Mechanisms of Surgical Disease and Surgery in Practice

Approaches to Surgical Problems

What Do Surgeons Do?

Surgeons are perceived as doctors who do operations, that is, cutting tissue to treat disease, usually under anaesthesia, but this is only a small part of surgical practice. The range individual surgeons undertake varies with the culture, the resources available, the nature and breadth of their specialisation, which other specialists are available, and local needs. The principles of operative surgery—access, dissection, haemostasis, repair, reconstruction, preservation of vital structures and closure—are similar in all specialties.

A general surgeon is one who undertakes general surgical emergency work and elective abdominal gastrointestinal (GI) surgery. In geographically isolated areas, such a surgeon might also undertake gynaecology, obstetrics, urology, paediatric surgery, orthopaedic and trauma surgery and perhaps basic ear, nose and throat, and ophthalmology. Conversely, in developed countries, there is a trend towards greater specialisation. GI surgery, for example, is often divided into ‘upper’ and ‘lower’, and upper GI surgery may further subdivide into hepatobiliary, pancreatic and gastro-oesophageal cancer surgery.

Surgeons are not simply ‘cutting and sewing’ doctors. The drama of surgery may seem attractive but good surgery is rarely dramatic. Only when things go wrong does the drama increase, and this is uncomfortable. Surgery is an art or craft as well as a science, and judgement, coping under pressure, taking decisive action, teaching and training and managing people skilfully are essential qualities. Operating can be learnt by most people, but the skills involved in deciding when it is in the patient’s best interests to operate are essential and must be actively learnt and practised.

Surgeons play an important role in diagnosis, using clinical method and selecting appropriate investigations. Many undertake diagnostic and therapeutic endoscopy including gastroscopy, colonoscopy, urological endoscopy, thoracoscopy and arthroscopy. Indications for laparoscopic surgery, supported by good quality clinical trials, continue to broaden as equipment and skills become more sophisticated.

A Short History of Surgery

There is no doubt that the first surgeons were the men and women who bound up the lacerations, contusions, fractures, impalements and eviscerations to which man has been subject since appearing on Earth. Since man is the most vicious of all creatures, many of these injuries were inflicted by man upon man. Indeed, the battlefield has always been a training ground for surgery. Right up to the 15th century, surgeons dealing with trauma were surprisingly efficient. They knew their limitations—they could splint fractures, reduce dislocations and bind up lacerations, but were only too aware that open wounds of the skull, chest and abdomen were lethal and were best left alone, as were wounds involving major blood vessels or spinal injuries with paralysis. They observed that wounds would usually discharge yellow pus for a time; indeed, this was regarded as a good prognostic sign and was labelled ‘laudable pus’.

The 15th century heralded a new and dreaded pathology—the gunshot wound. These injuries would stink, swell and bubble with gas. There was profound systemic toxicity and a high mortality. Of course, we now know that this was the result of clostridial infection of wounds with extensive anaerobic tissue damage caused by shot and shell. The surgeons of those times were shrewd clinical observers but surmised that these malign effects were caused by gunpowder acting as a poison, for it was not until centuries later that the bacterial basis of wound infection became evident. At that period, the remedy was to destroy the poison with boiling oil or cautery. Boiling oil was the more popular since it was advocated by the Italian surgeon Giovanni da Vigo (1460–1525), the author of the standard text of the day, Practica In Arte Chirurgica Compendiosa . These treatments not only produced intense pain but also made matters worse by increasing tissue necrosis.

The first scientific departure from this barbaric treatment was by the great French military surgeon Ambroise Paré (1510–1590) who, while still a young man, revolutionised the treatment of wounds by using only simple dressings, abandoning cautery and introducing ligatures to control haemorrhage. He established that his results were much better than could be achieved by the old methods.

Ignorance of the basic sciences behind the practice of surgery was slowly overcome. The publications of The Fabric of the Human Body in 1543 by Andreas Vesalius (1514–1564) and of The Motion of the Heart by William Harvey (1578–1657) in 1628 were two notable landmarks.

Surgical progress, however, was still limited by two major obstacles. First, the agony of the knife: patients would only undergo an operation to relieve intolerable suffering (e.g., from a gangrenous limb, a bladder stone or a strangulated rupture) and, of course, the surgeon needed to operate at lightning speed. Second, there was the inevitability of suppuration, with its prolonged disability and high mortality, often as high as 50% after amputation. Amazingly, both these barriers were overcome in the same couple of decades.

