End of Life/Ethics in Anesthesia Case File

End of Life/Ethics in Anesthesia Case File

Lydia Conlay, MD, PhD, MBA, Julia Pollock, MD, Mary Ann Vann, MD, Sheela Pai, MD, Eugene C. Toy, MD

Case 53

A 52-year-old woman with end-stage metastatic breast cancer is scheduled for plating of her femur, indicated because of a lytic lesion at risk of fracture. She is anemic and thrombocytopenic, and will likely require transfusion of blood and platelets during the case. The patient has signed papers requesting a DNR/DNI (do not resuscitate/do not intubate) status.

➤ What issues need to be considered before an anesthesia plan is made?

➤ How is DNR dealt with in the OR?

➤ What are some of the other types of ethical issues that anesthesiologists face?

ANSWERS TO CASE 53:

End of Life/Ethics in Anesthesia

Summary: A 52-year-old patient with metastatic breast cancer presents for elective palliative surgery. She has a standing DNR/DNI request. She is anemic and has a low platelet count.

➤ Preoperative evaluation: Includes an assessment of the patient’s medical condition(s), their potential impact on the anesthetic plan if any, the type and complexity of the surgery to be performed, and an assessment of the possible need for transfusion of blood or blood products. In addition, prior to entering the OR, this patient warrants a clear and complete discussion of the goals for her treatment. This discussion should include members of the surgical team, family, and primary physician.

➤ DNR in operating room: Given the patient’s right to self-determination, it is she who will ultimately determine how the DNR will be dealt with in the OR. One useful technique involves discussing the patient’s goals of care, for example, not to be on a ventilator for the rest of their life, which permits the anesthetist to determine the means of best achieving those goals.

➤ Other ethical issues: Anesthesiologists also face other types of ethical dilemmas including issues involving informed consent, patient privacy, a colleague’s impaired function, and production pressure.

ANALYSIS

Objectives

1. Become acquainted with the concept of a patient’s right of self-determination, and its impact in the operative setting.

2. Understand how the DNR status is managed in the OR.

3. Become acquainted with other types of ethical challenges that may affect an anesthesiologist.

4. Recognize the physician’s options when his or her ethical value system differs markedly from the patient’s.

Considerations

This patient has a standing request for DNR/DNI status. A discussion with the patient and the rest of her care team should occur well before the scheduled surgery to confirm her wishes, and to determine the need for any accommodation of DNR requests in the operating room. This discussion should optimally include members of the patient’s family, the surgery and anesthesia care teams, and the primary physician.

Because of the low platelet count, the patient is not a candidate for regional anesthesia, and will thus require general anesthesia. In the setting of impaired clotting, regional anesthesia, especially neuraxial techniques, could result in bleeding and cause unnecessary harm. Since this patient requires general anesthesia, it is important that she understands and agrees to the possibility of intubation if necessary. A procedure- or goal-directed approach can be taken to suspension of DNR for patients in the operating room.

APPROACH TO

End of Life/Ethics in Anesthesia

DEFINITIONS

DNR/DNI: Do not resuscitate/do not intubate. A patient’s requests to limit resuscitation from a cardiac arrest, usually verified by a primary physician’s order in the patient’s medical record. (May also be stated as DNAR: do not attempt resuscitation.)

SELF-DETERMINATION: The right to self-determination allows a patient to make independent, informed decisions about their health care. Also described as the principle of patient autonomy.

ADVANCE DIRECTIVES: Instructions from a patient stating their desires for certain types of care if they are unable to speak for themselves.

INFORMED CONSENT: The autonomous, informed authorization by a patient for a specific procedure.

PRODUCTION PRESSURE: Incentives and pressures on a person to place production and not safety as the priority.

CLINICAL APPROACH

Every patient has a right to self-determination, which refers to the autonomy to decide what kind of care they would or would not like to receive. Indeed, the concept of patient self-determination and principle of patient autonomy guide the ethical practice of medicine. Such dilemmas may involve the ultimate health-care decision: the choice to limit health care at the end of life, including a decision as to whether to be or not be resuscitated from cardiac or respiratory arrest. These decisions may also address whether or not a patient wants to be intubated and placed on a ventilator.

The discussion regarding the patient’s DNR status in the OR should occur well before the time of surgery, and should include the surgical and anesthesia team members, the primary physician, and family if the patient desires it. It goes without saying that any such discussions with patients and

other physicians must be clearly documented in the patient’s record, especially if other anesthesia personnel may be called on to care for the patient in the OR.

