The ethics of interventional procedures for patients too ill for surgery

Purpose of review Minimally invasive interventional procedures are increasingly popular options for patients who are high-risk candidates for open surgical procedures. It is unclear how to proceed in the rare circumstance of a complication during an interventional procedure, where addressing the complication would require exposing the patient to the full risk that was being avoided with the minimally invasive technique. This review provides recommendations on how to approach this paradoxical scenario. Recent findings Risk stratification, communication frameworks, and advanced care planning can facilitate shared decision-making between physicians and patients. Risk stratification may include mortality predictive models, disability and frailty scores, and patient-centered outcome studies. In the event of procedural complication or failure, aggressive surgical treatment or limited repair should be guided by patient preferences to best ensure value concordant care. Summary Interventional procedures, and emergent open surgery, should be offered as long as patients are fully informed about the benefits and risks, including the implications of potential life-sustaining treatments, and whether their respective goals of treatment are consistent with the intervention. Implementing this framework will require a cultural shift in physician attitudes to recognize that in some cases, nonintervention or less aggressive treatment may be a reasonable alternative to surgical intervention. Correspondence to Michael Nurok, Cedars-Sinai Heart Institute, 127 S. San Vicente Blvd., A3100, Los Angeles, CA, 90048, USA. Tel: +1 310 248 7369; e-mail: michael.nurok@cshs.org Copyright © 2018 YEAR Wolters Kluwer Health, Inc. All rights reserved.

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