In 1846, William Morton (1819–1868), a dentist working in Boston, Massachusetts, introduced ether as a general anaesthetic. This was followed a year later by chloroform, employed by James Young Simpson (1811–1870) in Edinburgh, mainly in midwifery. These agents were taken up with immense enthusiasm across the world in a matter of weeks.

The work of the French chemist Louis Pasteur (1822–1895) demonstrated the link between wound suppuration and microbes. This led Joseph Lister (1827–1912), then a young professor of surgery in Edinburgh, to perform the first operation under sterile conditions in 1865. This was treatment of a compound tibial fracture in which crude carbolic acid was used as an antiseptic. The development of antiseptic surgery and, later, modern aseptic surgery progressed from there.

So at last, in the 1870s, the scene was set for the coming enormous advances in every branch of surgery whose breadth and successes form the basis of this book.

Prof. Harold Ellis, CBE MCH FRCS

What Sort of Patients Come to Surgeons?

Different types of surgeons practise in very different ways. In the United Kingdom, most patients are referred by another doctor, for example, GP, accident and emergency (ER) officer or physician. The exceptions include trauma patients who self-refer or arrive by ambulance. In some countries, patients can self-refer to the specialist they consider most appropriate. Regardless of the route, surgical patients fall into the following categories:

Emergency/acute , that is, symptoms lasting minutes to hours or up to a day or two—often obviously surgical conditions, such as traumatic wounds, fractures, abscesses, acute abdominal pain or GI bleeding
Intermediate urgency —usually referrals from other doctors based on suspicious symptoms and signs and sometimes investigations, for example, suspected colonic cancer, gallstones, renal or ureteric stones
Chronic conditions likely to need surgery, for example, varicose veins, hernias, arthritic joints, cardiac ischaemia or rectal prolapse

The Diagnostic Process

To manage surgical patients optimally, a working diagnosis needs to be formulated to guide whether investigations are necessary and their type and urgency, and to determine what intervention is necessary. The process depends upon whether immediate life-saving intervention is required or, if not, the perceived urgency of the case. For example, a patient bleeding from a stab wound might need pressure applied to the wound immediately whilst resuscitation and detailed assessment are carried out. At the other end of the scale, if symptoms suggest rectal carcinoma, a systematic approach is needed to obtain visual and histologic confirmation of the diagnosis by colonoscopy and radiologic imaging. Tumour staging (see Ch. 13 , p. 185) aims to determine the extent of cancer spread to direct how radical treatment needs to be. Treatment may be curative (surgery, chemotherapy, radiotherapy) or palliative if clearly beyond cure (stenting to prevent obstruction, local tumour destruction using laser, palliative radiotherapy).

Formulating a Diagnosis.

The traditional approach to surgical diagnosis is to attempt to correlate a patient’s symptoms and signs with recognised sets of clinical features known to characterise each disease. While most diagnoses match their ‘classical’ descriptions at certain stages, this may not be so when the patient presents. Patients often present before a recognisable pattern has evolved or at an advanced stage when the typical clinical picture has become obscured. Diagnosis can be confusing if all the clinical features for a particular diagnosis are not present, or if some seem inconsistent with the working diagnosis.

This book seeks to develop a more logical and reliable approach to diagnostic method than pattern recognition, by attempting to explain how the evolving pathophysiology of the disease and its effect on the anatomy bring about the clinical features. The overall aim is to target investigations and management that give the best chance of cure or symptom relief with the least harm to the patient.

Principal Mechanisms of Surgical Disease

Surgical patients present with disorders resulting from inherited abnormalities, environmental factors or combinations in varying proportions. These are summarised in Box 1.1 , as a useful ‘first principles’ framework or aide-mémoire upon which to construct a differential diagnosis. This is useful when clinical features do not immediately point to a diagnosis. This approach is known as the surgical sieve ; however, it is not a substitute for logical thought based on the clinical findings.

BOX 1.1

The Surgical Sieve

When considering the causes of a particular condition, it may be helpful to run through the range of causes listed here. This should only be a first step and not a substitute for thought. This approach gives no indication of the likely severity, frequency or importance of the cause.

