Ethical Dilemmas in Anesthesia

Educational Objectives

The goal of this program is to improve decision-making when faced with ethical and legal dilemmas and to review current requirements for demonstrating clinical competence. After hearing and assimilating this program, the clinician will be better able to:

1. Counsel patients about options for do-not-resuscitate orders and advance directives.

2. Recognize the intent of unconventional medical directives.

3. Make ethical treatment decisions in situations in which there is conflict between the principles of autonomy and beneficence.

Summary

Medical oaths: Hippocratic Oath — much of it inappropriate for modern practice, but some parts remain relevant; many variations of Hippocratic Oath have been formulated to rectify shortcomings; conflicts between ethical oaths and economic constraints may be encountered; American Medical Association (AMA) code of ethics (1847) — “derogatory to professional character it is for a physician to hold a patent for any surgical instrument or medicine”; this contradicts modern standards; concept of ethics has changed over time

Medical ethical issues: futile care (eg, prolonged ventilation for patient with brain death); treatment of family members; cultural concerns; truth-telling and disclosures; do-not-resuscitate (DNR) in operating room (OR); brain death and organ harvesting; working while impaired (due to, eg, drugs, lack of sleep)

Principles of ethics: beneficence, nonmaleficence, autonomy, justice, dignity, truthfulness, and informed consent; first 4 concepts together referred to as principlism; advance directive (or living will) — defined as declaration of competent adult concerning treatment preferences should he or she become incompetent and unable to make choices; durable power of attorney for health care — document that designates person authorized to make decisions on patient’s behalf should he or she be unable to do so; could be relative or medical colleague; has advantage over advance directive because all circumstances cannot be anticipated

DNR in OR: previously, DNR considered suspended because anesthesia concurrent with resuscitation; American Society of Anesthesiologists (ASA) formulated guidelines in 1992 for ethical care of patients with DNR orders; requires discussion with patient to determine which medical procedures desired; 3 choices — full attempt at resuscitation; limited attempt at resuscitation defined with regard to specific procedures (eg, intubation, insertion of pacemaker, chest compressions); limited attempt at resuscitation defined with regard to patient’s goals and values

Unconventional directives: DNR tattoos — intent of patient underlying legal principle, even if choices not documented in conventional way; improper documentation — Jehovah’s Witness presented with undated and unwitnessed card in wallet declaring wishes; patient received transfusion, survived, and sued; judge ruled that intent of patient clear (ie, she did not wish to have blood transfusion); informed consent — previously considered “process” (did not legally require signature of patient; sufficient to document that discussion with patient about which procedures he or she agreed to undergo took place, and that patient’s wishes being carried out); however, Joint Commission has determined that signature required

Moral principles in medicine: beneficence — treatment guided by benefit to patient; nonmaleficence — do no harm; autonomy — personal right to refuse or choose treatment; conflicts between principles — questions raised about which principle takes precedence in particular situation (eg, Jehovah’s Witness who does not want blood transfusion [ie, autonomy] in conflict with saving life [ie, beneficence]); in Western societies, autonomy usually prevails over other principles in adults; however, power of autonomy not universal; justice — fair distribution of scarce resources

Theories of ethics: character ethics (or virtue ethics) — ie, “what would a good person do”; based on character; conduct ethics — more common; defined as “what should you do”; “good” difficult to define

Approaches to conduct ethics: deontological approach — rule- or duty-based approach (eg, do not kill innocent people); consequentialist approach — determined by consequences; practical differences between 2 approaches — according to deontological approach, bombing of Japan during World War II immoral because innocent civilians killed; consequentialism considers that bombing probably saved more lives (Japanese and American) than were lost, and therefore morally correct; utilitarianism — one approach within consequentialism; calculates utility (eg, how many lives saved by different actions); defines actions as morally right if they promote happiness, ie, pleasure and absence of pain; asserts that pleasure and pain can be quantified; many argue that such entities cannot be measured

Lying: consequentialist approach — may argue that lying wrong because it leads to loss of trust in relationship; however, may also argue that certain consequences may make lying acceptable; deontological approach — lying always wrong regardless of any potential good; virtue ethicist — focuses how lie reflects on person’s character or moral behavior; example — Nazis ask residents of Netherlands if any Jews present; for consequentialist, lying would be moral; deontologist would consider lying wrong, which illustrates shortcoming of this approach (ie, many factors need to be considered in moral decisions)

