Growing scrutiny of a quality standard that may influence end-of-life decisions for heart surgery patients ​

In early 2021, a physician confided in Tener that Dr. Giovanni Ciuffo was keeping patients with little or no chance of recovery alive “via mechanical means such as ventilators, heart pumps, and feeding tubes,” all in an effort to avoid being blamed for their deaths, according to her lawsuit against MercyOne Siouxland Medical Center. For heart surgeons, 30 days after the operation is a milestone: If the patient dies within that time frame, the death is recorded as related to the surgery.

When the 30-day mark passed, Ciuffo had the life-sustaining measures withdrawn and the patient would die naturally, Tener asserted. Tener accused the hospital of firing her in retaliation after she aired these and other concerns to administrators. Ciuffo strenuously denied her allegation.

The Iowa case is among a number of similar claims across the country that cardiac surgeons, in at least isolated cases, may try to lower their surgical death rate by using artificial supports to keep patients without real hope alive, a practice which can have a deep impact on families facing end-of-life decisions for their loved ones.

Nurses and palliative care doctors said this has created a perverse incentive for cardiac surgeons to push for heroic measures that give families false hope and will not ultimately save the patient. The emotional toll for families, who are often at the bedside as machines whir and the patient’s body deteriorates, can be immense, nurses said.

Some surgeons are believed to “game the system to improve their statistical outcomes,” said Dr. Mary Braun, who has worked as a palliative care doctor in New Hampshire. In these cases, “suffering is typically tremendous for frail, near-death patients being subjected to these extreme measures to keep them alive.”

This issue emerged in a recent two-part Boston Globe Spotlight Team investigation of Catholic Medical Center in Manchester, N.H., where a once-celebrated cardiothoracic surgeon, Dr. Yvon Baribeau, amassed a record 21 malpractice settlements. Colleagues also accused Baribeau of pushing to keep patients alive for 30 days on life-support, including one man who was unconscious and whose chest tissue had allegedly begun to blacken and die due to lack of blood flow.

Clinicians there suspected Baribeau encouraged this course to protect his and the cardiac surgery program’s mortality metrics — allegations that both CMC and Baribeau have repeatedly denied. Baribeau’s supporters said the surgeon may have used life-support measures longer because he didn’t like to give up on patients.

But these accusations are not isolated to this surgeon, or this New Hampshire hospital.

The Globe has learned that similar allegations surfaced against heart doctors at a Missouri teaching hospital around 2018, when nurses contended that the physicians maintained near-death patients on life-support machines so they would not die within 30 days of surgery, according to a former union representative who received the complaints.

In San Francisco, Dr. Alex Smith, a palliative care researcher, said he regularly hears from fellow clinicians across the country that the 30-day performance measure often delays the introduction of hospice and other end-of-life comfort measures that families and their loved-ones often need most when death is near.

“It’s a thorny issue,” Smith said. “Patients should be aware that this metric is out there.”

Researchers say it is difficult to determine how often this performance standard — which is publicly reported most widely for cardiac surgery — influences decisions to prolong the lives of critically ill patients. Surgeons often want to hold on to the possibility of saving a life, even when the chances of recovery are slim.

In the Iowa case, Tener’s attorney, Jessica Källström-Schreckengost, declined to elaborate on their allegations of manipulated survival metrics, but said in a statement, “We look forward to telling Ms. Tener’s story in court.” The physician, Ciuffo, through his attorney, William Hale, called these allegations “outrageous and completely false.”

In an e-mail to the Globe, Hale said that the nurse misunderstood the way these surgical metrics work, and that “the falsity of those allegations will be brought to light through the legal process.”

Michaela Feldmann, a MercyOne spokeswoman, said the hospital stands by the quality of its heart program, but cannot comment further while the legal case is pending. She said Ciuffo no longer works at MercyOne.

But this much is clear: Heart surgeons and hospitals have powerful reputational and financial incentives for keeping patients alive for at least 30 days after surgery. Several organizations that track quality of care publicly post these mortality rates for cardiac surgery at individual hospitals, including those in Boston, creating what amounts to an advertisement to attract new patients.

Some clinicians stress that patients undergoing heart surgery, as well as their families, should know all possible factors that may drive a surgeon’s decision-making, just as they would want to know if doctors have a financial interest in a new medical device they are recommending.

Deciding when to take an extremely sick patient off of life-support is complicated, and surgeons consider many factors, including the likelihood that treatment will succeed and the patient’s personal preferences about how much intervention they want. Families depend on surgeons for advice in these situations, but it’s impossible to know all the conscious, or unconscious, factors that may be weighed inside a surgeon’s mind.

Patricia Arthur said a doctor at Catholic Medical Center, whose name she can’t recall, told her that caregivers were not permitted to disconnect her husband, Richard Arthur, from the ventilator that was helping him breathe until 30 days after his valve replacement surgery in 2017, even though his family believed he had little chance of recovery.

She did not know if the performance metric played a role. “I wouldn’t know that was the case would I?,” she said. They said “that was the rule. That was how it was done.”