Congenital

Genetic
Environmental influences in utero

Acquired

Trauma—accidents in the home, at work or during leisure activities, personal violence, road traffic collisions
Inflammation—physical or immunological mechanisms
Infection—viral, bacterial, fungal, protozoal, parasitic
Neoplasia—benign, premalignant or malignant
Vascular—ischaemia, infarction, reperfusion syndrome, aneurysms, venous insufficiency
Degenerative—osteoporosis, glaucoma, osteoarthritis, rectal prolapse
Metabolic disorders—gallstones, urinary tract stones
Endocrine disorders and therapy—thyroid function abnormalities, Cushing syndrome, phaeochromocytoma
Other abnormalities of tissue growth—hyperplasia, hypertrophy and cyst formation
Iatrogenic disorders—damage or injury resulting from the action of a doctor or other healthcare worker; may be misadventure, negligence or, more commonly, system failure
Drugs, toxins, diet, exercise and environment
- Prescription drugs—toxic effects of powerful drugs, maladministration, idiosyncratic reactions, drug interactions
- Smoking—atherosclerosis, cancers, peptic ulcer
- Alcohol abuse—personal violence, traffic collisions
- Substance abuse—accidents, injection site problems
- ‘Western diet’—obesity, atherosclerosis, cancers
- Lack of exercise—obesity, osteoporosis, aches and pains
- Venomous snakes, spiders, scorpions and other creatures—local and systemic toxicity
- Atmospheric pollution—pulmonary problems
Psychogenic— factitious disorder, unspecified (Munchausen syndrome) leading to repeated operations, problems of indigent living, ingestion of foreign bodies, self-harm
Disorders of function—diverticular disease, some swallowing disorders

Congenital Conditions

The term congenital defines a condition present at birth, as a result of genetic changes and/or environmental influences in utero such as ischaemia, incomplete development or maternal ingestion of drugs such as thalidomide. Congenital abnormalities of surgical interest range from minor cosmetic deformities such as skin tags through to potentially fatal conditions such as congenital heart defects, posterior urethral valves and gut atresias.

Congenital abnormalities become manifest any time between conception and old age, although most are evident at birth or in early childhood. Some are diagnosed antenatally , for example, foetal gut atresias with grossly excessive amniotic fluid (polyhydramnios). There are expanding specialist areas involving intrauterine or foetal surgery, for example, for urinary tract obstruction. During infancy, conditions such as congenital hypertrophic pyloric stenosis come to light. In childhood, incompletely descended testis may become evident. Finally, some disorders may present at any stage . For example, a patent processus vaginalis may predispose to an inguinal hernia even into late middle age.

Whilst many congenital abnormalities give rise to disease by direct anatomical effects , others cause disease by disrupting function , with the underlying disorder revealed only on investigation. For example, ureteric abnormalities allowing urinary reflux predispose to recurrent kidney infections.

Acquired Conditions

Acquired surgical disorders result from trauma or disease or from the body’s response to them, or else present as an effect or side-effect of treatment. For example, bladder outlet obstruction may result from benign prostatic enlargement, from urethral stricture after gonococcal urethritis or from damage inflicted during urethral instrumentation. The classification detailed here is a framework, but conditions may fit more than one heading, and the mechanism behind some disorders is still poorly understood.

Trauma

Tissue trauma, literally injury, includes damage inflicted by any physical means, that is, mechanical, thermal, chemical or electrical mechanisms or ionising radiation. Common usage tends to imply blunt or penetrating mechanical injury, caused by accidents in industry or in the home, road traffic collisions, fights, firearm and missile injuries or natural disasters, such as floods and earthquakes. Damage varies with the causative agent, and the visible injuries may not indicate the extent of deep tissue damage.

Inflammation

Many surgical disorders result from inflammatory processes, most often stemming from infection. However, inflammation also results from physical irritation, particularly by chemical agents, for example, gastric acid/pepsin in peptic ulcer disease or pancreatic enzymes in acute pancreatitis.

Inflammation may also result from immunological processes, such as in ulcerative colitis and Crohn disease. Autoimmunity, where an immune response is directed at the body’s constituents, is recognised in a growing number of surgical diseases, such as Hashimoto thyroiditis and rheumatoid disease.

