4
Ethics Ethical Guidelines in Surgical Patient Care Peter Angelos, MD, PhD In a recent survey of ethics in surgery, emphasis was placed on the importance of the physician-patient relationship, as contrasted with the relation of phy- sicians to one another and to society. 1 In the manage- ment of certain difficult surgical problems, an under- standing of ethical guidelines can provide practical help with surgical decisions. This statement is exem- plified by review of a complex clinical case report. AS, a 65-year-old man was transferred to the vas- cular surgery service of a tertiary care hospital for treatment of extensive visceral arteriovenous malfor- mations. There was a long history of chronic gastro- intestinal bleeding; he was in congestive heart failure and in renal failure requiring dialysis. Daily transfu- sions for anemia had strained the blood bank’s re- sources, and many consultants had agreed that fur- ther treatment for his gastrointestinal bleeding was not indicated. Some physicians suggested withdrawal of all treatment, labeling further intervention “an ex- ercise in futility.” The patient had named his sister as a surrogate in a durable power of attorney document; a psychiatrist had judged him now incompetent to make decisions. Despite this, when roused from his somnolent state, he expressed a wish for treatment so he could go home. Three women were closely involved in his care: an adult daughter, his sister, and a live-in companion. The daughter favored cessation of treatment, the sis- ter was uncertain, and his female companion wanted everything possible done. The attending surgeon was unsure how to proceed. A number of ethical issues in treatment are raised by the account of this patient’s illness. A central fac- tor is the concept of “futility” and how it may be defined. The issues of autonomy, advance direc- tives, and the determination of incompetence are relevant. Use of scarce medical resources in pa- tients considered near the “end of life” is a prom- inent consideration. The issues just listed have generated extensive literature in books and journals of clinical ethics. I will discuss some relevant ethical guidelines to dem- onstrate their practical value for decision making in difficult cases. CLINICAL ETHICS AND ETHICAL ISSUES In recent years, the study of ethical issues in medicine has increasingly moved from the theoretical to the practical, clinical level. Clinical ethics has been de- fined as: a practical discipline that provides a structured ap- proach to decision making that can assist physicians to identify, analyze, and resolve ethical issues in clin- ical medicine. 2 Clinical ethics is contrasted with more theoretical questions that do not have a specific impact on pa- tient care. For example, deciding on an appropriate conception of the physician-patient relationship has often been discussed in the medical ethics literature. 3-5 Despite the importance of the physician-patient relationship, its analysis has less di- rect impact on decisions for action in a particular case. There is now a journal devoted specifically to clinical ethics (The Journal of Clinical Ethics), and several clinical ethics fellowships are available throughout the US. The emphasis on clinical ethics may be particularly appealing to practicing physi- cians who need a focused area in the medical ethics literature where they get guidance in deciding about troubling cases such as the one presented here. A number of ethical issues are raised by the case of AS. Received September 25, 1998; Accepted October 6, 1998. From the Department of Surgery, Northwestern University, Chicago, IL. Correspondence address: Peter Angelos, MD, Department of Surgery, North- western University, 300 E. Superior,Tarry 11-703, Chicago, IL 60611. 55 © 1999 by the American College of Surgeons ISSN 1072-7515/99/$19.00 Published by Elsevier Science Inc. PII S1072-7515(98)00270-1

Ethical guidelines in surgical patient care

Embed Size (px)

Citation preview

Ethics

Ethical Guidelines in Surgical Patient Care

Peter Angelos, MD, PhD

In a recent survey of ethics in surgery, emphasis wasplaced on the importance of the physician-patientrelationship, as contrasted with the relation of phy-sicians to one another and to society.1 In the manage-ment of certain difficult surgical problems, an under-standing of ethical guidelines can provide practicalhelp with surgical decisions. This statement is exem-plified by review of a complex clinical case report.

