Měli by být pacienti informováni o lepší alternativě jinde?
Článek s tímto názvem se minulý týden objevil v International Herald Tribune. Autor zde popisuje příběh své příbuzné, která před čtyřmi lety onemocněla rakovinou konečníku. Chirurg v místní nemocnici s ní probral zákrok, který měla podstoupit, aby se podařilo nádor odstranit. Informoval ji, že s největší pravděpodobností nebude vzhledem k velikosti nádoru možné zachránit svaly svěrače a bude tedy nutné zavést chirurgické vyústění tlustého střeva. To pro pacienta znamená, že po zbytek života musí nosit pytlík, přes který se vylučuje stolice.
Žena se nakonec raději rozhodla nedůvěřovat pouze tomuto chirurgovi z okresní nemocnice a podnikla dvouhodinovou cestu do centra specializujícího se na léčbu rakoviny. Našla zde chirurga se specializací na rakovinu konečníku a po úspěšném zákroku jsou svaly svěrače neporušeny. Třeba by se stejně úspěšný zákrok podařil také v okresní nemocnici, ale co když ne?
Výsledek operace často závisí na tom, kde je provedena
Doktor Leonidas Koniaris z Millerovy lékařské fakulty na University of Miami se v textu publikovaném v říjnu minulého roku v časopise PLoS Medicine zabývá otázkou, zda lékaři nemají povinnost v rámci informovaného souhlasu pacienta poučit o tom, že v jiné nemocnici mohou stejnou léčbu realizovat úspěšněji než v jejich zařízení. Podle doktora Koniarise se je lékařská věda už minimálně třicet let vědoma skutečnosti, že výsledek operace velmi často závisí na tom, kde je zákrok proveden. Obvykle platí, že zdravotnická zařízení, která danou operaci provádějí často, v ní mají také nejlepší výsledky.
Podle některých zdravotnických odborníků by komplikované operace týkající se rakoviny nebo srdečních problémů měly být prováděny pouze regionálně ve specializovaných centrech. Doktor Koniaris namítá, že volba by měla být na pacientovi. Určitá část lidí preferuje to, aby byl zákrok proveden v blízkosti jejich bydliště, přestože riziko může být vyšší.
Jde o právní povinnost?
Měli by tedy lékaři mít povinnost informovat pacienta o možnosti úspěšnějšího zákroku v jiném zařízení? Podle doktora Koniarise je taková povinnost spíše etická. Obecně není jako právní povinnost přijímána a další odborníci, kteří v časopise PLoS Medicíně s doktorem Koliniarisem diskutují, poukazují na některé slabiny takového přístupu. Na druhou stranu je pravda, že i v České republice má zdravotník povinnost pacienta před zákrokem informovat o jeho rizicích a alternativách k němu. Zároveň je dost dobře možné si představit situaci, že pokud by pacient měl k dispozici informaci o tom, že operaci je jinde možné provést s nižším rizikem či méně závažnými důsledky, tak by se rozhodl zákrok podstoupit jinde.
Určitou obdobu lze hledat v kauzách, kde soudy dospěly k závěru, že pacient měl být předtím, než dal se zákrok souhlas, poučen o kvalifikaci daného lékaře. Např. ve věci Johnson v. Kokemoor, kterou řešil nejvyšší soud státu Wisconsin, soud dospěl k závěru, že v daném případě žalovaný lékař pochybil, když 1) pacientovi neprozradil rozsah svých zkušeností s daným typem operace, 2) nepodal informace o srovnání úmrtnosti velmi zkušených operatérů a méně zkušených lékařů, jako byl on sám, a 3) neupozornil pacienta na možnost obrátit se na specializované centrum, kde by byl k dispozici daleko zkušenější operatér, než byl žalovaný lékař.
K podobným závěrům dospěl australský vrchní soud v případu Chappel v. Hart. Spory tohoto typu jsou již vedeny i v České republice, není mi však známo žádné české rozhodnutí v obdobné věci. Striktně aplikovaná povinnost lékaře informovat o možnostech provést zákrok s nižšími riziky jinde by s sebou samozřejmě přinesla řadu problémů (např. je-li nutno informovat o zařízeních v celé zemi, příp. i v zahraničí; jak vůbec zjistit, které zařízení má nejlepší výsledky apod.), přesto by neměli zdravotníci ani obdobné informace zanedbávat, neboť pro pacienta mohou být relevantní.
Více informací pro všechny
Pacienti i v České republice stále volají po tom, aby bylo veřejně k dispozici více informací, které by jim umožnily si mezi nemocnicemi vybírat již dopředu (ve prospěch existence žebříčku nemocnic se v anketě na stránkách Férové nemocnice vyjádřilo přes 95 % z více než sto dvaceti hlasujících). Určité srovnávací informace o oblasti porodnictví a náhrad kolenního a kyčelního kloubu již obsahují stránky Národního referenčního centra. Doufejme, že další data budou brzy následovat.
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