Application to clinical situation: example — patient presents for simple operation that will be performed by inexperienced surgeon; in holding area, patient asks anesthesiologist about quality of operating surgeon; according to consequentialist approach, best response one which would not frighten patient; deontologist would say that “truth must be told”

Conclusions about theories of ethics: some consider deontology and consequentialism too binary (clinical decisions require more nuanced approach); in practice, moral intuition drives ethical choices

Case study: 73-yr-old man with peripheral vascular disease, right hemiplegia, and progressive dysphasia; DNR order documented in chart; patient appears depressed; he states unequivocally that he does not want resuscitation regardless of cause or prognosis; patient undergoes subarachnoid block; he has cardiac arrest in OR, presumably because subarachnoid block traveled too high; from medical point of view, cardiopulmonary resuscitation not futile, but patient clearly stated wishes; deontological approach would dictate that patient’s instructions must be followed; consequentialism would weigh consequences of patient’s survival against those of his death (eg, physician may be sued)

Participation in judicial executions: forbidden by AMA, ASA, and other organizations; almost certainly, some innocent people have been executed because of false testimony; AMA Council on Ethical and Judicial Affairs prohibits any participation, including electrocardiography, technical advice, prescribing of medication, preparation, or supervision; counterargument — capital punishment legal; duty of physician to provide comfort and relieve pain and suffering; physicians most logical source of skills needed to provide most humane execution; currently, lethal injection consists of sodium pentothal, pancuronium, and potassium chloride; however, application of nitrous oxide hood would succeed in anesthetizing prisoner and then producing anoxia, which would be bloodless and painless

Readings

Suggested Reading

Burkle CM et al: Patient and doctor attitudes and beliefs concerning perioperative do not resuscitate orders: anesthesiologists’ growing compliance with patient autonomy and self determination guidelines. BMC Anesthesiol 2013 Jan;13:2; Davis DA et al: Changing physician performance: a systematic review of the effect of continuing medical education strategies. JAMA 1995;274(9):700-5; Fallat ME et al: Do-not-resuscitate orders for pediatric patients who require anesthesia and surgery. Pediatrics 2004 Dec;114(6):1686-92; Forsetlung L et al: Continuing education meetings and workshops: effects on professional practice and health care outcomes. Cochrane Database Syst Rev 2009 Apr;(2):CD003030; Lagasse RS: Innocent prattle. Anesthesiology 2009 Apr;110(4):698-9; Lagasse RS: National performance data registries: preparing for the perfect storm. Anesthesiology 2012 Sep;117(3):449-50; Localio AR et al: Relation between malpractice claims and adverse events due to negligence — result of the Harvard Medical Practice Study III. N Engl J Med 1991 Jul;325;245-51; Satterlee WG et al: Effective medical education: insights from the Cochrane Library. Obstet Gynecol Surv 2008 May;63(5):329-33; Scott TH, Gavin JR: Palliative surgery in the do-not-resuscitate patient: ethics and practical suggests for management. Anesthesiol Clin 2012 Mar;30(1):1-12; Truog RD et al: DNR in the OR: a goal directed approach. Anesthesiology 1999 Jan;90(1):289-95.

Disclosures

In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty and members of the planning committee to disclose relevant financial relationships within the past 12 months that might create any personal conflicts of interest. Any identified conflicts were resolved to ensure that this educational activity promotes quality in health care and not a proprietary business or commercial interest. For this program, members of the faculty and planning committee reported nothing to disclose.

Acknowledgements

Dr. Doyle spoke at the 64th Annual Postgraduate Symposium on Anesthesiology, held April 11-13 in Kansas City, MO, and presented by the Departments of Anesthesiology and Continuing Education and Professional Development, University of Kansas Medical Center, Kansas City, KS. For information on upcoming CME meetings from the University of Kansas Medical Center, please visit kumcce.ku.edu, or visit our website, Audio-Digest.org, and click on “Upcoming Meetings.” The Audio Digest Foundation thanks the speaker and the sponsors for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0 CE contact hours.

Lecture ID:

AN571701

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.