AS, a 65-year-old man was transferred to the vas-cular surgery service of a tertiary care hospital fortreatment of extensive visceral arteriovenous malfor-mations. There was a long history of chronic gastro-intestinal bleeding; he was in congestive heart failureand in renal failure requiring dialysis. Daily transfu-sions for anemia had strained the blood bank’s re-sources, and many consultants had agreed that fur-ther treatment for his gastrointestinal bleeding wasnot indicated. Some physicians suggested withdrawalof all treatment, labeling further intervention “an ex-ercise in futility.”

The patient had named his sister as a surrogate ina durable power of attorney document; a psychiatristhad judged him now incompetent to make decisions.Despite this, when roused from his somnolent state,he expressed a wish for treatment so he could gohome. Three women were closely involved in his care:an adult daughter, his sister, and a live-in companion.The daughter favored cessation of treatment, the sis-ter was uncertain, and his female companion wantedeverything possible done. The attending surgeon wasunsure how to proceed.

A number of ethical issues in treatment are raisedby the account of this patient’s illness. A central fac-tor is the concept of “futility” and how it may bedefined. The issues of autonomy, advance direc-

tives, and the determination of incompetence arerelevant. Use of scarce medical resources in pa-tients considered near the “end of life” is a prom-inent consideration.

The issues just listed have generated extensiveliterature in books and journals of clinical ethics. Iwill discuss some relevant ethical guidelines to dem-onstrate their practical value for decision making indifficult cases.

CLINICAL ETHICS AND ETHICAL ISSUES

In recent years, the study of ethical issues in medicinehas increasingly moved from the theoretical to thepractical, clinical level. Clinical ethics has been de-fined as:

a practical discipline that provides a structured ap-proach to decision making that can assist physiciansto identify, analyze, and resolve ethical issues in clin-ical medicine.2

Clinical ethics is contrasted with more theoreticalquestions that do not have a specific impact on pa-tient care. For example, deciding on an appropriateconception of the physician-patient relationship hasoften been discussed in the medical ethicsliterature.3-5 Despite the importance of thephysician-patient relationship, its analysis has less di-rect impact on decisions for action in a particularcase.

There is now a journal devoted specifically toclinical ethics (The Journal of Clinical Ethics), andseveral clinical ethics fellowships are availablethroughout the US. The emphasis on clinical ethicsmay be particularly appealing to practicing physi-cians who need a focused area in the medical ethicsliterature where they get guidance in deciding abouttroubling cases such as the one presented here. Anumber of ethical issues are raised by the case of AS.

Received September 25, 1998; Accepted October 6, 1998.From the Department of Surgery, Northwestern University, Chicago, IL.Correspondence address: Peter Angelos, MD, Department of Surgery, North-western University, 300 E. Superior, Tarry 11-703, Chicago, IL 60611.

55© 1999 by the American College of Surgeons ISSN 1072-7515/99/$19.00Published by Elsevier Science Inc. PII S1072-7515(98)00270-1

AutonomyCentral to the physician-patient interaction is theprinciple of respect for autonomy. The shift from anattitude of physician paternalism to a pattern involv-ing patient-sharing in decisions has been a steadyevolution over the last 3 decades. Allowing patientsto play an active role in making decisions about theirown medical care is currently well accepted. Parallel-ing the respect for patient autonomy is the require-ment for informed consent that is so important tosurgeons.6

Advance DirectivesIn an effort to extend patient choice into those peri-ods when patients can no longer make decisions forthemselves, advance directives have recently beenemphasized. Most commonly formulated as a livingwill or durable power of attorney for health care,advance directives can now be used to extend patientautonomy beyond the point at which they can makeconscious choices. In step with the increasing use ofadvance directives, the use of do-not-resuscitate(DNR) orders has also increased. Accordingly, themedical ethics literature has increasingly addressedthe appropriate role of advance directives and DNRorders including guidelines on who should make thedecisions regarding such directives, and what aretheir limits.7

End-of-LifeProbably no ethical area in medical care has receivedmore attention in recent years than the issues thatarise at the end of life. The notion of “end-of-lifecare” as a distinct topic within medical practice is arecent phenomenon. It arises from advances in med-ical care that prolong lives beyond the expectations ofa few decades ago. Within this category of end-of-lifecare, the questions of professional participation ineuthanasia, physician-assisted suicide, palliative care,and the concept of futility have been widely ad-dressed by ethicists.