Infection

Primary infections presenting to surgeons include abscesses and cellulitis, primary joint infections and tonsillitis. Typhoid may cause caecal perforation, and abdominal tuberculosis may be discovered at laparotomy. Amoebiasis can cause ulcerative colitis-like effects. Preventing and treating infection is an important factor in surgical emergencies, such as acute appendicitis or bowel perforation. Despite the rational use of prophylactic and therapeutic antibiotics, postoperative infection remains a common complication of surgery.

Neoplasia

Certain benign tumours , such as lipomas, are common and are excised mainly for cosmetic reasons. Less commonly, benign tumours cause mechanical problems, such as obstruction of a hollow viscus or surface blood loss, for example, leiomyoma. Benign endocrine tumours may need removal because of excess hormone secretion (see Endocrine disorders later). Finally, benign tumours may be clinically indistinguishable from malignant tumours and are removed or biopsied to obtain a diagnosis.

Malignant tumours may present with signs and symptoms from the primary, the effects of metastases (‘secondaries’) and sometimes, systemic effects, such as cachexia. Malignant tumours are responsible for a large part of the general surgical workload.

Vascular Disorders

A tissue or organ becomes ischaemic when its arterial blood supply is impaired; infarction occurs when cell life cannot be sustained. Atherosclerosis progressively narrows arteries often resulting in chronic ischaemia , causing symptoms, such as angina pectoris or intermittent claudication. It also predisposes to acute-on-chronic ischaemia when diseased vessels finally occlude. Other common causes of acute arterial insufficiency are thrombosis, embolism and trauma. Arterial embolism causes acute ischaemia of limbs, intestine or brain; emboli often originate in the heart. If blood supply is restored after a period of ischaemia, further damage can ensue as a result of reperfusion syndrome .

When a portion of bowel becomes strangulated, the initial mechanism of tissue damage is venous obstruction, and this progresses to arterial ischaemia and infarction.

An aneurysm is an abnormal dilatation of an artery resulting from degeneration of connective tissue. This may rupture, thrombose or generate emboli.

Chronic venous insufficiency in the lower limb causing local venous hypertension is responsible for the majority of chronic leg ulcers in the West.

Degenerative Disorders

This is an inhomogeneous group of conditions characterised by deterioration of body tissues as life progresses. In the musculoskeletal system, osteoporosis decreases bone density and impairs its structural integrity, making fragility fractures more likely. Spinal disc and facet joint degeneration is common, causing back pain and disability, and osteoarthritis is widely prevalent in later life: the almost universal musculoskeletal aches and pains are probably caused by degeneration of muscle, tendon, joint and bone.

Other degenerative disorders include age-related retinal macular degeneration, glaucoma, the inherited disorder retinitis pigmentosa, and certain neurological disorders (Alzheimer, Huntington and Parkinson disease, bulbar palsy). Atherosclerosis and aneurysmal arterial diseases are often nonspecifically labelled degenerative.

Metabolic Disorders

Metabolic disorders may be responsible for stones in the gall bladder (e.g., haemolytic diseases causing pigment stones) or in the urinary tract (e.g., hypercalciuria and hyperuricaemia causing calcium and uric acid stones, respectively). Hypercholesterolaemia is a major factor in atherosclerosis and hypertriglyceridaemia is a rare cause of acute pancreatitis.

Endocrine Disorders and Hormonal Therapy

Hypersecretion of hormones, as in thyrotoxicosis and hyperparathyroidism, may require surgical removal or reduction of glandular tissue. Endocrine tumours, benign and malignant, may present with metabolic abnormalities, such as hypercalcaemia caused by a parathyroid adenoma, Cushing syndrome resulting from an adrenal adenoma or episodic hypertension caused by a phaeochromocytoma.

Diabetes mellitus , particularly when poorly controlled, causes a range of complications of surgical importance, for example, diabetic foot problems, retinopathy and cataract formation, as well as predisposing to atherosclerosis.

Hormone replacement therapy in postmenopausal women brings mixed benefits: it slows osteoporosis and reduces colorectal cancer risk whilst slightly increasing risk of breast and endometrial cancer. There is also evidence of an increased rate of thromboembolism, as with higher oestrogen-containing oral contraceptive pills.