Jeff Trudel, Richard Arthur’s stepson, said the surgeon who performed the operation, Dr. David Caparrelli, told him that Arthur could gasp for breath for days if caregivers disconnected the ventilator. He said a nurse standing behind the surgeon vigorously shook her head. “She was saying ‘no, that would not happen,’” Trudel said.

The family said they insisted that doctors discontinue life support, saying Arthur, 70, a retired auto mechanic, would not want to live that way. They did so 28 days after his operation, and he died quietly within minutes, his wife said.

CMC executives and Caparrelli would not discuss specific cases because of patient confidentiality rules. But Lauren Collins-Cline, a CMC spokeswoman, reiterated that cardiac surgeons did not manipulate the 30-day metric. “Patient care at CMC was, and always is, determined by the needs of each individual patient and had nothing to do with rules about reporting case information,” she wrote in an e-mail.

During a Globe interview with CMC executives and cardiac surgeons in May, when the 30-day issue was raised involving Baribeau’s cases, Caparrelli said surgeons do not like to give up if they think a patient has a chance. When he talks to patients before surgery, he tells them “you have to commit to this, because … if you’ve had surgery, and two days later, you are struggling, you’re not off the ventilator yet, that’s not the time to pull the plug.”

The question of whether the 30-day metric influences end-of-life decisions has generated a limited number of research studies, but they have reached different conclusions. A national study published in 2014 found an abrupt spike in inpatient deaths 30 days after cardiac surgery, suggesting the mortality metric may have played a role, but other studies have shown little difference.

Dr. May Hua, an anesthesiologist at Columbia University Irving Medical Center, was lead author on a 2017 study that found no uptick in deaths 30 days after cardiac bypass surgery in New York and Massachusetts, including Boston, indicating that delays in withdrawing life-support were not routine.

While she says those results would suggest the practice is not widespread, “I don’t want to say it’s never happening.”

The 30-day statistic began as an effort to identify heart surgeons who routinely had poor outcomes, and many top surgeons say it is a critical way to assess performance and safety. Organizations that track surgical mortality, however, do so slightly differently.

The federal Medicare program counts a patient who dies within 30 days of their heart operation as a surgical death, no matter where they die. The Society of Thoracic Surgeons has a similar system, however if the patient dies after 30 days but was never discharged and died within the same initial hospitalization, it is still counted as a surgical death.

The 30-day standard looms in the minds of many who work in cardiac care. Nurses at SSM Health Saint Louis University Hospital in Missouri said a nurse supervisor there told cardiac ICU nurses not to discuss end of life care with families, even when patients had symptoms of “brain death” and had no hope of recovery but were still on ventilators.

“Patients’ families were told that the patient was going to be fine. Then patients’ families were talking to nursing staff because it was evident they would not be fine,” said Marti Rodolfo, a critical care nurse and a former union representative who helped bring these complaints to the administration. The nurses were “threatened with discipline if they had these conversations,” she said. “Nurses quickly figured out [doctors] were waiting until the 31st day and then disconnecting them.”

Patrick Kampert, an SSM Health spokesman, said due to federal privacy laws, he cannot discuss details of patients’ care, but that the health system’s “top priority is to always provide safe, high-quality care,” including “conducting a thorough investigation and taking appropriate action” with any complaints about patient care.

Dr. Zara Cooper, a trauma surgeon and palliative care doctor at Brigham and Women’s Hospital in Boston, said that broader cultural issues make it hard to tease out the impact of the 30-day metric. When a patient meets with a surgeon before the operation, optimism often runs high and the patient looks relatively healthy.

“The rest of us meet the patient in the ICU when they are on a vent, on coma-inducing meds, on dialysis. It’s a lot easier for me to look at this person and say they are not going to do well,” she said. “The nurses are seeing the suffering.”

Cooper said she does not have any clear-cut evidence of surgeons extending life to safeguard their mortality scores. “What I saw more often ... was surgeons doggedly being optimistic even when the writing was clearly on the wall,” she said.

Still, broader concerns remain about the appropriateness of the 30-day measure, which has “a dark side,” said Dr. Andrew Esch, a palliative care physician in Florida. “Clearly there is a temptation to manipulate those figures.”

One woman wonders if this happened to her New Hampshire family.

When Priscilla Loiselle suffered life-threatening organ failure soon after her heart operation at Catholic Medical Center in 2016, her family endured a weeks-long battle that included connecting the 79-year-old homemaker to breathing and dialysis machines, implanting a heart pump, and threading a feeding tube through her stomach wall.

“The doctor was telling us there’s hope she will recover and go into rehab and everything will be OK,” recalled Loiselle’s daughter, Diane Loiselle.

Then on Day 30, Loiselle was discharged to hospice care, and she died soon afterward. “I hate to think that 30-day mark was the finish line. It’s nauseating to think that it was purposeful,” said Loiselle. “I hope not. And also, did she suffer needlessly?”

Liz Kowalczyk can be reached at lizbeth.kowalczyk@globe.com. Rebecca Ostriker can be reached at rebecca.ostriker@globe.com. Follow her on Twitter @GlobeOstriker. Deirdre Fernandes can be reached at deirdre.fernandes@globe.com. Follow her on Twitter @fernandesglobe.