H E C FORUM o 1992 KluwerAcademic Publishers. 1992; 4(1):37-39. Printed in the Netherlands.

E T H I C A L C O N S I D E R A T I O N S IN A S U R G I C A L R E S I D E N C Y

H. D A V I D CROMBIE, M.D.

In recent years the dramatic advancement of medical technology to save and prolong life has at times created a "can do--will do" attitude among physicians, particularly in the hospital setting. By the early 1980s considerable national sentiment appeared in the public arena criticizing the automatic utilization of high-tech life-preserving measures in the absence of ethical considerations. As is so often true in medicine, patients and their families questioned, both during and after these interventions, whether they indeed had true merit. Hospital ethics committees began appearing in major hospitals throughout the country, and Hartford Hospital established its multi-disciplinary Hospital Ethics Committee in 1983. Simultaneously, medical schools were adding to their curriculum courses, lectures and discussions for students of medicine on matters of bioethics.

Much of this activity appeared strange to practicing physicians who received their training prior to the advent of massive technological interventions in medicine. Many felt that ethical considerations were an individual matter, that they had always been a major consideration for practicing physicians, and these individuals were perplexed at what they perceived to be a consultative service within a hospital that made decisions and policy about ethical care, particularly regarding the critically ill patient. While this concern has not entirely been eliminated, the frequent articles in the literature have called to the attention of practitioners such issues as autonomy in the competent and incompetent critically ill patient. While this has been slow to gain the universal acceptance of the medical staff at Hartford Hospital, it is definitely undergoing a favorable evolution as reflected in the use of "do not resuscitate" orders, the willingness of members of the medical staff to engage in discussions regarding withholding and withdrawal of life-support measures, and other bioethics issues.

While medical school attention to the teaching of ethics focused on the medical student, and the education of attending practitioners was receiving attention by hospital ethics committees, the opportunities for

37

38 H.D. Crombie

housestaff physicians to discuss and become informed on matters of bioethics seemed to be largely omitted from the post-graduate training curriculum. It was decided that a forum for the discussion of ethical issues, particularly as they impact upon the surgical house officer, should be added to the general surgery curriculum at Hartford Hospital. Drawing upon experience elsewhere, it was clear that a lecture format was not the ideal setting. Ethical principles and value systems could be examined best in group discussion, blunting, as much as possible teacher-student, senior- junior distinctions. The Department of Surgery therefore established, in July 1989, a monthly session called "Ethics Round Table" -- meeting at 4:30 p.m. on Thursday afternoon. The sessions avoid didactic presentation and favor interactive discussion among medical students, junior and senior house staff, and one or more faculty surgeons. At the outset a case- oriented format was selected, allowing clinical cases to serve as the springboard for discussions of end-of-life decisions, intubation, tracheostomy, gastrostomy feedings, ventilator support, etc.

The subject of "do no resuscitate" orders (DNR) received one full hour with questions such as: Why should they be written? How should the chart reflect the order? When, in the illness of the patient, should they be written?, By whom? What does a DNR order mean in addition to withholding cardiac resuscitation, and what does it clearly not mean in terms of withholding supportive care? A member of the chaplaincy staff brought in a well-known video illustrating the conflicts between the traditional paternalism of the physician and the more current ethic honoring patient autonomy. In this discussion, the patient's wish to die was explored as was the conduct of the physicians in reacting to that wish.

A session was devoted to the persistent vegetative state and the decision to withdraw or withhold life support using contemporaneous articles from JAMA and The New England Journal of Medicine. A session was devoted to "AIDS and the Surgeon" with particular emphasis on the protection of patient confidentiality and the obligation to treat. A session was devoted to elderly "abuse." The use of restraints and isolation, the risks of neglect, role of medication, honoring the values of patients and families, as well as physicians, in the care of the elderly were explored.

In July, 1990, as the U.S. Supreme Court handed down its decision in Cruzan v. Director, the round table explored advance directives, the role of surrogate decisionmakers for incompetent patients, the importance of dialogue within families as well as the importance of discussions of life and death matters in every family when all members are healthy. A session was devoted to confusional states in the elderly and the value systems which residents and attending staff bring to the bedside of such elderly patients. This discussion was facilitated by the presence of Dr. Robert

Ethical Considerations in A Surgical Residency 39

Dicks, newly arrived gerontologist. A session was devoted to the subject of the patient with

intravenous drug abuse, and a positive HIV assay, who develops bacterial endocarditis and requires a heart valve replacement. True tests of the ethical positions of various participants appeared when, after a long abstinence from drugs, the patient returned to drug habituation and developed recurrent endocarditis, and was now a proposed candidate for a second heart valve replacement. One session was devoted to nutrition and the exploration of the differences between ordinary nutrition, eating and drinking, as contrasted with various levels of extraordinary nutrition, nasogastric tube feedings, surgically-placed gastrostomy and jejunostomy tube feedings and life-long intravenous hyperalimentation. Again case- oriented format utilizing patients under the care of the surgical residents served to highlight these issues. Early in 1991 a session was devoted to the landmark opinions on patient autonomy and surrogate decisions dating back to In re Quinlan in 1976 through the most recent Missouri Court decision in Cruzan v. Director, 1990. A glossary of terminology relating to medical bioethics was also distributed and discussed to provide some meaningful didactic information for residents engaged in these ethical dilemmas on a daily basis. A recent discussion focused on the Sounding Board article in the New England Journal of Medicine on March 7, 1991, regarding physician-assisted suicide. The article, as well as a New York Times editorial response to it, were distributed in advance, and a lively interaction was held testing the values of students, residents and attendings.

Overall, the addition of this session to the curriculum in surgical residency training at Hartford Hospital has been well regarded, well attended by students, residents, some attending faculty and guest faculty from outside the department, and from the Chaplaincy. This activity has also highlighted the need for discussion to extend beyond the conference room, to include families, nurses, pharmacists and pain-control services, attending physicians in all disciplines, and of course patients themselves. The Department of Surgery plans to continue this effort to convey the role of ethical matters in the education of surgeons with the expectation that better patient care and a more human and compassionate interaction between patients and their surgeons will result in the future.