Other Abnormalities of Tissue Growth

Growth disturbances, such as hyperplasia (increase in number of cells) and hypertrophy (increase in size of cells) may cause surgical problems, in particular benign prostatic hyperplasia, fibroadenosis of the breast and thyroid enlargement (goitre).

In surgery, the term cyst imprecisely describes a mass which appears to contain fluid because of characteristic fluctuance and transilluminability. A cyst is defined as a closed sac with a distinct lining membrane that develops abnormally in the body. A variety of pathological processes produce cysts. Most are benign but some cysts may be malignant.

Iatrogenic Disorders

Iatrogenic damage or injury results from the action of a doctor or other healthcare worker. It may be an unfortunate outcome of an adequately performed investigation or operation, for example, perforated colon during colonoscopy or pneumothorax from attempted aspiration of a breast cyst. These are termed surgical misadventure . However, if the damage results from a patently incorrect procedure, for example, amputation of the wrong leg or removal of the wrong kidney, then negligence is likely to be proven. Such wrong site surgery is termed a never event and is now rare because of mandatory preoperative site marking and comprehensive theatre staff briefing (World Health Organization [WHO] checklist). Other never events include retained foreign objects postprocedure (i.e., surgical swab, guidewire), transfusion of incompatible blood products or administration of medication via the wrong route. Prescription or administration of the incorrect drug or dose is usually iatrogenic. It is unusual for iatrogenic problems to be caused simply by one person’s failure. More often it is a system failure , with inadequate checks and balances in the system. Complications of bowel surgery, such as anastomotic leakage may result from poorly performed surgery but can occur in expert hands; audited results can demonstrate whether the surgeon is proficient.

Drugs, Toxins and Diet

Problems with prescribed drugs include unavoidable toxic effects of certain chemotherapeutic agents, for example, neutropenia, and the side-effects of drugs, such as nonsteroidal anti-inflammatory drugs (NSAIDs) causing duodenal perforation, or codeine phosphate causing constipation. Drug allergy, idiosyncrasy or anaphylaxis may result from individual responses to almost any drug, and interactions between drugs cause adverse effects; in this respect warfarin is a prime culprit. Maladministration of drugs may also cause problems with, for example, the wrong drug given for intrathecal chemotherapy causing paralysis (a never event).

In many countries, venomous creatures, such as spiders, snakes or scorpions cause toxic and sometimes fatal harm.

Although major advances have now been made to discourage it, cigarette smoking has been the biggest single preventable cause of death and disability in developed countries. Cigarette smoke is highly addictive and contains an array of carcinogens in the tar, the vasoconstrictor nicotine, and carbon monoxide that binds preferentially to haemoglobin. Not surprisingly, smoking is a powerful factor in a huge range of diseases including cardiovascular disorders of heart, limbs and brain, dysplasias and cancers of lung, mouth and larynx, respiratory disorders, such as pneumonias, chronic obstructive pulmonary disease (COPD) and emphysema via small airways inflammation, stillbirth and peptic ulcer disease. Smoking compounds the atherogenic effects of diabetes and is also strongly associated with premature skin ageing. Environmental pollution adversely affects health: for example, microfine particles produced by diesel engines cause pulmonary inflammation.

Alcohol and substance abuse may have a surgical dimension: alcohol can lead to personal violence or road traffic collisions; cannabis smoke is carcinogenic and causes dysplasias and premalignant lesions of the oral mucosa, as well as contributing to mental health problems. Misdirected injection of opioids and other drugs may cause abscesses, false aneurysms and even arterial occlusion. Misuse of ketamine can cause intractable bladder pain, cystitis and urinary symptoms.

The so-called Western diet, rich in fat and calories and low in vegetables, fruit and fibre, is linked with a range of diseases including colorectal and breast cancers, obesity, dyslipidaemias, diabetes and hypertension. This is particularly so when combined with a lack of exercise. Dietary fibre protects against colorectal adenomas and carcinomas as well as diverticular disease.

Psychogenic Disorders

Psychogenic disorders are not often a source of surgical disease but factitious disorder (previously referred to as Munchausen syndrome ) patients may present with abdominal pain and become subjects of repeated laparotomies, psychiatric patients living rough may suffer from exposure and frostbite, and others may repeatedly cause self-harm or swallow foreign bodies, even such items as razor blades or safety pins.

