Surgeons' attitudes to intraoperative death: questionnaire survey

Intraoperative death is a situation any surgeon might encounter. A news item in the BMJ discusses the outcome of an inquiry by Sheriff Albert Sheenan into an incident that involved the death of a patient having elective surgery. The inquiry recommended that a surgeon should not operate for a period of 24 hours after such an event because “the surgeon is . . . not in the frame of mind to continue to operate that day.”¹

After the intraoperative death of a trauma patient at our own hospital, we were advised by a defence association that the surgeons involved should not operate for the next 24 hours. Although we considered this advice surprising, as the patient had sustained injuries likely to be fatal irrespective of any intervention, we duly followed it. A later literature search failed to find any references considering the psychological state of surgeons after an intraoperative death. We decided to find out if there is a consensus of opinion among orthopaedic surgeons about how to cope with intraoperative death.

Participants, methods, and results

The proposal to carry out a survey was approved by the regional research ethics committee. Forty four consultants employed in Welsh health trusts and listed in the British Orthopaedic Association Handbook 1999 were sent questionnaires to be completed anonymously. The questions were related to the surgeons' experiences of intraoperative death, and were based on concerns raised by the Sheenan inquiry and related issues.

Thirty one (70%) questionnaires were completed. Sixteen (53%) acknowledged experience of intraoperative death. Five deaths (31%) were expected trauma deaths, five (31%) were unexpected trauma deaths, and five (31%) were deaths during elective surgery. In one (6%) death the respondent could not recall the category.

Of the 16 surgeons who experienced the intraoperative death of a patient, 13 (81%) performed further operations that day. All those who continued to operate felt their competence had not deteriorated. Only one (6%) did not operate when ordinarily he would have been expected to operate; he did so through personal preference and not as a result of external influences.

Eight (50%) of the surgeons who experienced the death of a patient during surgery felt that some time without operating would have been advisable; of those not experiencing such an event, four (26%) felt that this would be advisable.

None of those experiencing the death of a patient during surgery received or considered counselling. All five experiencing the death of a patient during elective surgery thought counselling should be offered. Four (80%) of those experiencing unexpected intraoperative death of a trauma patient thought counselling should be offered, and one (20%) of those experiencing expected intraoperative death of a trauma patient felt it should be offered.

Comments

There was no general consensus among the orthopaedic surgeons we surveyed about how to cope with intraoperative death. The nature of the specialty is reflected in the division between deaths during elective surgery and those relating to trauma. We were not surprised to find that all but one of the surgeons continued to operate and that the prevailing attitude was one of “it's part of the job.”

A recent study considering stress levels in various medical specialties showed that stress levels are actually lowest in surgeons.² We found no references specifically addressing surgeons' attitudes to intraoperative death, but our findings are not surprising as it has been suggested that surgeons are able to cope with situations that might be thought of as stressful to others.²

Because of the size of the study, we cannot draw conclusions about the difference in attitudes towards counselling between surgeons experiencing the death of a patient during elective surgery or an unexpected traumatic intraoperative death, and those experiencing an expected traumatic intraoperative death. We also acknowledge that we do not know whether counselling services were available nor whether the surgeons were aware of such services if they were available.