Making Difficult Decisions & The Art of Medicine
By: Brian Hoeflinger, MD
March 2, 2025 | #36
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Disclaimer: Opinions are my own. Not medical advice.
Medical Trivia of the Week
Which vitamin is ascorbic acid? (the correct answer is at the end of this email)
- A) Vitamin A
- B) Vitamin E
- C) Vitamin C
- D) Vitamin D
The Art of Medicine
I have spent many sleepless nights wondering if my capabilities as a brain and spine surgeon outweigh a patient’s right to choose whether to live another day. In other words, is surgery always the right answer simply because I am capable of performing it? Let me illustrate my point with several true-to-life scenarios. I invite you, the reader, to put yourself in the surgeon’s position and consider what you would do.
Case 1: The Emergency Brain Bleed
A 65-year-old male is flown to our hospital by helicopter for a large brain bleed. Earlier that evening, he suddenly developed trouble speaking and lost movement on the right side of his body. He was sitting at the kitchen table eating dinner when it happened, without any warning signs or head trauma. Upon arrival, the man is in a coma, intubated, and unable to move his right side. A head CT reveals a very large blood clot deep in the left side of his brain, exerting dangerous pressure. He requires emergency surgery, or he will die.
Case 2: Severe Spinal Stenosis
A month later, in a busy office day with 38 patients scheduled, one case particularly stands out—a 91-year-old woman in a wheelchair who is now unable to walk. Just a year ago, she walked unassisted. She explains that the pain in her back and legs is so severe that she cannot stand or walk, and she would rather die than live in constant pain. Having exhausted every treatment option except surgery, an MRI confirms she suffers from severe spinal stenosis, a narrowing of the spinal canal. The dilemma is clear: should I offer surgery knowing that at her age it may not help and might even worsen her condition if complications arise? Desperate for relief, she insists on surgery. Before making a final decision, I order additional x-rays to check for any spinal instability.
Post-Operative Reflections
Before I can decide on the woman’s treatment, I visit my next patient. I open the exam room door to find a man slumped in his wheelchair, head bowed and drooling. It is the 65-year-old man from Case 1, returning from the rehab facility for his first post-op visit. He cannot speak due to expressive aphasia, even though he understands everything, he is unable to communicate verbally. In addition, he remains paralyzed on the right side. On examination, the scalp incision is healing well. Although the emergency surgery successfully removed the blood clot (as confirmed by a new CT scan), the damage from the clot, located deep in the left brain, the center for speech and control of the right side of the body, appears permanent.
I ask the office nurse if any family members are present, but there is none. I sit down with him and carefully explain what has happened, knowing he fully understands but cannot express his feelings. Frustration is evident in his eyes as he is unable to communicate his inner thoughts. I do my best to explain his condition and schedule a follow-up visit in two months.
By this time, the elderly woman with spinal stenosis has returned from her x-ray. With no instability detected, she is eager to discuss surgery. I explain in detail what the operation would entail, the potential risks and benefits, especially at age 91. I make it clear that the surgery may not work, and any complications could worsen her quality of life. Despite the risks, she remains adamant that she wants the surgery. Now, the final decision rests with me.
The Moral of the Matter
These two cases are typical of what I encounter as a neurosurgeon. Patients rely on us to make difficult decisions that often involve quality-of-life issues. In the case of the 65-year-old man, his family insisted on emergency surgery despite my frank discussion about his likely post-operative quality of life. Although they listened, they could not bear the thought of letting him go. I saw him many times afterward, and he never improved; he eventually moved to a nursing home, with his family absent from every follow-up visit. We can never truly know if he was satisfied with his quality of life, which is what should matter most in the end.
Returning to the 91-year-old patient, I have performed thousands of these relatively straightforward surgeries. I decide to proceed with her operation. During surgery, I encounter severe narrowing of the spinal canal but successfully decompress the nerves. The surgery goes smoothly, and she is admitted to the hospital floor. The following morning at 6 a.m., I find her room empty and my heart sinks with worry: Did she suffer a heart attack? Was she transferred to the ICU, or worse, did she pass away? Moments later, I find her walking upright in the hallway with her nurse. She smiles and thanks me, relieved that the excruciating pain in her back and legs is gone and that she can now walk. In that moment, I know I have made a difference.
These examples highlight the art of medicine from a neurosurgeon’s perspective. Patients entrust us with their lives, expecting us to make the best decisions for their care, a responsibility that must never be taken lightly. While I have occasionally disagreed with the decisions of patients and their families, my duty is to explain the situation as clearly as possible, drawing on my experience to guide them. I have learned that the “best” decision is not always the best treatment for the patient, and it is within this moral dilemma that the true art of medicine lies.
New Podcast Episode
Check out this week's new podcast episode - Dr. Z Neurosurgery: Becoming a Neurosurgeon
YouTube, Spotify, Apple Podcasts
Impactful Quote of the Week
"Medicine is a science of uncertainty and an art of probability.”
- William Osler
All my best,
Brian Hoeflinger
P.S. - if you enjoyed this newsletter, you may enjoy my book that details my life as neurosurgeon and the loss of my oldest son, Brian (see below a synopsis).
My Book
Life and Death . . . Two words with such opposite meaning and which inflict such contradictory emotions and yet are so closely intertwined in our lives. As parents, we bring meaning and life into this world through our children. Our lives become defined as a result. We learn the joy, hardship, and responsibility of shaping an innocent life. But a day will come when that life will be taken. For some, death will come too soon. This is the story of my son, Brian Nicholas Hoeflinger, who died unexpectedly at age 18.
https://doctorhoeflinger.com/products/the-night-he-died-the-harsh-reality-of-teenage-drinking
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Medical Trivia Answer:
The correct answer is C) Vitamin C