Patients may be unaware that routine anesthesia care is often considered resuscitation in other parts of the hospital. In the past, many hospitals automatically suspended DNR requests for patients going to the OR. However, this action does not properly address the patient’s right to self-determination in an ethical or legal manner. A measured approach to this issue evolves from a discussion with patient leading to partial or total suspension of DNR. Alternatively, limitations on resuscitation can be made in a goal-directed or procedure-directed fashion. A goal-directed suspension of DNR asks a patient to clarify and state their goals of care, for example, not to be on a ventilator for the rest of their life, and frees the physician to utilize various means to achieve this goal. These goal-directed approaches are often extended into the postoperative period. It is crucial that all medical teams agree upon these goal-directed suspensions of DNR. For example: in a patient who agrees to general anesthesia under the condition that they will not be intubated for a long period after surgery. All specialties need to concur that at a certain time the patient will be extubated, regardless of the medical situation.

A procedure-directed suspension of DNR allows a patient to make a checklist of procedures they would not permit, such as chest compression or defibrillation. A patient who wishes to maintain full DNR/DNI status can go to the OR for a minor procedure requiring minimal sedation. However, even under minor sedation events could occur, for example, a reaction to antibiotics or local anesthesia, which would be reversible with basic resuscitation techniques. General anesthesia, because of the potential need for intubation and paralysis, coupled with the anesthesiologist’s responsibility to do no harm, almost always requires at least a partial suspension of the DNR/DNI status. Each hospital has its own policies regarding DNR in the OR, and these policies can vary significantly.

In an urgent situation or when formal discussions are impossible, full resuscitative measures are instituted to meet the tenet of “do no harm.” In some cases, where a patient is unable to communicate, either advance directives or a person designated as the health-care proxy decision-maker can convey the patient’s desires for resuscitation. The legally accepted method of surrogate decision making varies according to state law. The most complete way to ascertain an incapacitated patient’s wishes is from both a written statement such as an advance directive or “living will” and the health-care proxy decision maker, which is often a family member. In most situations, only one of these means of information is available. However, if the patient’s wishes are unknown or unclear, full measures are undertaken since the consequences of refraining from resuscitation are usually permanent.

Obtaining consent for routine methods of airway management are sometimes the most difficult part of this process. Patients may not understand that intubation and the use of resuscitative drugs go part and parcel with anesthesia care, and that refraining from their use would be a significant (and possibly even unethical) departure from normal clinical practice. However, an understanding and informative discussion of these points may be sufficiently reassuring for a patient fearing prolongation of life on a ventilator in an ICU.

Even if the use of another type of airway device is planned, consent for possible intubation is required for general anesthesia. This does not mean that the patient’s desires cannot be accommodated. However, just because a patient states that they do not want an intervention, such as intubation, a physician is not required to agree to something that they think is unsafe or unethical. For example, even a regional anesthetic may fail requiring conversion to general anesthesia. When disagreements occur, a physician should withdraw and find a replacement, or ask for intervention from a third party, such as the hospital’s ethics committee.

For extremity surgery, regional anesthesia may be an option for the patient who does not want to be intubated. However, the medical comorbidities near the end of life often preclude the use of a regional block. Coagulopathy, thrombocytopenia, and lytic lesions at the area of surgery pose a significant risk for bleeding and hematoma formation. If a neuraxial block is utilized, a hematoma could result in paralysis and even require emergent surgery for evacuation.

Informed Consent

Informed consent is another manner in which a patient expresses their right to self-determination. The process of informed consent has several steps. A patient must possess the ability to understand the medical information, must have the capacity to make a decision, and must be acting voluntarily.

The physician needs to provide adequate information for the patient to make an educated decision. The “subjective person standard” requires the physician to be aware of the individual’s medical conditions, wants, and needs to provide sufficient information. The ethical standard expects the physician to provide specific information appropriate for that particular patient. For example, the risks and benefits of intubation are different for an opera singer than it is for someone not dependent on vocal nuances for their livelihood. The legal standard for information is the “reasonable person standard,” that which any usual person would require to make a decision. The physician is obligated to make a recommendation based on medical knowledge to assist the patient in making an adequately informed decision. This recommendation is often meant to persuade, but coercion or manipulation should be avoided.

Once the patient has an understanding of the information, an autonomous authorization or consent can be obtained. A common limitation on informed consent for anesthesiologists is the rushed or distracted consent process that may occur in the holding area prior to a procedure, when the patient is seen and interviewed only minutes before they go into the OR. The elements of understanding and being voluntary can be limited when a patient is hesitant to ask questions or change their minds moments before a procedure.

Despite a physician’s best efforts to inform and recommend, patients occasionally make bad decisions. It is important to remember that they have the right to do so according to the principle of patient autonomy. When physicians disagree morally with a patient’s choice or think that it is inappropriate, they may withdraw from caring for that patient, and should attempt to find a replacement. The Ethics Consultation Service or Committee also provides guidance when there are ethical disputes between physicians, or between physicians and patients or families.