CLINICAL DECISION MAKING AND THEMEDICAL ETHICS LITERATUREConsider how medical ethics literature can be usefulto physicians in making decisions for AS. Amongethical issues raised by this case report, the most fun-damental are those related to the concept of futilityand of respect for autonomy at the end-of-life. Howcan medical ethics literature help with decision mak-ing in this instance?

Three Approaches to FutilityA central issue to be addressed is the concept of “fu-tility.” At least some of the physicians caring for AShave suggested that continuing treatment is “an ex-ercise in futility.” Although the word “futility” is fre-quently raised when there are limited treatment op-tions for severely ill patients, a precise definition ofthe term is difficult to find. Recent medical ethicsliterature includes several attempts to define futiletreatment.

A useful starting point for exploring futility isprovided by Schneiderman and colleagues.8,9 Theseauthors suggest that a definition of futility can becouched in objective, statistical terms. Specifically,they would regard a treatment as futile if empiricaldata show that the treatment has less than a 1 in 100chance of benefiting the patient. Moreover, in accordwith previous authors, Schneiderman and colleaguesargue that physicians are not obligated to offer futiletreatments even if such treatments are requested bypatients or family members.10-12 If the treatment sug-gested for Mr. S has a less than 1 in 100 chance ofbenefiting the patient, the physician has no obliga-tion to provide that treatment.

This approach to the concept of futility has someinitial appeal. It seems to make the question ofwhether a treatment is futile an objective one that canbe answered with empirical data. However, 2 majorproblems remain. First, determining which treat-ments have a less than 1 in 100 chance of success canbe difficult. How similar must the 100 patients be?13

Can a physician just think back to the last 100 pa-tients with similar problems and draw conclusionsabout futility or is a formal study necessary? Suchquestions are not readily answered by the statisticalapproach to futility. Second, in trying to decidewhether an intervention is likely to benefit a patient,the definition of “benefit” becomes important. Suchdefinitions involve the value systems of both patientsand physicians.

Truog and colleagues13 point out the value-ladennature of futility when suggesting, “It is meaninglesssimply to say that an intervention is futile; one mustalways ask, ‘Futile in relation to what?’ ” In otherwords, if one does not know what a patient values asthe goal of a medical intervention, one cannot assesswhether there is any benefit to be gained from theintervention. These authors suggest that futility isnot a useful concept because it hides value judgmentswithin a term that sounds as if it is based on objectivefacts.

56 Angelos Ethical Guidelines in Surgical Patient Care J Am Coll Surg

Prendergast14 suggests another approach to “fu-tility.” He agrees that futility is a value-laden concept,but has added the important point that the complex-ity of the care process is as important as the prognosisin determining what is futile care. As he states,“ . . . an intervention looks different if it is cheap,easy, and without morbidity than if it is technologyintensive, expensive, and likely to involve great painand suffering.”14 Prendergast suggests that ratherthan using a concept like futility to turn down somepatient requests, physicians should explicitly addressthe disproportionate nature of the intervention interms of risks and benefits. By so doing, patientswould be more fully involved in assessing what care isappropriate to their particular situation.

This brief examination of some approaches to“futility” in the medical ethics literature shows thatthe concept is not a simple fact that can be assessed inmuch the same way the heart rate can be assessed.Rather, defining futility involves a complex assess-ment of numerous aspects of a particular treatmentin relation to a particular patient. Because of thetendency to use “futile” as an objective descriptionrather than a value-laden statement, the term shouldbe avoided. A more useful approach is to examineexplicitly the patient’s underlying values and the risksand benefits associated with various treatment op-tions. This will force physicians and patients to ad-dress the complex problem of assigning value to dif-ferent treatments and outcomes. In the long run,such an approach is likely to improve the physician-patient relationship.

End-of-Life and Advance DirectivesThe cited case report raises another set of issues aboutdefining appropriate care for patients at the end oflife. Central to these issues is the determination thata patient is near the “end of life.” Although in somecases the boundary of the “end of life” state may notalways be clear, by any definition, AS has reached theend of life.

