Appendicitis and shared decision making

Staying with the current theme of appendicitis on my blog, here is a summary of recent developments. A JAMA Surgery Viewpoint suggested that because of the findings of a Finnish randomized trial, surgeons now should give patients with appendicitis a choice between an appendectomy or treatment with antibiotics.

The paper acknowledged my criticisms of the Finnish study which found that simple appendicitis could be treated successfully with antibiotics in almost 75% of patients.

I respect the authors of the JAMA Surgery article and am happy they referenced the blog post noting my concerns about that Finnish trial: the trial compared antibiotics to open appendectomy—an operation with more complications than the more commonly performed laparoscopic appendectomy; the antibiotic used in the Finnish trial is not a first line choice in the United States; patients were followed for only one year.

The JAMA surgery paper answered three questions I posed in a previous post. One, the Viewpoint authors consider antibiotic therapy for appendicitis mainstream. Two, surgeons must assume that patients might opt for antibiotics despite at least a 25-30% chance of suffering a recurrence of appendicitis. Three, an informed consent discussion now should include a mention of antibiotics as an option.

I disagree with the Viewpoint authors’ assertion that antibiotics are as safe and effective as surgery for treating appendicitis. Based on one flawed study, antibiotic therapy cannot yet compare to the many years of excellent results of laparoscopic appendectomy.

Here are some other problems.

Let’s talk about shared decision-making. After hearing all the options, some patients will want to guide their own care. However, most patients would rather not. A 2011 Journal of Medical Ethics study of over 8000 patients found that 97% “of respondents wanted doctors to offer them choices and to consider their opinions. However, two out of three (67%) preferred to leave medical decisions to the doctor.”

What about the medicolegal implications of antibiotic therapy for appendicitis? Right now, the “standard of care” for appendicitis is appendectomy. Suppose a surgeon, in the interest of shared decision-making, explains the Finnish study to a patient and neglects to mention that it only involved patients with simple appendicitis. Or suppose that patient’s CT scan is read as simple appendicitis but is not accurate, and the patient actually had complicated appendicitis that went on to perforate despite antibiotic therapy.

If that patient becomes septic and requires a laparotomy and suffers a subsequent wound infection and massive hernia or dies, who is going to be held responsible for not recommending an appendectomy? Certainly not the patient.

In the era of shared decision-making and patient autonomy, maybe patients should be required to carry malpractice insurance so they can sue themselves if the decisions they make turn out badly.

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