The Death of Joan Rivers: Endoscopy and Anesthesia Risks

The press release said Joan Rivers died at Mount Sinai Hospital on September 4th, 2014, but in reality she died when she stopped breathing and her heart stopped beating when she underwent anesthesia for a "minor" office procedure the week before. The details are vague, but during or shortly after Ms. Rivers was administered anesthetic for endoscopy in an outpatient office setting, she went into cardiac arrest. Cardiopulmonary resuscitation (CPR) was performed and her heart was restarted, but Ms. Rivers never reawakened.

There are always risks when a person undergoes an anesthetic (anesthesia). Just as surgeons do their best to choose the correct operation to maximize benefits and minimize complication risks for the patient, the person responsible for the anesthetic needs to do the same thing.

There is not a one-size-fits-all approach to anesthesia. Patients come in all sizes and shapes, not all are young and healthy, and there are different options in using anesthesia. In a medical emergency, increased anesthetic risk is allowed because of the potentially life-threatening condition of the patient. But when the procedure is elective, there is time to decide how best to proceed in making the patient comfortable.

Outpatient office surgery/procedures are now commonplace, yet patients and families are not always aware that a procedure requiring anesthesia occurs in tandem with the procedure or surgery.

There are a variety of uses for general and local or regional anesthesia. Examples include:

• Some dental procedures
• Some medical procedures
• Some screening procedures like colonoscopy and endoscopy
• Elective surgeries such as cosmetic surgery
• General surgery

There are risks associated with anesthesia, and preparations by the health-care team and patient are two ways to minimize the risks. However, even the best planning cannot reduce the risks of undergoing anesthesia to zero.

Standards are required for office-based anesthesia and these common practices and include:

• Evaluate the patient's status and know what reasonable anesthetic options should be considered.
• Explain to the patient the risks and benefits.
• Have appropriate personnel, monitors, equipment, and medications to care for the patient.
• "Continuous clinical observation and vigilance are the basis of safe anesthesia care."
• Make certain that the patient recovers in a safe environment after the procedure is done.
• Keep good records of the medical care provided.
• Have a plan when things go wrong: adequate equipment to resuscitate the patient and protocols to call paramedics and transfer the patient to a hospital if needed.
• "The patient has the right to dignity, respect and consideration of legitimate concerns in the office setting. Patients should be involved with all aspects of their care."

Patients and families spend significant amounts of time talking and planning with their doctor and surgeon about a potential medical procedure or surgery. The anesthetic is an afterthought and routinely, the patient meets the anesthesiologist or the nurse anesthetist on the day of the surgery. This is the person that will literally have your life in their hands as they put you to sleep, keep you sedated or paralyzed, and then wake you up when it's over. Yet, most people will only know the name of that person when they receive the bill.

In the office, there may not be another doctor involved in the anesthetic care and while it is accepted practice, it is often hard for the doctor who is concentrating on the procedure to also be equally concentrating on the sedation. The tragedy that befell Ms. Rivers might have been unavoidable, and the facts of the situation will eventually be released.

Meanwhile, the lesson to be learned is that there is no such thing as a "minor" procedure or surgery, especially if an anesthetic is planned. And that leads to the next lesson: There is always risk associated with any operation, even if it happens "routinely" in the office.

QUESTION

In the U.S., 1 in every 4 deaths is caused by heart disease. See Answer