PIG Meeting: 29th April 2021
53-year-old lady for cystoscopy and intravesical botox for urge incontinence
- BMI 48
- COPD. Current smoker. 40 pack years
- PFTs showed normal lung volumes but reduced TLCO (likely in keeping with her known pulmonary hypertension)
- NIDDM. Poor glycaemic control. HbA1c = 9.9%
- HFpEF and moderate pulmonary hypertension
- Uncontrolled hypertension
- Non-obstructive CAD
- T-cell lymphoma – currently in remission since chemotherapy and stem-cell harvest but moderate prognosis disease with 43% 5-year mortality rate
- Extremely poor exercise tolerance, resting every 10-20 steps
- Consult in clinic and advised on multiple areas for optimisiation including.
- Weight loss and dietician via GP
- Smoking cessation
- Diabetes optimisation
- Sleep studies
- Patient had pursued none of these recommendations, citing social stressors.
- Surgeon contacted to request a further 3mth delay.
- Surgeon decided to cancel the procedure, believing conservative measures were more appropriate and that her other health problems were far more important to optimise.
Was this the right decision?
- Should we be more compassionate regarding the contribution of her social stressors to her health inertia?
- Is an incontinence procedure likely to be effective in a morbidly obese smoker? Thought to be low value healthcare.
- Could this procedure be done under LA (group consensus was no, based on previous experience).
- Is this paternalistic?
- Possible that the surgical team requested a ‘consult’ in the hopes that we would say no?
- Ideally the decision to cancel should have been communicated by the surgical team, rather than via periop clinic.
- A letter was sent to the GP which clearly outlines ownership of the decision.