Institutions differ with regards to their policies which govern patient care in an emergency. Many hospitals require that a physician provide emergency care in accordance with the patient’s wishes until another physician can assume that role. Others allow physicians to withdraw from providing care, or certain types of care. It is important to understand the Medical Staff Bylaws which govern a physician’s practice.

Production pressures are overt or covert incentives and pressures on a person to place production, not safety as the priority. There are organizational, economic and social demands on the anesthesiologist, especially in fast paced ambulatory practices. These pressures may lead an anesthesiologist to avoid canceling cases, or to cut corners or work faster to reduce costs or maximize income. Production pressures cause errors, stress and fatigue, which are detrimental to both physicians and patients.

The Right to Privacy

Patient privacy is another common ethical issue encountered by anesthesiologists. Today, many patients receive anesthesia interviews and instructions over the phone. Messages left on answering machines can violate a patient’s right to privacy, much as taking a history in front of family members may reveal guarded personal information. Operating room schedules and other documents with patient’s medical histories need to be shielded from public view.

Comprehension Questions

53.1. Which of the following statements regarding DNR/DNI is most accurate?

A. It is irrevocable and unchangeable once stated.

B. It is an expression of a patient’s choice to limit health care.

C. It can be applied only when expressed by an awake, competent patient.

D. It is invalid in the operating room.

53.2. The concept of self-determination includes which of the following?

A. It requires a physician to do anything a patient requests.

B. It is a replacement for informed consent.

C. It is not valid if the patient is unconscious or incompetent to make decisions.

D. It affirms the principle of patient autonomy.

53.3. Which of the following statements is accurate about the informed consent process?

A. Consent forms should be signed prior to the patient preoperative interview.

B. Consent forms exist solely to meet legal requirements.

C. The process requires both disclosure and a recommendation by the physician.

D. Preferably, this should be done in the holding area immediately before a procedure.

53.4. If a physician disagrees morally or ethically with a patient’s decision, or believes that that decision may cause unnecessary harm, the physician should do which of the following?

A. He does not generally have the right to withdraw from providing care.

B. He may assign the hospital administrator to find a replacement for providing care.

C. He may state whatever objections in the chart, but should continue to provide care.

D. He may be aided by the institution’s Ethics Service or Committee.

ANSWERS

53.1. B. Do not resuscitate/do not intubate is a request by a patient to limit resuscitation, guided by the concept of self-determination. Although it is expressed in the chart as a physician order, all physicians caring for the patient should have their own discussion on how this should be expressed. Sometimes this request needs alteration or suspension when a patient is going to the operating room or undergoing a procedure. When a patient is unconscious or incompetent to make decisions, these desires can be ascertained through advance directives or a health-care proxy decision-maker.

53.2. D. Self-determination and the principle of patient autonomy reinforce the same concept: patients have the right to make their own decisions about their health care. Respect for patient autonomy guides the physician to adequately inform the patient, disclose risks and benefits, and make recommendations for their care. A physician is not required to do something unsafe or unethical just because the patient requests it. A patient’s advance directives or health-care proxy can assert a patient’s right to self-determination when they are unable to do it on their own.

53.3. C. Informed consent requires the physician to both gain an understanding of a patient’s conditions and needs and to disclose information to provide an individual with adequate understanding of the risks and benefits of a procedure. This discussion is best accomplished when both the patient and physician have the time and voluntariness to do so. When rushed or distracted, the physician may not give the patient adequate information or allow time for the patient to ask questions. Informed consent fulfills not only a legal obligation, but also an ethical one.

53.4. D. If a physician disagrees morally or ethically with a patient’s decision, or believes that that decision may cause unnecessary harm, the physician has the right to withdraw from providing care. However, if the physician withdraws from providing care, he or she must seek a replacement. The institution’s Ethics Service or Committee can be invaluable in providing guidance and support.

Clinical Pearls

➤ All patients have the right to participate fully in health-care decisions.

➤ DNR orders are not necessarily suspended automatically when a patient goes into the OR.

➤ Educating patients as to the typical and usual tools used during an anesthetic and using goal-directed or procedure-directed approach to DNR is helpful for patients anticipating the need for surgery.

➤ Physicians may withdraw from providing care which they deem likely to cause unnecessary harm, or with which they disagree morally or ethically.

➤ When in doubt, consult the Ethics Service or Committee.

References

ASA Ethical Guidelines for the Anesthesia Care of Patients with Do-Not-Resuscitate Orders. Amended in 2001. asahq.org/publicationsandservices/standards/09.html. 

ASA Syllabus on Ethics. asahq.org/publicationsandservices. 

Truog RD, Waisel DB, Burns JP. DNR in the OR: a goal-directed approach. Anesthesiology. 1999;90:289-295.

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