Decision‐Making in Surgical Patients: Discarding “Heroic Measures” in Favor of Goal‐Oriented Care at the End of Life

The challenge of delivering clear and compassionate recommendations at the end of life poses difficulty for even the most experienced surgeons. In these complex settings, the phrase “heroic measures” may mislead patients and families when making crucial surgical decisions. Surgeons describe a “heroic measure” as a treatment unlikely to result in a success outcome; in contrast, patients anticipate success. The discrepancy in communication with the term “heroic measures” should discourage its use. When considering the archetype of a hero, traditional references point to prominent figures of history that serve as inspiring role models, characters of legend or tale, or perhaps popular comic book protagonists. Surgeons have also been called “heroes” for performing seemingly miraculous operations (or standard operations with miraculous outcomes), colloquially termed “heroic measures,” that save patients from otherwise certain death or morbidity. This manuscript discusses heroism in the context of societal norms and the realm of medicine, and how its usage in surgical discussions may hinder accurate communication. Our conclusion provides an appropriate alternative to “heroic measures” that more precisely conveys the intended meaning. The societal perception of a hero must be carefully examined to appropriately facilitate discourse about heroism and its place in surgery. Numerous characteristics delineate a hero but the unifying feature is a fundamental willingness to self-sacrifice, often in an extreme manner, toward a noble cause or goal. An analysis of the critical behaviors of Medal of Honor recipients from 1863 to 1979 determined that the most prominent dimensions of military heroism were devotion to duty, setting an example of behavior for others, and persisting despite personal risk of danger to self [1]. In another study on the concrete actions that define heroism, a list of acts deemed heroic included entering a burning building to rescue others, jumping on a grenade to save fellow soldiers, or retrieving someone from a flood [2]. In contrast, non-heroic gestures included actions with far less personal risk such as donating blood to charity or volunteering at a soup kitchen. Thus, the societal definition of heroism is the performance of rare and impressive feats despite personal peril. The archetypal hero endeavors to help without bias, typically succeeds in the quest, and works to benefit society with their gifts and actions [3]. No matter how arduous the challenge, it is assumed that the hero will prevail. The term heroism has reached near-ubiquity in contemporary medicine, as modern-day healthcare workers are often called “heroes” for treating and saving patients' lives. The term was first observed in medical literature in 1915 in a journal titled “The Hospital,” discussing medical heroism during epidemics. This article advocated for the same honors given during war to be given for medical heroism due to the personal risk involved during unpredictable times [4]. Other historic publications document heroism in medical journals as rare acts of valor despite monumental personal risks, like saving a man from a flood during a house call or undergoing a treacherous route to treat a patient [5, 6]. The risks were not necessarily inherent to clinical duties but rather in the extra measures taken to ensure the safety of others at the potential cost of their own well-being. The definitions of “hero” and “heroic measures” differ between the perspectives of surgeons and the public. Surgeons describe “heroic measures” as surgical attempts requiring significant skill and effort that are unlikely to benefit a patient on the brink of death. In contrast, the public understands a “heroic measure” as one in which the surgeon performs a near impossible feat that few could complete but will likely be successful—like the heroes of the aforementioned literature. The discrepancy between these two definitions highlights the differences in expectations of an attempted “heroic measure,” in which patients and families anticipate success from these procedures while surgeons perceive it as unlikely. Furthermore, the consequences of these surgical interventions ultimately lie with the patient and not the surgeon, fundamentally deviating from the societal idea of a “heroic measure” where the risk lies upon the hero. This fundamental misunderstanding in the definition of “heroic measures” allows for a failure in communication and understanding of the risks, benefits, and likelihood of success of proposed interventions. There is no risk to the physician; there is little to be said of the technical feat or the effort. Rather, the term is intended to imply a low likelihood of success. It is of paramount importance that there is a unified understanding about the probable result of “heroic measures” when speaking with a family and offering such a procedure. “Heroic measures” is not an appropriate term for surgical care at the end of life. The surgeon may require courage and skill, but the true risk lies with the patient. Precise language must be used to promote surgical decisions that accurately capture patients' unique preferences. We propose an algorithm to describe different types of care and the respective appropriate terminologies (Figure 1). Though this algorithm appears clear-cut, it represents transition points along a spectrum with fluidity from one category to another. Surgical interventions may be delineated based on indication, risk, and likelihood of success. For example, cardiopulmonary resuscitation in a 90-year-old patient with progressive metastatic pancreatic cancer would be a nontherapeutic treatment that is not clinically supported. By similar logic, just because a surgery can technically be performed, does not mean that it ought to be performed. Offered treatments are separated into those of appropriate risk and reasonable success, termed recommended treatments, versus treatments with high risk and low success, termed longshots. It is imperative to describe to the patient the precise reason a long-shot therapy is considered, explaining the low likelihood of success measured against the high risk. The term “heroic” is avoided to maintain the clear message of low success and high risk to the patient. The term longshot and its subsequent explanation allow appropriate discussion between surgeons and patients (or surrogates) to accurately note the risks and benefits of proposed interventions. Labeling procedures as a “longshot,” instead of “heroic measures,” allows the intervention to be perceived by patients and surrogates in the appropriate context. Surgeons possess the opportunity for clear communication, highlighting the complexity of an intervention by communicating the possible pitfalls that may ensue, in addition to the low likelihood of a successful outcome. Stating that an intervention is a longshot underscores to the patient and/or surrogate that the intended treatment is at the limit of medical care. Though the treatment is reasonable to consider, it is extreme. Although popular throughout the history of medicine and other fields, the term “heroic treatment” has no role in modern medicine. The term “heroic” may inadvertently shift away from accurate understanding of the risks, benefits, and alternatives of a specific intervention and the risk to the patient. Instead, we suggest the use of the term “longshot” for therapies that come with great risk and little likelihood of successful patient outcome. Utilization of proper terminology in counseling patients, especially for high-risk surgeries at the end of life, can help to maximize informed consent and autonomy in the practice of surgery. The authors have nothing to report. The authors declare no conflicts of interest. The authors have nothing to report.