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Primum Non Nocere:A Discussion of Ethics in Anesthesia
Presented by: Darren Li, MD
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Disclosures
No Financial Disclosure
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Contents
● Brief discussion of ethics
● Ethical case and dilemma
● Risk assessment and stratification
● Ethics Consultation
● Conclusion
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What is Ethics?
● 'Medical Ethics' is a system of moral principles that apply values and judgments to the practice of medicine.
● These can be referred to by the professional in case of confusion or conflict
● Different from morality, which is judged on a personal level
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What is Ethics?
● 1847, the AMA adopted its first code of ethics based largely on Thomas Percival book “The Code of Ethics”
● However in 1960s-1970s, medical ethics transformed into bioethics as a field due to several well known cases
● Establishment of IRBs, hospital ethics committees, and informed consents
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What is Ethics?
● Values are defined by upbringing, culture, personal values, etc.
● Standardization of these moral values is becoming the norm
● Ethics vs Law
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Basic terminology
Autonomy
Beneficence
Nonmaleficence
Justice
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Defining Futility
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Defining Futility
Historically, used futility to withhold treatment against the patients or their DPOA’s will
Futility is a subjective and personal decision for the patient or their surrogate
Prioritization of one reduces the value of the other
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Our Case
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Case
94 year old F admitted to Gen Med with altered mental status and increasing oxygen requirements, 1 week after unwitnessed fall.
CT scan - acute compression fracture of T12 with unstable spine requiring emergent stabilization/fusion.
● Severe Alzheimer's● Restrictive lung disease● Severe osteoporosis● Failure to thrive● Mod-Severe mitral regurgitation
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Surgical Decision
Time line:
● Primary medical service ruled out all other causes of AMS.
● Unstable thoracic spine from fractures are an emergent surgical intervention
● Family is very adamant for surgical intervention. Surgery team was hesitant to perform.
● Proceed with 6 level posterior spinal fusion for stabilization pending approval from medicine/anesthesia.
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What to do?
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Weighing the outcomes
Good:
Stabilization of spine
Bad:
Mechanical failure of fusion given osteoporosis.
Prolonged ICU course.
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Why do we care?
32% of patients who died will have undergone surgery within the last year of their life.
8% in last week of life.
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How do we determine risk?
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Mortality Prediction Modeling
● POSSUM (1991)
● P-POSSUM (1996)
● Surgical Risk Scale (2002)
● ACS-NSQIP (2013)
● SORT (2014)
● POSPOM (2016)
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Ideal Risk Stratification Tool
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Risk for our patient
● P-POSSUM Predicted mortality: 71.9%, Predicted morbidity 97.8%
● SRS 30 day mortality risk is 36.1%
● NSQIP serious complication rate of 35%. Risk of death 45%
● Frailty diagnosis
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What are our options?
● Multidisciplinary approach to family discussion (primary, surgery, anesthesia)
● Who can we call for help?
● Social work, Ethics consult, Palliative Care
● Escalation to Risk Management, Evaluation of competency
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• SCHOLARSHIPS • SERVICES• Health Communication and Decision Making• Health, Justice, and Community• Genomics, Health, and Society • Medicine and Society • Global Health Ethics• Gender Equity and Reproductive Justice
• Clinical Ethics Service• Research Ethics Service • Education & Training • Outreach
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• Co-chiefs of clinical ethics service
• Faculty ethicists (share one FTE)
• One full-time clinical ethicist
• One pre-doctoral fellow
• Administrative staff and center manager
Faculty and Staff
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• Review case and help to articulate the ethical question • Discussion with multiple stakeholders, family meetings • Offer suggestions about justifiable courses of action and/or mediate disputes• Consult documented in medical record • Final decisions are made by the patient, family and the health care team • Follow a case over time and/or across settings
How the Process Works
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• All ICUs, different interprofessional team configurations
• Goals:– Interrupting pathway between moral and ethical conflict– Early, team-based, ethics dialogue as a standard of care– Respond to early indicators of moral disagreement– Give practical tools to productively discuss values differences
Preventive Ethics (PE) Rounds
Pavlish C, Brown-Saltzman K, Fine A, Jakel P. Making the call: a proactive ethics framework. HEC forum, 2103; 25(3): 269-283.Hamric A, Blackhall L. Nurse–physician perspectives on the care of dying patients in intensive care units: Collaboration, moral distress, and ethical climate. Crit Care Med, 2007; 35(2), 422–429.
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Preventive Ethics: Patient/Family Risk Factors
Systemic Issues• Limited resources
• Discharge plan concerns
• Home safety
Family Issues• Parents/Family internal disagreement
• Parents/Family disagree with medical team
Mental Health• Suicidality• Substance Abuse
• Psychiatric disorder
Decision Making• Informed consent/ refusal
• DPOA• Capacity• Guardianship• Best interest• Patient autonomy/Parental authority
• Emerging patient autonomy
End of Life/Goals of Care• Code status• Appropriate level of care
• Medical futility/non-beneficial treatment
Diversity • Religion• Culture• Language barriers
Legal/Ethics Interface• Adult/Child neglect or abuse
• Patient privacy• HIV/AIDS disclosure
• Prisoner rights
* Includes adult and pediatric ICUs Graphic provided by Elizabeth Karikomi
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Our course of action
Group discussion among various practicing anesthesiologists.
Discussion between anesthesiologist and surgeon in regards to presenting a united front.
Called ethics to ask what our options were and where we stood.
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Outcome
Did not pursue surgical intervention.
Medically managed, and transitioned to palliative care
Patient is reported to be deceased.
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Summary Slide
Take away points:
● Speak up and address ethical concerns
● Utilize perioperative risk stratification tools if appropriate
● Seek assistance from your colleagues as well as additional available fields (ethics, social work, palliative care, etc.)
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Thank You
● Vijay Tarnal, MD; Robert Fraumann, MD, Andrew Shuman, MD, Trent Rook, MD
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Resources
For information, or assistance on cases, please contact: The Health System Legal Office (764-2178) for legal consultation
Adult Ethics Committee (888-296-2481) for consultation on ethical issues concerning adults
Pediatric Ethics Committee (888-296-2481) for consultation on ethical issues concerning minors
How to broach discussions on serious illness. https://www.ariadnelabs.org/areas-of-work/serious-illness-care/
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CitationBeauchamp, J. (2013). "Principles of Biomedical Ethics". Principles of Biomedical Ethics. 7.
Baumann, Audibert, Lafaye, Puybasset, Mertes, Claudot, Antoine, Gerard, Caroline Guibert, Louis, Paul-Michel , Frederique (January 26, 2013). "Elective Non-therapeutic Intensive Care and the Four Principles of Medical Ethics". Medical Ethics. 39 (3): 139–142. doi:10.1136/medethics-2012-100990. JSTOR 43282683. PMID 23355225.
Gawande A. Being Mortal: Medicine and What Matters in the End. New York, NY: Metropolitan Books; 2014
Goldenberg E, Saffary R, Schmiesing C. New Role for the Anesthesia Preoperative Clinic: Helping to Ensure That Surgery Is the Right Choice for Patients With Serious Illness. Anesth Analg. 2019;129(1):311-315.
Jericho BG. Ethical Issues in Anesthesiology and Surgery. Springer; 2015.
Nurok M, Sadovnikoff N. Why are we doing this case? can perioperative futile care be defined? Curr Opin Anaesthesiol. 2013;26(2):176–81.
Riddick, Frank (2003). "The Code of Medical Ethics of the American Medical Association". The Ochsner Journal. 5 (2): 6-10. PMC 3399321. PMID 22826677.