Disorders of Function

A range of common disorders are defined by the functional abnormalities they cause, although their pathogenesis often remains ill understood. The GI tract is particularly susceptible, with conditions, such as idiopathic constipation, irritable bowel syndrome and diverticular disease.

Medical Ethics and Confidentiality

The term medical ethics refers to the universal principles upon which medical decisions should be based, and governs the beliefs and actions that influence the day to day judgements of doctors. Whilst benevolence should govern all medical practice, other factors, such as self-interest, money, the distribution of resources and individual technical skills are important motivating factors.

To some extent, the practice of surgery is influenced by the need for self-protection but in trying to avoid litigation, a surgeon may overtreat or overinvestigate in ways that are unnecessary and may even be unethical. A degree of self-interest is inevitable but the guiding principle should be that the patient’s interests are paramount. Desirable attributes in a surgeon are listed in Box 1.2 .

BOX 1.2

Desirable Attributes in a Surgeon

After Professor George Youngson, Emeritus Prof. of Paediatric Surgery, University of Aberdeen.

Technical knowledge and clinical experience
Listening and communication skills with patients, secretary, colleagues and managers
Qualities of leadership and the ability to work in a team
Personal attributes—kindness and empathy
The ability to make reasoned judgements and decisions under pressure, often with incomplete information
Situation awareness—the ability to collect and synthesise information rapidly
Problem solving ability—often in situations not previously encountered
Insight into one’s own practice and a willingness to change plans or behaviours if shown to be incorrect. Being prepared to listen and to learn from constructive criticism
Organisation and planning ability to cope effectively with a heavy workload
Professional integrity and honesty
A genuine desire to continue learning and professional development
Reliability in fulfilling responsibilities and commitments
The ability to recognise one’s own values and principles and understand how they differ from others

Surgeons generally aspire to practise their craft in line with the principles of the Hippocratic Oath . This originated from the Greek School of Medicine around 500 bc and its essence is as follows:

Doctors must be instructed and then registered to protect the public from amateurs and charlatans.
Medicine is for the benefit of patients, and doctors must avoid doing anything known to cause harm.
Euthanasia and abortion are prohibited.
Operations and procedures must be performed only by practitioners with appropriate expertise.
Doctors must maintain proper professional relationships with their patients and treatment choices should not be governed by motives of profit or favour.
Doctors should not take advantage of their professional relationships with their patients.
Medical confidentiality must be respected (see later).

Confidentiality

Patients allow the National Health Service (NHS) to gather sensitive information about their health and personal matters as part of seeking treatment. They do this in confidence and legitimately expect staff will respect this trust.

In the United Kingdom, patient information is held under legal and ethical obligations of confidentiality. This information must not be used or disclosed in a way that might identify a patient without their consent. Caldicott Guardians are senior staff in the NHS and social services appointed to protect patient information locally. The doctor’s duty of confidence is a legal obligation derived from case law and is a requirement in professional codes of conduct. Even if a patient is unconscious, the duty of confidence is not diminished.

Whilst cases are often discussed over lunch and elsewhere with colleagues, this should not be done in a public place. When patients are discussed at meetings, identification data should be concealed and written notes about patients should not be left lying around or taken from the hospital except using official channels, for example, during patient transfer.

Do Not Resuscitate Orders

A do not resuscitate (DNR) order on a patient’s file means that doctors are not required to resuscitate a patient if their heart stops. It is designed to prevent unnecessary suffering and potential side-effects such as pain, broken ribs, ruptured spleen or brain damage. The British Medical Association and the Royal College of Nursing say that DNR orders can be issued only after discussion with patients or family, difficult though this may be. Decisions should not be made by junior doctors alone but in consultation with seniors. The most difficult cases are those involving patients who know they are going to die and are suffering pain or other severe symptoms but who could live for months.

All adult patients who are admitted to hospital should have documentation of their resuscitation status. A DNR order does not mean that patients cannot be offered any active treatment. Discussion should take place with the patient and family to set boundaries on acceptable treatment of potentially reversible factors (such as antibiotics for infection), but it may be agreed that it is not appropriate to escalate care to a high dependency unit if the condition significantly deteriorates.

