Predictable Science or Myth?
Is there a negative consequence to patient premonitions?
It takes a while to digest stuff-
Yeah- did a heart today, and then another- first was an aortic valve replacement- second was a guy missing the last half of his right foot, who had lost his wife a year ago and needed a new motor.
Sometimes people send post cards to their loved one’s on the other side. Those cards can be delivered promptly if the will to survive or succumb from an open heart procedure is in doubt.
We anticipate these postcards as potential premonitions of death and dying, taking them very seriously- here in the land of open heart surgery.
In the pursuant conversation with this gentleman, it was casually clarified that the intention to undergo surgery wasn’t a latent urge for an immediate hookup with his lost other half- instead I think, he was a little more focused on a reunion with the remaining half of his foot.
That was clarified right up front by the operating surgeon.
We see a close relationship with death wishes and premonitions- they seem to co-mingle with really poor outcomes, so we try to address what is a strange and touchy subject.
He truly was a train wreck, but survived the operation intact- albeit a few unanticipated hurdles (anatomical issues).
Premonition of Death in Trauma:
Department of Surgery, Columbia University College of Physicians and Surgeons, New York, New York, USA. [email protected]
Prognostication in western medicine has traditionally been based on objective scientific criteria, yet providers often rely on a feeling or “sense” based on experience to provide prognoses. In trauma, some providers believe that patients who express a feeling of death are more likely to die. We randomly surveyed 302 members of the Eastern Association for the Surgery of Trauma regarding patient’s premonitions of death (POD). Ninety-five per cent of respondents reported encountering patients who expressed POD. Fifty per cent agreed patients expressing POD had a higher mortality rate. Fifty-seven per cent believe patient willpower affects outcome. Forty-four per cent agreed patients have an innate ability to sense their ultimate outcome after injury; 85 per cent believe patient’s POD do not cause deviations from protocols. Most trauma providers have encountered patients expressing POD. Whereas most believe that a patient’s willpower affects outcome, they do not believe that expressing a desire to live decreases mortality with seemingly fatal injuries. Providers who have witnessed negative POD believe these patients are more likely to die, however, they do not deviate from treatment protocols. This survey represents the first attempt to understand the magnitude of premonition of death in trauma and the need for future research. Am Surg. 2009 Dec;75(12):1220-6.
An internist suggests that a patient’s premonition of death may be an indication for a more thorough evaluation.
“Two months ago,” says the internist, “an obese patient came in for preop for a second knee replacement. She simply voiced a bad feeling about the surgery. We decided to cancel. On review of systems, the patient had a little bit of stomach discomfort, which turned out to be renal cell carcinoma. Listen to patients, as they are sometimes on the right track.”
Other contributors comment that a psychiatric consult may be useful to rule out suicidal ideation or major depression that might require treatment before the patient undergoes elective surgery. An anesthesiologist suggests that hypnosis, as part of the psychiatric consult, could be useful for defusing the patient’s premonition of death. “Placebo response implies a subconscious control over the power to heal or the power to drive disease. A self-fulfilling prophecy leading to death may have the same quality. The placebo effect is accessible using hypnosis, and it may emerge that hypnosis can provide a tool that permits a patient to understand the prophesy’s purpose, and provide understanding and fulfillment of the purpose without danger to the person as a whole.”
In the end, a patient has the right to refuse surgery, but some MPC contributors argue that cancelling surgery may not be the best practice. “I do not think that a patient’s apprehension should drive our decision-making process,” says a surgeon. “I do not see evidence-based medicine in such a situation.”
Evidence of the relationship between psychological factors and surgical outcomes, although not conclusive, has been assessed in patients undergoing cardiac procedures. A review of the literature found that depression and, to a lesser degree, anxiety are associated with worse outcomes after coronary surgery. One small study evaluated state anxiety (short-term anxiety, which might arise in response to a threatening situation) and trait anxiety (long-term anxiety, such as neurosis) in 94 patients 24 to 48 hours before cardiac surgery. The authors found that acute preoperative anxiety was significantly associated with adverse outcomes, acting as an independent risk factor for postoperative morbidity and mortality. Whether state anxiety and premonition of death are linked is unclear.
“People die simply because they are convinced that they will, or want to!” says an anesthesiologist. “What’s the mind-body connection up to here?!” A surgeon replies, “The longer I am in this field and the more life experience I acquire, the more I realize the mind functions in ways we do not fully understand.”
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