I'd like to donate my organs...

I was consenting one of my patients for a routine operation the other day (more on "informed consent" another day), when while discussing the incidence of major complications such as stroke, myocardial infarction, or death, he said to me: "Doc, if anything like that happens to me, or if it looks like I'm going to die, I'd like to donate my organs."

It struck me as rather odd that he would say that. I am sure that he had his own reasons, and I was not all that interested in why, but it made me think... would there ever be a situation where I would seriously consider referring his organs for donation? We often consider patients who present with major trauma and sudden death for organ donation, or those in ICU with head injuries and effective brain death, but patients who die as a complication of elective surgery?

The fact is, if something goes wrong while you are having elective surgery, and you end up dying, you will probably have everything possible done for you until all of your organs fail and there is not much worth harvesting. Most fatal complications of elective surgery involve cardiac failure, respiratory failure, acute renal failure. We don't often give up before at least two of these organs have failed irretrievably, and by that stage the other organs are pretty much stuffed ("stuffed" - a medical term derived from the Latin "stuffio" meaning to be beyond salvage, analogous to FUBAR).

About the only organs left are the corneas, and I have only ever successfully convinced one patient to donate them.

On the other hand, I did have a patient who died recently that had arranged to donate their body to the Anatomy School at our local university where I have previously taught. His wife had died several years ago and donated their body to research and teaching at the university, and he had made similar arrangements in advance. Even in the setting of major organ damage, this can be a useful exercise, and, in fact, is even more educational for the students when there is major pathology present. Unfortunately, permission has to be arranged for this well in advance of death for the University to be able to accept such a donation, so it is not a decision that can be made by a family after a relative dies.

Perhaps my university is a bit of a dinosaur, but we still conduct anatomical cadaveric dissections, and I believe that it is an essential learning experience, and a major tool in medical research. So the next time you are thinking of filling out your organ donation form, think also about what you want to happen to your body if it is not suitable for organ donation... perhaps donation to medical science may be a more productive way to go?

I love LUSCS?

Doctors told to reduce caesarean births

The New South Wales Health Department has issued a new directive aimed at trying to reduce the number of unnecessary caesarean deliveries in state public hospitals.

The new policy says a request from a mother to have a caesarean section is no longer a justifiable reason for performing the procedure, if there is no medical reason.

Dr Andrew Child from the Health Department says under the changes a doctor must fully explain to a woman all of the risks associated with a caesarean section before one can be performed.

"It will change the attitude of the staff," he said.

"At the moment the staff are tending to just give it a quick tick whereas this will enforce the need to make sure that all the risks and dangers are very clearly put on the table."

Firstly, does the NSW Department of Health seriously believe that anybody performs Caesarean Sections on a whim, without due consideration for the indication, benefits and risks? Or that women agree to a Caesarean Section without appropriate consultation, advice and consideration?

Secondly, like any surgical procedure, it is normal practise to explain to the patient the risks associated with the procedure that is planned. The only exception to this rule is where the patient is incapacitated (and therefore the explanation goes to the person who is most responsible for the patient), or in the setting of a life or limb-threatening emergency where the patient is unable to understand or comprehend the situation, or time is so critical that there is no option (these usually all happen together). Though obviously in the Health Minister's mind, a Caesarean Section is not like any other operation. Perhaps the only "change in attitude" should start at the top. A Caesarean Section is an operation. A Caesarean Section is an operation. A Caesarean Section is an operation...

Lastly, perhaps there should be a similar edict warning mothers of the risks of not proceeding with a Caesarean Section when recommended, the risks or home birthing, or the risks of getting pregnant in the first place!

Perhaps it might have kept this poor couple out of trouble: Twins' home birth risk 'downplayed'

I am sure that Dr Crippen would have plenty to say, given his Campaign Against Reckless Midwives (or "Madwives", as he prefers). Perhaps we are inevitably heading towards the NHS model of perinatal care - though not if this article from The Times has anything to do about it.

Personally, having just been through the whole business recently, we had a fantastic obstetrician and some excellent midwives in the delivery suite, though once we left for the post-natal ward the quality and empathy of the ward midwives left a great deal to be desired. You get the whole range from the uncaring to the overbearing. Nevertheless, we have each other. And now two little boys.

Mind the Gap: Part 3 - Estimates of Costs

This is Part 3 of a series outlining the Australian Health Insurance industry from the perspective of a health provider. Dr Dork has prompted me to add an extra section to my series.

3. Estimates of Costs

Dr Dork said:

What disturbs me is when there is not financial disclosure prior to a procedure. I personally outline costs with every patient, and believe this is always necessary.

As a patient, I've also had some surgeons send me large unexpected bills. The bills don't piss me off. The fact that it is unexpected does.

Precedents demonstrate that lack of financial consent excuses the patient from paying, if they so choose.

Of course patients should expect an indication of the costs involved in their care - but just like when you contract a builder or any other tradesperson, the initial quote can balloon out if there are unexpected issues that need to be addressed.

As the "point man" (or "woman", or "person" etc...) the surgeon is often put under the spot to supply quotes or cost estimates from the private hospital, the assistant, the anaesthetist, the visiting physician, orthotics, physiotherapy etc. As things stand today, it is impossible for one doctor to presume to know what everyone else will charge.

Ultimately, such cost estimates are only indications of likely cost, and the failure is in the practitioner's ability to explain that to the patient. Usually this is because the patient is so worried about what the "gap fee" will be!

Things are somewhat easier for a physician (for the benefit of our US readers, internist) treating a patient as an outpatient - a set fee is charged per visit. Imagine giving the patient a quote for their hospital admission for, say, community acquired pneumonia? Who is to say how long they will be in hospital and how many inpatient visits or procedures you may be involved with? Should the patient refuse to pay anything beyond the first week because you said they would probably only be in hospital for that long?

Obviously the patient has the right to walk out of the hospital after a week, just as you have the right to fire your builder - but that's not very productive when you've got a half-built house. At the end of the day, if the builder fixed an unexpected major problem that had you been there you would have agreed to anyway (possibly because there is little or no choice) then would you deny payment just because they didn't talk to you first? Perhaps that is an issue of principle over pragmatism.

More on this series next week.