Considering surgery
for Harry

Considering surgery for Harry

The issue is raised at the lunch time ward meeting. The team is divided as to how they should proceed in light of Harry’s indecision.

View more of Harry’s story below to see what transpires.

The team decides to delay the surgery and gather more information to ensure that Harry understands the implications of a decision to proceed or not to proceed with surgery. Harry is asked to explain his preferences and concerns in more detail.

Harry: “I know I’ve got cancer and I do want you to make me better, but I’m worried my heart might give out in the operation, and if it goes wrong I might never be able to walk again. There’s no way I want to spend the rest of my life in a nursing home.”

Neurosurgical Registrar: “It’s your decision. You have to look at the risks and benefits of having or not having the surgery. There are risks on both sides.

You’re getting a lot of pain now when you walk and do other things. Pain killers can help make you comfortable, but it would be difficult in this situation to be pain free on movement and mobilising using medicines alone.

But more importantly, if we don’t stabilise your fracture it could suddenly get much worse, and if it damages the nerves you could lose control of your legs, your bowels, and bladder.”

Harry: “I just wanna go home and do normal stuff, you know, play golf, have a drink at the club, and do a bit of gardening”

Neurosurgical Registrar: “Despite the risks with the surgery, I think the risks of not having it are greater. In my opinion, your chances of going home and doing the things you like are overall better if you have the surgery.”

Harms Vs Benefits

There is no indication in the discussion between Harry and the neurosurgical registrar that Harry’s decision-making capacity is impaired. As highlighted in this discussion, the issue of proportionality (harms vs benefits) plays an important part in the decision to proceed with treatment.

In each case, decide if you think this issue is a harm or a benefit in considering the option of proceeding to surgery in Harry’s case. Drag the issue to the appropriate side of the scale (as demonstrated to the right).

Learn More: Obligation to proportionality (harms vs benefits)

Obligation to proportionality (harms vs benefits)

Clinical decision-making relies in part on our obligation to ensure that all interventions we offer patients accord with ‘proportionality”. That is, that the overall harms of the intervention are outweighed by the expected benefits. If specific interventions do not meet this ‘test’, they should not be offered. It should be noted, however, that what constitutes harm and what constitutes benefits can be contested, and may differ between different assessors. This is why we rely upon the shared decision-making process to ensure all of those perspectives are heard and considered.

Harm or Benefit

The assessment of proportionality (harms vs benefits) and best interests is specific to each individual patient, and their specific context. Next, we’ll see how this process looks in considering Harry’s surgery.