the hepatic artery dilates or expands to pick up the slack and compensate for decreased flow of oxygenated blood to the liver through the portal vein. However, in people with cirrhosis, chronic changes in the liver architecture, such as fibrosis and nodularity, mess with the ability of the hepatic artery to dilate and increase the flow of oxygenated blood to the liver. Additionally, anesthetics also interfere with the compensatory dilation of the hepatic artery thus compounding the problem.

In other words, people with cirrhosis have trouble compensating for drops in blood flow to the liver, which is caused by surgery and anesthesia as well as altered liver architecture. Without an adequate flow of oxygenated blood to the liver during surgery, a person can experience severe liver damage and failure.

Type of Surgery
Before a person with liver disease is operated on, it's important to consider whether the specific type of surgery performed will place the person at even greater risk for complications.

During abdominal surgery (think laparotomy), any direct contact with the liver blood vessels can cause further trauma and liver damage. Moreover, poking around these blood vessels can further reduce blood flow to the liver during surgery.

People with serious liver disease, like cirrhosis, who need emergency surgery on account of a circulatory insult, such as sepsis or trauma, are at high risk of dying after the procedure.6

Cardiovascular surgery further interferes with blood flow to the liver and exacerbates the problem. Additionally, pressors (medications given to increase blood pressure during the perioperative period) and cardiopulmonary bypass may worsen the liver injury.

As previously mentioned, anesthetics can also reduce blood pressure and blood flow to the liver and further contribute to liver damage. Moreover, in people with liver disease, anesthetics may stick around longer and not get metabolized as easily thus resulting in a longer duration of action.

Conclusion
First, if your liver enzymes are merely elevated but your liver disease is otherwise controlled, you may be a good candidate for surgery. Second, if you have chronic hepatitis with relatively good liver function, you may still be a good candidate for surgery. Third, if you have alcoholic hepatitis and have quit drinking for some time and have no flare-up in disease, you may be a good surgical candidate.

Please keep in mind that just because you have cirrhosis doesn't mean you can't have surgery. However, the presence of cirrhosis definitely affects outcomes and thus shouldn't be decompensated at the time of surgery (think jaundice, ascites, gastrointestinal, or variceal, bleeding and so forth).

If you have acute hepatitis or decompensated cirrhosis, surgery is likely a bad idea. It's best to think of the liver in people with serious liver disease like hepatitis or cirrhosis as a sleeping giant. Essentially, surgeons are operating around a sleeping giant, and flare-ups or inhibited liver function secondary to decompensated cirrhosis make this sleeping giant very restless.

The consequences of surgery in those with liver disease can get pretty serious. Some people experience liver failure and die after such surgery. Thus, the recommendation to perform surgery in people with liver disease is carefully considered by your healthcare team. Furthermore, as a patient, you must also provide informed consent, or agree to the procedure.

You should be asked to provide informed consent only after your physician and healthcare team have completely described the risks, benefits, and consequences of the procedure. Remember that having surgery is also a decision that you make.

If You Have Liver Disease, Should You Have Surgery?
...

Hepatitis C, The Risk of Surgery in Patients WithLiver Disease | Hepatitis Central
...

 

[A Kuske]

Thank you for all your advice. I didn't want to force the docs hand or anything, it's just so
much worse a problem now than two years ago. I think the only option now is to wait till he possibly can get the liver transplant and hope it can go from there. Thank you again.

 

[cbg]

My father needed a liver transplant over 20 years ago. He'd acquired Hep C from some tainted food when he was overseas and was asymptomatic until the damage was too serious to be corrected. He was a rare blood type and while we waited for a donor of the appropriate type to be available, it got to the point where every time the phone rang I was expecting it to be my stepmother telling me when the funeral was. He was at the top of the transplant list for four months. Trust me when I tell you that when that is the case, you don't want to do ANYTHING that might upset the applecart.

But take heart. After the transplant, while there were some lingering side effects to be dealt with (transplant recipients need to take immunosuppressant medication to prevent their system from rejecting the "foreign" organ, his health improved immensely. My youngest brother literally could not remember when his father had not been ill - he'd never seen his dad healthy before. After the transplant surgery, pretty much anything was possible.

My best wishes for the same results for your brother. Take care.

 

[army judge]

Speaking of transplants, my wife and one of our granddaughters are approved for the paired donor program. Notwithstanding the approval, the wait promises to be a little less lengthy. Our grand is B positive blood type, while my wife is O positive, making a potential match somewhat difficult.

Nonetheless, every time I think of my grand's humanity and willingness to do this for granny, I'm heartened and humbled, because there are many good news stories happening everyday.

Here's another:

CHICAGO (WLS) -- A Northwestern Memorial Hospital doctor who donated her kidney got to meet her recipient in person, along with the recipient's husband who became a donor to a patient at Northwestern.

Sacrifice, survival and solidarity were all celebrated at Northwestern Memorial Hospital Thursday after nephrologist Dr. Aleksandra Gmurczyk started a spectacular chain reaction by donating her own kidney.

Gmurczyk donated her kidney as part of a pool. Her kidney went to a woman in Virginia. Then that woman's husband donated his kidney to a patient at Northwestern.

"Every day I see patients on dialysis and see how their lives are," Gmurczyk said. "They're very difficult. They have to be there for four hours three times a week."

Gmurczyk said she went under the knife eight weeks ago to show her patients and the world just how easy, safe and effective kidney donation can be.

"Really the first step is really the most difficult one," Gmurczyk said. "The decision to do it. And everything else is pretty easy."

Her recipient Ginger, who lives in Virginia, says she's living like never before thanks to Dr. Gmurczyk's gift.

Gmurczyk donated her kidney to Ginger in a kidney swap. Ginger's husband Gary donated his kidney in exchange. Now Gary's kidney is working in Chicagoan Arturo Reyes, who was overcome with emotion meeting his donor and Dr. Gmurczyk.

"Your life changes completely, and I'm just so thankful that there are kind people out there in this world," Reyes said.

Doctors at Northwestern said that 90,000 people are on the waiting list for a new kidney.

Gmurczyk says she's also hoping to inspire others to consider donation. She said it's already working, and one of her patients is now being evaluated for a possible transplant.

"It's like a dream come true," Gmurczyk said. "I've been thinking about this for so long. It's

making me emotional. It's making me cry, but it's all joy. I'm just extremely happy."

Doctors at Northwestern said that 90,000 people are on the waiting list for a new kidney.

"I have the most amazing thing, which is hope," Reyes said. "I can continue with my life as it was before. I can do things and enjoy life again."

Northwestern Medicine kidney doctor donates own kidney to stranger, saving 2 lives
......

Nephrologist Donates Kidney to a Transplant Patient
......

 

[Tax Counsel]

Doctors at Northwestern said that 90,000 people are on the waiting list for a new kidney.

The story of the doctor's sacrifice and the chain reaction it started to get several people new kidneys is indeed inspiring. But the above fact from the article was more than a little disheartening. There is so much more demand for healthy organs than there is supply to meet it. If more people add themselves to the list of potential donors it could have a major impact on the lives of those on waiting lists like kidney list mentioned in the article. It's not difficult to do and can do so much good. Something to think about on this holiday weekend.