Primum Non Nocere:A Discussion of Ethics in Anesthesia

Presented by: Darren Li, MD

Disclosures

No Financial Disclosure

Contents

● Brief discussion of ethics

● Ethical case and dilemma

● Risk assessment and stratification

● Ethics Consultation

● Conclusion

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

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

What is Ethics?

● Values are defined by upbringing, culture, personal values, etc.

● Standardization of these moral values is becoming the norm

● Ethics vs Law

Basic terminology

Autonomy

Beneficence

Nonmaleficence

Justice

Defining Futility

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

Our Case

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

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.

What to do?

Weighing the outcomes

Good:

Stabilization of spine

Bad:

Mechanical failure of fusion given osteoporosis.

Prolonged ICU course.

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.

How do we determine risk?

Mortality Prediction Modeling

● POSSUM (1991)

● P-POSSUM (1996)

● Surgical Risk Scale (2002)

● ACS-NSQIP (2013)

● SORT (2014)

● POSPOM (2016)

Ideal Risk Stratification Tool

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

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

• 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

• 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

• 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

• 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.

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

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.

Outcome

Did not pursue surgical intervention.

Medically managed, and transitioned to palliative care

Patient is reported to be deceased.

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.)

Thank You

● Vijay Tarnal, MD; Robert Fraumann, MD, Andrew Shuman, MD, Trent Rook, MD

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/

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.