One attempt to assist physicians in caring forpatients at the end of life has developed out of thepalliative care literature. Often when the end of life isreached, the traditional goal of medical interventionsmust be altered. Much of medical care is organizedaround the curative model of medicine. In the cura-tive model, the goal of medical care is to cure a pa-tient of a particular illness. At the end of life whencure cannot be attained, an alternative model of med-ical care must become dominant. The palliativemodel of medical care aims toward improving the

patient’s quality of life even when cure is not possi-ble.15 Physicians sometimes have difficulty movingfrom within the curative model to the palliativemodel. Furthermore, as in AS’s situation above, pa-tients and families are often not prepared to movefrom the curative model of medicine into a palliativemodel.

AS’s case is further complicated by the difficultyof determining how to best abide by the patient’swishes regarding end-of-life care. A substantial bodyof ethics publications over the last 30 years relates tothe principle of respect for patient autonomy.16 Re-specting patients’ choice regarding their own medicalcare is generally assumed to be acceptable. The diffi-culty arises when a patient is questionably capable ofmaking a choice in a reliably discriminative way.

A formal advance directive is a document pre-pared by a patient in good health with full mentalcapacity that directs how the decisions are to be madein the event of illness or mental incapacity. Formaladvance directives most commonly take the form of aliving will or durable power of attorney for healthcare. These and other advance directives provide themechanism to extend patients’ control over their au-tonomous decision making into the period whenthey are no longer competent.

Ever since Congress passed the Patient Self-Determination Act in 1990, patients have been en-couraged to make decisions regarding their medicalcare should they become incapacitated.17 Beginningin 1991, hospitals have been required to ask patientsif they have a living will, durable power of attorneyfor health care, or other advance directives. Despitethis requirement, several studies have shown lowrates of advance directive use and a questionable re-lationship between advance directives and patientwishes.18-20

In the case of AS, we find a patient who actuallyhas a formal advance directive, yet the questions sur-rounding what to do for him remain. AS has namedhis sister as surrogate decision maker in a documentproviding durable power of attorney for health care.He has been found by a psychiatrist to lack the ca-pacity to make decisions for himself. For this reason,the sister is the appropriate decision-maker. Mr. S’sstatement that he “wants to be treated so he can gohome” may not be congruous with the surrogatedecision-maker’s choices. If the patient is not compe-tent, one cannot be certain that he is accurately ex-pressing his wishes with such a statement. Further-more, if the aim of going home is not a realistic goalof treatment, there seems to be less impetus to follow

57Vol. 188, No. 1, January 1999 Angelos Ethical Guidelines in Surgical Patient Care

Mr. S’s wishes in this regard. The ideal situationwould be if Mr. S has clearly expressed his desires tohis surrogate so that she can make a decision that isreflective of his longstanding goals. The disagree-ments among the other family members and friendsbecome less problematic when the patient has clearlynamed the person to make decisions on his behalf.

It is obvious from examining this case in light ofthe medical ethics literature that no article or studycan make a complex case simple. Nevertheless, themedical ethics literature helps a thoughtful clinicianto clarify his or her thinking and to avoid issues thatare irrelevant to the required decisions. For example,in Mr. S’s case, by understanding how a durablepower of attorney for health care document func-tions, one can avoid entering a complex negotiationamong various family members about who shouldmake the decision. Furthermore, understanding thelimitations of the futility concept allows one to dis-pense with this term and focus more clearly on thegoals of the potential interventions. By avoiding la-beling interventions as “futile,” the physicians in thiscase may be able to encourage an explicit discussionof what might be the best course of action for thispatient even though he is near the end of life.

Though the medical ethics literature does nothold answers to all the thorny questions faced bypracticing surgeons and physicians, it does allow oneto define more precisely the location of true conflictsamong values. Nonphysicians have written much ofthe medical ethics literature, but the available infor-mation can provide real help for practicing physi-cians. In Mr. S’s case, after numerous discussionswith the family, they came to realize the poor likeli-hood that he would leave the hospital well, no matterhow aggressive the treatment interventions. Whilethe sister assumed the role of surrogate decision-maker, other family members and the live-in com-panion continued to be included in discussionsabout the goals of treatment. When the patient’s re-spiratory status worsened to the point that intuba-tion was considered, the decision was made to with-hold intubation and mechanical ventilation. Thepatient was kept comfortable and died a short timelater.

