About this post: Understanding
Indications for surgery are Absolute or Relative.
When the diagnosis has been made, and the conservative treatment has failed to bring about the desired result, surgery becomes an option. Certain questions arise:
- Is it essential for a patient to have an operation for a specific condition, or not?
- Who decides on the surgery?
- Does the patient have a choice?
Surgery is just another step in the development of an ongoing management plan for a condition the patient suffers from. Fortunately, it does not have to come to surgery in every circumstance the patient presents to the physician, however, often enough it does become a consideration.
When surgery becomes the suggested treatment, the doctor is obliged to explain to the patient the details of the proposed operation. This includes the nature and the extent of the surgery, including the consequences, the advantages, the short-comings as well as the risks of the specific procedure. Furthermore, the surgeon has to explain to the patient if the indications for surgery are absolute (absolutely necessary) or relative (could be done).
When dealing with the prognoses, the risks and consequences on the short as well as the long-term have to be considered. This should be made clear to the patient regarding the surgery envisioned, as well as the risks and consequences of not having the suggested surgery.
As much as it cannot be expected that the patient, who is not a trained medical professional, will understand the highly technical facts of the suggested procedure, it remains the right of every patient to be adequately and properly informed about the operation in a way that he or she understands what is about to happen to them. Understanding the difference between an absolute and relative indication will assist the patient in the decision making process.
This is an ethical principle in medicine, this represents good medical practice and the unalienable right of every patient.
So how does a patient decide if the indications are absolute or relative, to go ahead with the recommended surgery or wait a while?
To be able to decide and give consent for the procedure to be performed, it is necessary to distinguish between an absolute indications and relevant indications for surgery.
A. Absolute Indication for Surgery.
The surgeon sees the decision to operate as mandatory, a medical necessity.
A patient with a condition presenting a risk to the life of the patient, to preserving a limb of the patient, or preserving body function, can be classified as a mandatory or absolute indication for surgery. When it is evident that the risk will lead to irreversible damage should the operation not be performed, the surgeon should confirm that the indication is absolute and recommend surgery.
Although the patient may refuse the surgery, the onus lies on the doctor to: Explain clearly the diagnosis and the risks of the disease. To explain precisely why the operation is necessary,to make sure that the patient also understands the consequences should the surgery not be performed.
This is called an absolute indication for surgery.
Example of an absolute indication is the Cauda Equina Syndrome.
This condition is described when a spinal lesion in the lower spine presents with back pain, complicated by radicular pain down the leg, saddle anaesthesia, as well as bladder and anal dysfunction (in most cases also sexual dysfunction, although not immediately recognised). Should the surgery be unduly delayed or not done at all, the sensory changes, the bladder and stool incontinence and the sexual dysfunctional will probably become permanent. This is quite a severe disability. This surgery should be done as an emergency procedure. A Cauda Equina Syndrome is always a medical and surgical emergency.
B. Relative Indication for Surgery.
Should a condition exist where there is no immediate risk to life or limb, the surgeon may still recommend surgery. However, the operation does not need to be done. The medical condition may cause distress to the patient, however, but by delaying the surgical option of treatment, or even omitting an operation entirely, no absolute risk to life or limb exists.
After explaining the condition, with the risks attached to doing the surgery, the patient should understand that the operation is not absolutely necessary. The symptoms the patient complains about can be managed by alternative means, and surgery could be delayed for a period of time, even omitted as a treatment option.
The decision to have the surgery is made by the patient. This decision is based on how the patient judges the effect of the disease on:
Life quality – when life quality is diminished because of pain, stiffness, or loss of function, thereby preventing the patient from participating in activities they should typically be able to do (given their age and abilities).
Activities of daily living – when activities that are necessary for everyday functions, e.g. washing, dressing, hair care, cooking and cleaning are becoming difficult because of the disease.
Ability to work – when the ability to perform the functions in the typical working environment is threatened, whereby the income for sustenance is reduced.
The expectation should be realistic, and the surgeon should not create impossible expectations for the suggested surgery.
The patient decides on the surgery, as well as the timing of such an operation.
This is called a relative indication for surgery.
Example of a relative indication.
Osteoarthritis of the hip joint.
A progressive disease of the Hip joint with pain that increases as the disease progresses. The total hip replacement operation as treatment for the condition could be done at any time, be it within the next month, or in 5 years time. The recommendation by the surgeon to do surgery because of pain, stiffness and loss of function is correct. The patient decides if, and when the operation will be done. This decision is made by the patient based on the impact the disease has on the above three life qualities.