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Comment by bradleyjg | Hacker News Reader

If someone has terminal cancer, gets palliative surgery, the surgeon makes a medical error, and the patient dies on the table has he died of medical error or cancer?

For this reason deaths caused isn't the best metric. It would be better to use QALY (quality of life adjusted years).

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the surgeon makes a medical error, and the patient dies on the table has he died of medical error or cancer?

Medical error. Just because the patient was going to die sooner than later, does not erase the fact that a medical error was committed.

Quality of life is a completely different topic, in my opinion, and I am sure we would find more common ground in that discussion.

> Quality of life is a completely different topic, in my opinion, and I am sure we would find more common ground in that discussion.

You don't understand why bradleyjg brought up QALYs.

If you can spare the time, it would be a mitzvah to give us a thumbnail sketch.

The point wasn't to highlight the distinction between low-quality life and high-quality life per se. (That's a separate issue, as epoxyhockey said.) The point was only that the badness of an accidental death, and the cost we might be willing to imposed to reduce them, should probably reflect that counterfactual where no mistake occurs. QALYs lost are one way to measure the badness of a death, but he could have also just said "expected days of life lost".

Of course, epoxyhockey's would likely still disagree.

On the one hand, I could see arguing that a surgeon's error is independent of the patient. To the extend that's true, it would be important to count errors whether or not the patient is close to death.

But on the other hand, maybe the surgeon is performing a risky, error-prone procedure precisely because the patient is close to death. To the extent that's true, it might be misleading to compare this surgeon's record with someone else's.

I wonder if some of the resistance we hear from doctors about measuring/enforcing these things, is because of difficulties like this that are obvious to them and really screw them over?

When my father was dying (liver cancer, he was goner, no surprises) a senior doctor in the hospital made one of the intern's life hell about not weighting the excreted urine when changing the bags.

The intern (and me) pointed out that it was pointless - his answer - "He is in our care, and if we do something, we do it right" - that is the attitude that saves lives.

A mistake is a mistake. It may even lose someone 15 minutes - doesn't matter - it was literally everything left that the patient had in the world. We are not talking about shit happens situations - there will always be risks when doing interventions.

Suppose you are in charge of approving grants for a particular program. Presented to you are two applications:

One attacks medical errors. The grant application claims that it will prevent 10,000 deaths caused by medical error and the loss of 100,000 quality adjusted years of life.

The other attacks diabetes treatment non-compliance and the grant claims it will prevent 5,000 deaths caused by diabetes and the loss of 200,000 quality adjusted years of life.

All other things being equal, which one do you fund?

What is treatment non compliance?

Generally in this context, not taking insulin correctly for whatever reason.

The first one. No question in my mind.

You made it easy by having the larger number of lives saved together with the one where people are dying due to no fault of their own.

(Also, I don't totally fault people for non-compliance - it's really hard to be perfectly compliant in any recommended thing. But I still prioritize it lower.)

An error is an error.

It would be different if the procedure was executed properly but the patient died anyway, but if the death is a result of an actual mistake by the doctor that could have been prevented, then it seems pretty straight forward.

Edit: I should add that the tricky part is deciding if the mistake could have been prevented, and if so, the level of negligence in play. Doctor was drunk during surgery? Easy. Doctor had a spasm during surgery? Harder to decide.

People aren't perfect, so I could see this causing many doctors to just avoid risky situations all together in fear of making a tiny mistake.

It's not always clear-cut -- if the surgeon nicked an artery during surgery (and immediately repaired it) but the patient died during surgery, did he die due to medical mistake? The surgeon clearly made a mistake, but did it contribute to the death?

If the error is a 'but-for' cause of death, then I think it ought to be counted. All treatments are aimed at addressing an underlying problem. Just because that problem is terminal doesn't change the fact that a mistake killed the patient. As someone who just watched up close a loved one die from cancer over a seven-year period, you really come to appreciate every minute that they're still breathing (with some allowance for the final, vegetative stages).

It still matters if the error occurred when the life expectancy was 7 years or 7 months, so ideally you'd want to count that.

It doesn't matter as far as errors go though.

There should not be any errors, period.

Yes, you can find mitigating factors, whatever. But that the end of the day we want to reduce all errors.

Any process with people is going to have mistakes.

At the end of the day we have to accept that the errors will be there, no matter what you or doctors do, period.

And as in all other industries where errors have a high impact, you have to design your process / systems / procedures so that you get an acceptable result even if people make mistakes, and it takes a combination of multiple errors (or an error combined also with negligence) to kill someone.

The argument against counting it is that extremely risky surgeries are generally only performed when the patient is going to die otherwise. Those risky surgeries have a much higher rate of mistakes, but that's generally deemed acceptable, as long as that risk is properly communicated to the patient's family.

The doctors most commonly sued for malpractice are those doctors with poor communication skills rather than the doctors who make the most mistakes.

I am not sure if you make distinction between failure and mistake. You don't have to do anything wrong to lose a critical patient.

If what you said is logical then is it not also logical that you should get a shorter sentence if you murder an older person, or the the victim was a smoker as opposed to not?

If the motivation is to punish and stop bad doctors, then the QALY doesn't matter.

But, if measuring QALY, then, riskier procedures with great reward, can be promoted; which maybe they get better?

Its a really hard choice as on the individual level as there is a lot of uncertainty as to which treatment will work, on the other hand the holistic statistics often lead to strange conclusions such as with the PSA test. Maximizing QALY is non-trivial.

On the other hand punishing a doctor who dropped a salad fork in your stomach is easy. These laws are designed to remove bad actors.

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