Laying Crepe

by James D. Hundley, MD

In days of yore, undertaker assistants were tasked with hanging crepe (black cloth) over the windows of homes of the deceased and were called “crepe hangers”.  Similarly, they laid crepe over the casket of the deceased.  “Hanging crepe” and “laying crepe” have become euphemistic terms for extreme pessimism.

Surgeons are castigated for “laying crepe” with patients and their families before surgery when the formal operative consent is obtained.  Critics claim this creates unnecessary fear in patients so that when the operation is successful the surgeon appears a hero or without fault if it’s not.

I disagree.  It’s neither about heroes nor about lawsuits.  It’s about “informed consent”.  Patients deserve to know the bad as well as the good before they have an operation.  Otherwise, how can they make informed decisions?

A good friend of mine was recently discussing upcoming surgery on his infant grandson.  The child has a congenital heart condition and has already undergone an open-heart operation.  The heart surgeon has apparently told the family that the second procedure is serious and will be more difficult than the first.  I told my friend, ”The surgeon was ‘laying crepe’.”

The surgeon is an esteemed, pediatric, cardiac surgeon.  He knows what he is doing in the operating room, and he knows that the family has a right and a need to be fully informed before consenting for their son to have surgery.  This is a serious situation and they deserve to know the good, the limits of good, and the bad.  They also need to know if additional surgery will be required in the near or distant future.  Thanks to a thoughtful surgeon, they are informed.

Taking this a step further, I’ve sometimes had patients tell me after the informed consent discussion, “Go ahead and do it, Doc.  It can’t be worse than it is now.”  My consistent response to that was, “Yes, it can always be worse.  I’m not sure you were listening.”

Finally, there is no way anyone can be fully informed.  Complications can occur that have never been reported or happen so infrequently that the surgeon feels these unnecessary to discuss for fear of losing the patient’s attention with such a long litany of potential problems that even careful listeners become overwhelmed and stop listening.

Perhaps the most important part of this discussion is what the surgeon may have left unspoken.  No ethical surgeon, except in dire, emergency circumstances when there is no other way to save life or limb, will perform a procedure that he is not confident can be successful.  He cannot promise a good outcome or that unexpected complications may not occur.  He can only promise that he is confident that he can perform the procedure properly and that he will do his best.

So, when your surgeon “lays crepe”, I think you should consider these things:

  1. Your surgeon would not be performing the procedure if he did not expect a successful outcome.
  2. The fact that he is telling you about potential complications tells you that he knows these things, will take measures to avoid them, and wants you to be as informed as possible before the surgery.
  3. By telling you what a good outcome will likely be, he is helping you set rational expectations.
  4. By telling you if additional surgery will be required, he is doing his best to avoid unpleasant future surprises.

What else does it tell you?  It says that he is not trying to “sell” (or talk you into having) the surgery by downplaying potential complications.  He sincerely wants you to be as informed as possible before making your decision.  You always have the right to say, “No.”, even as they are wheeling you into the operating room.

Dr. Hundley is a retired orthopaedic surgeon and the founder and president of OrthopaedicLIST.com.

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