Clinics in Medical Education

Ethics Analysis of A Complex Perioperative Case

Shahla Siddiqui, MD

Published December 2, 2024 | Clinics in Medical Education 

Issue 4 | Volume 1 | November 2024

A 74 year old patient with a h/o stroke and MI is listed in the OR for a decortication of a possibly malignant pleural effusion. There is a DNR and DNI order in place and the patient lives in a care facility, is non-verbal and has a medical order for life sustaining treatment (MOLST) form in the chart with her prior wishes, preferences and goals expressed. The anesthesiologist discussed the goals of care and code status prior to the procedure with the family, who agree to rescind the DNR DNI order peri-procedure, but do wish for the team to discuss with them, if any heroic therapy is required to save her life. The patient suffers an intraoperative cardiac arrest after induction of anesthesia and the family urgently called from the OR while resuscitation is started. The family discuss prognosis with the care team (surgeon, anesthesiologist and an intensivist whom the anesthesiologist urgently contacted). The patient has return of spontaneous circulation, but given the circumstances, and discussion between the family, surgeon and anesthesiologist, the procedure is aborted and the patient is moved to the ICU for palliative care and comfort measures. Palliative care staff are involved, along with the ICU team. Spiritual care staff and other family are at the bedside and the patient is moved to comfort measures and expires peacefully. The family appreciate the care and communication.

Questions

  1. Is it necessary to rescind DNR code status perioperatively?
  2. Who assesses decisional capacity?
  3. If the status is ‘full code’ is it ethical to discuss decompensation in the OR with the family?
  4. If the patient lacks capacity, can the sister (HCP) make a decision to revoke her MOLST wishes?
  5. What duty of care do perioperative physicians carry towards discussion of code status? Who does it?
  6. Is it helpful to have a discussion with the family in real time from the OR?

TABLE 1

Jonsen’s 4 box model of ethical decision making [3].

Decisional Capacity vs Competency in Informed Consent

Capacity is defined as “a functional determination that an individual is or is not capable of making a medical decision within a given situation.” This is relative to the baseline abilities of the patient, pertains only to the current situation, and takes into consideration the severity of the possible consequences. Determination is made by any clinician for any specific situation.

Competency is defined as “the ability of an individual to participate in legal proceedings”. Legal competence is presumed – to disprove an individual’s competence requires a hearing and presentation of evidence. Competence is determined by a judge. This legal determination is never determined by medical providers.

All adults are presumed to have sufficient capacity to decide on their own medical treatment, unless there’s significant evidence to suggest otherwise. Capacity means the ability to use and understand information to make a decision, and communicate any decision made. A person lacks capacity if their mind is impaired or disturbed in some way, which means they’re unable to make a decision at that time. Informed consent can be obtained only if the patient can understand, retain and deliberate on their decision specific to the procedure. In the case of our patient this was absent and a surrogate was asked for a decision (healthcare proxy/sister).

Surrogate Decision Making (SDM) vs Shared Decision Making (Relational Autonomy)

A surrogate decision maker shall make decisions for the person conforming as closely as possible to what the person would have done or intended under the circumstances, taking into account evidence that includes, but is not limited to, the person’s philosophical, religious, moral and ethical beliefs. However, the SDM decisions are typically made according to a process governed by a hierarchy of 3 distinct decision-making standards: (1) patients’ known wishes, (2) substituted judgments, and (3) best interests.

In this case the sister weighed all 3 standards, and applied 1, 2 but within limits and when the best interest standard was challenged opted to limit care and shift goals to comfort and dignity. Having ‘shared’ decisions made with the care team in real time and with ALL stakeholders (surgeon, anesthesiologist and intensivist) helped guide her care decision. Assurance that ‘care’ will not be withdrawn for her sister- human nature is to desire support in making tough decisions, as well as get direction in ‘best’ medical course to achieve goals.

Principle of Proportionality- Burden vs Benefit of Therapy

The principle of proportionality states that responses should be proportional to the good that can be achieved and the harm that may be caused. As it relates to medical ethics, this means that medical interventions and risks should be proportionate to the possible benefits achieved.

In this case, proceeding to do the surgery with a questionable outcome from the cardiac arrest as well as the risk of further deterioration and worsened quality of life outweighed the benefit of removing the pleural effusions. At the same time, proceeding towards comfort measures was acceptable by the family in view of the suffering caused by invasive treatment and a worse QOL by the patient. The HCP was guided by the care team in such difficult decision making. This is not always possible but prevents institution of measures that may violate a patient’s right to self determination and prior expressions of preference and values.

Empathic Communication and Empathic Actions

Empathy is understanding in the truest and most authentic form the suffering of another person or their family. Empathy is displayed in not just words expressed and communicated but also in actions and behavior: such as respecting a patient’s wishes and choices, also respecting their surrogates’ opinions and recognizing the emotional needs of family members (as this is respectful to the patient). In providing real time information, involving all stakeholders and experts in a timely manner to dis- cuss prognosis and risks and benefits with the family in an iterative manner, the most compassionate decisions could be made.

REFERENCES

1.  Allen MB, Bernacki RE, Gewertz BL, Cooper Z, Abrams JL, Peetz AB, Bader AM, Sadovnikoff N. Beyond the Do-not-resuscitate Order: An Expanded Approach to Deci- sion-making Regarding Cardio- pulmonary Resuscitation in Older Surgical Patients. Anesthesiology. 2021 Nov 1;135(5):781-787. PMID: 34499085

2.  Allen MB, Siddiqui S, Nwoko- lo O, Kuza CM, Sadovnikoff N, Mann DG, Souter MJ. Reviewing Ethical Guidelines for the Care of Patients with Do-Not-Resuscitate Orders after 30 Years: Rethink- ing Our Approach at a Time of Transition. Anesthesiology. 2024 Sep 1;141(3):584-597. PMID: 39136474.

3.  Toh HJ, Low JA, Lim ZY, Lim Y, Siddiqui S, Tan L. Jonsen’s Four Topics Approach as a Framework for Clinical Ethics Consultation. Asian Bioeth Rev. 2018 Mar 23;10(1):37-51. PMID: 33717274; PMCID: PMC7747427.

4.  Malenfant S, Jaggi P, Hayden KA, Sinclair S. Compassion in healthcare: an updated scoping review of the literature. BMC Pal- liat Care. 2022 May 18;21(1):80. PMID: 35585622; PMCID: PMC9116004.