CONCLUSIONSContemporary medical ethics literature is a vast andgrowing body of work. Although the discussion ofethical issues has important philosophical and re-search benefits, the primary gain for most practicing

surgeons from the medical ethics literature will be adirect benefit for patients.

By exploring an actual case that raises difficultethical issues, I have tried to show that the ethicsliterature can be helpful in treating actual patients. Inthe case of Mr. S, the primary benefit of the medicalethics literature is to define the issues more clearly sothat they may be managed on a more rational basis.Medical ethics literature includes many issues thathave little to do with patient care, but there are alsohighly pertinent, clinically applicable topics directedtoward improving patient care. Only if practicingphysicians actively participate in the discussions ofmedical ethics will the field remain helpful and vitalto patient care.

References1. Hanlon CR. Ethics in surgery. J Am Coll Surg 1998;186:41–49.2. Jonsen AR, Siegler M, Winslade WJ. Clinical ethics: a practical

approach to ethical decisions in clinical medicine. 3rd ed. NewYork: McGraw-Hill, Inc., 1992:1.

3. Emanuel EJ, Emanuel LL. Four models of the physician-patientrelationship. JAMA 1992;267:2221–2226.

4. Pellegrino ED. Patient and physician autonomy: conflicting rightsand obligations in the physician-patient relationship. J ContempHealth Law Policy 1994;10:47–68.

5. Emanuel EJ, Dubler NN. Preserving the physician-patient rela-tionship in the era of managed care. JAMA 1995:273:323–329.

6. Faden R, Beauchamp TL. A history and theory of informed con-sent. New York: Oxford University Press, 1986.

7. Bartholome WG. “Do not resuscitate” orders: accepting responsi-bility. Arch Intern Med 1988;148:2345.

8. Schneiderman LJ, Jecker NS, Jonsen AR. Medical futility: itsmeaning and ethical implications. Ann Intern Med 1990;112:949–954.

9. Schneiderman LJ, Jecker NS, Jonsen AR. Medical futility: re-sponse to critiques. Ann Intern Med 1996;125:669–674.

10. Brett AS, McCullough LB. When patients request specific inter-ventions: defining the limits of the physician’s obligation. N EnglJ Med 1986;315:1347–1351.

11. Blackhall LJ. Must we always use CPR? N Engl J Med1987;317:1281–1285.

12. Paris JJ, Crone RK, Reardon F. Physician’s refusal of requestedtreatment: the case of Baby L. N Engl J Med 1990;322:1012–1015.

13. Truog RD, Brett AS, Frader J. The problem with futility. N EnglJ Med 1992;326:1560–1564.

14. Prendergast TJ. Futility and the common cold: how requests forantibiotics can illuminate at the end of life. Chest 1995;107:836–844.

15. Fox E. Predominance of the curative model of medical care: aresidual problem. JAMA 1997;278:761–763.

16. Beauchamp TL, Childress JF. Principles of biomedical ethics. NewYork: Oxford University Press, 1979:56–96.

17. Cox DM, Sachs GA. Advance directives and the patient self-determination act. Clin Ger Med 1994;10:431–443.

18. Elpern EH, Yellen SB, Burton LA. A preliminary investigation ofopinions and behaviors regarding advance directives for medicalcare. Am J Crit Care 1993;2:161–167.

19. Emanuel LL, Barry MJ, Emanuel EJ, Stoeckle JD. Advance direc-tives: can patients’ stated treatment choices be used to infer un-stated choices? Medical Care 1994;32:95–105.

20. Virmani J, Schneiderman LJ, Kaplan RM. Relationship of ad-vance directives to physician-patient communication. Arch InternMed 1994;154:909–913.

58 Angelos Ethical Guidelines in Surgical Patient Care J Am Coll Surg