Guidelines for When a DNR May be Issued

If a patient’s condition is such that resuscitation is unlikely to succeed.
If a mentally competent patient has consistently stated or recorded they do not want to be resuscitated.
If an advance notice or living will says the patient does not want to be resuscitated.
If successful resuscitation would not be in the patient’s best interest because it would lead to a very poor quality of life.

In the United Kingdom, NHS Trust Hospitals must agree explicit resuscitation policies that respect patients’ rights and are readily available to patients, families and carers; policies must be regularly monitored.

Communication

With Patients

Doctor–patient relationships are best learnt by following good examples in the clinic and ward in an apprenticeship model. Patients are vulnerable, often with unpleasant symptoms and usually with little understanding of anatomy, physiology or pathology. They rarely understand the likely progress of a disease or its treatment and may have been conditioned by the media to expect miracle cures or to believe that the latest technology is what they need. Patients take in only about 10% of what is said during a consultation, but this can be improved in the right setting and with reinforcement. Important messages need to be given in comfortable surroundings, without giving the impression the doctor is in a rush, perhaps with family present and with a nurse who can later ensure messages have been understood.

Doctors are in a privileged position, able to make decisions on a patient’s behalf that can have dramatic effects on their life and that of their family. Patients these days generally wish to know more about their condition, but can then take greater responsibility for it than in the old days of the paternalistic doctor. Thus an effective doctor–patient relationship involves not only taking an accurate history but also intelligent listening to discover what patients know, or think they know, about their health and likely treatments, and responding to their concerns in ways they can understand. A good interview also involves imagining ‘the third eye’, how both sides of the consultation might appear to an observer. Patients frequently complain, with good reason, that they ‘don’t know what is going on’. They pick up bits of information that may be inaccurate, so doctors should anticipate what they should explain to patients and families and give information in a timely fashion.

During the process of diagnosis and treatment, there is often uncertainty and incomplete information, so it is valuable to explain at intervals the stage reached, both to the patient and, with the patient’s permission, to relatives. Where there are different treatment options, a balanced view of the alternatives should be given, perhaps with some statistics, but when the doctor has reason to prefer one approach, this should be explained too, and then the patient can make a considered choice. It can be easy to persuade patients to undergo treatment—after all, you are the expert in their eyes—but trust, respect and empathy teach that patients may wish to reflect at leisure. Except in emergencies, patients should be able to go away and consider options rather than having to sign a consent form just before treatment. They may even wish to take a second opinion if choices are uncertain or potentially life-changing; this should be welcomed rather than discouraged. By helping patients understand their condition, their self-management will be more effective. Similarly, key factors such as diet or smoking habits can be discussed in an atmosphere of trust with more hope of success.

Palliative Care

Sometimes cure is not possible. Then quality of life may become the goal, with palliative treatment being offered. Patients generally want to know what will happen, including their mode of dying. Whilst this can be hard to predict, they need to know their symptoms, particularly pain, will be managed effectively and that they will be looked after. Experience teaches it is usually impossible to say with accuracy when a patient will die except a few days before it will happen, so it is unwise to predict life span except in general terms.

Breaking Bad News

All doctors in clinical practice experience the need to break bad news, such as an unfavourable outcome, unsatisfactory care, a cancer diagnosis or a poor prognosis. It is an event doctors tend to remember and a moment in the patient or relative’s life they will never forget.

Ideally, bad news should be conveyed by the most senior member of the team but in reality, bad things often happen at night, often in the A&E department, and the most junior doctor is the one on the spot. Discuss what is to be said with your seniors even under these circumstances wherever possible. The following general points apply:

Bad news is private. Find a quiet space, preferably an office with chairs (you do not need a desk).
Avoid hiding behind jargon: ‘the metastatic nature of the neoplasm makes it inoperable’ is useless. ‘I’m sorry to say that the cancer has spread and an operation won’t help’ is better.
Give time and space; turn off pagers and phones if possible.
Do not be defensive and do not be afraid to express regret.
Avoid filling the silence of grief with continuous chatter.
Allow time for questions. If you do not know the answer, say so and try to find out.
Always offer another meeting, ideally with the head of the team.
Many patients/families will wish to discuss what has been imparted with their family doctor, so it is vital that you get all information to the GP before that visit.

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