Q: I have a patient who needs a carpal tunnel release. My problem is that this procedure is most safely done after stopping anti-coagulation and her cardiologist wants her to only be off her medication for five days while I consider ten as my safety margin. There is no option to not do the surgery – her life is really miserable now because of pain and she is progressing to permanent nerve damage. Can I tell her that ten days would be my minimum but that I will defer to the cardiologist although I cannot sign off that this is safe for her operatively and let her make the choice once she is given the facts? What about if she then just follows my preference even though I didn’t demand it?

A: A statement that you disagreed with the cardiologist but would go along with them would facially comply with the requirement of informed consent that a patient be told what a reasonable patient in their position would want to know since a reasonable patient contemplating this surgery would want to know that there were differing approaches as to the cessation of their anti-coagulant medication. If she then elected to go ahead using the cardiologist’s timetable and despite your stated concerns that would be her choice.

However, that presumes that doing the surgery with less anti-coagulation is within the Standard of Care and you literally invoking the idea of this being unsafe under the cardiologist’s conditions presumptively removes it from that ambit.

That you say that you are “deferring” to the cardiologist would not impact on that because you actually cannot do so.  You can take what that specialist said into account concerning their area of expertise but as the operating surgeon the choice to go ahead with the procedure under those conditions is yours and is non-delegable.

In other words, even if she would consent to an unsafe procedure you cannot consent to perform such, and declaring that you would do so is a pre-emptive declaration of malpractice.

That malpractice would then even be potentially not covered by your insurance because the carrier could argue that rather than negligence it was an intentional deviation from good and accepted medical practice, which is not indemnified.

So, the real issue then is whether you are talking about an ideal situation versus an acceptable one or an acceptable situation versus an unacceptable one.

Can careful surgery followed by careful monitoring reduce the risk of hematoma or compartment syndrome enough so that this patient, who desperately needs the surgery, can have it under the cardiologist’s standards for her medication?  If so, you may proceed if she, after being informed of the risks and benefits, agrees.

As to your second question, the patient taking her own initiative to follow you rather than the cardiologist is a non-starter.  Just as you cannot delegate to the cardiologist you also cannot delegate to the patient. You would obviously be aware that she was doing it because of when the procedure was scheduled for, so it would then be entirely under your aegis.

If she then had a stroke or an MI because she was off her anticoagulants for longer than the cardiologist advised, and then sued you, she would claim that you clearly approved because you set up the case and she relied on that approval.  A note in the chart saying that, no, you were accepting just five days because the cardiologist was the binding authority would be of no defense because that is not what you actually did.

Just handle this in a straight-forward manner. Explain the matter to her fully and then document that while you consider ten days of cessation optimal that five can be adequate with close post-operative monitoring, and that the compelling need for the surgery (disabling pain, developing nerve damage) factors into this assessment, and that the patient was informed of that clinical balancing and the attendant risks and benefits, and elected to go forward on that basis.