Issues in Surgical Ethics

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Withdrawal of care in a potentiallycurable patientJennifer Murphy, BA,a Oluwadamilola Fayanju, MD,b Douglas Brown, PhD,c and Ira J. Kodner, MD,FACS,d St. Louis, MO

From the School of Medicinea and Department of Surgery,b Washington University, St. Louis; EthicistBarnes-Jewish Hospital,c St. Louis; and Washington University Center for the Study of Ethics and HumanValues,d St. Louis, MO

INFORMATION

gh joint sponsorship with the American College of Surgeons, therly Ethics articles published by SURGERY will now offer thethe option of earning 1 CME credit per article. These articles cand to earn credit for three years from the time of publication.

ceive a CME certificate, participants must read the article andsfully complete a short post-test and evaluation form based onthics article. Additional information, the article in its entirety,st/evaluation, and certificate are located on the Americane of Surgeons website:

/www.facs.org/education/SURGERYethicsarticles.html.

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ditation Statement

ctivity has been planned and implemented in accordance withssential Areas and Policies of the Accreditation Council fornuing Medical Education through the joint sponsorship of thecan College of Surgeons and SURGERY. The Americane of Surgeons is accredited by the ACCME to provideuing medical education for physicians.

PRA Category 1 Credits�

merican College of Surgeons designates this educational activitymaximum of 1 AMA PRA Category 1 Credit�. Physiciansonly claim credit commensurate with the extent of their par-

ion in the activity.

sure Information

ordance with ACCME regulations, the American College ofns, as the accredited provider of this journal CME, mustthat anyone in a position to control the content of the

tional activity has disclosed all relevant financial relationshipsny commercial interest. The editor and author(s) of this article

were required to complete disclo-sures and any reported conflicts havebeen managed to our satisfaction.However, if you perceive a biaswithin the article, please advise usof the circumstances on the evalua-tion form.

The requirement for disclosure is notintended to imply any impropriety ofsuch relationships, but simply to iden-tify such relationships through full dis-closure, and to allow readers to formtheir own judgments regarding thematerial.

Disclosure of Significant Relationships with Relevant Commer-cial Companies/Organizations: Jennifer Murphy has no significantrelationships to disclose. Oluwadamilola Fayanju has no significantrelationships to disclose. Douglas Brown has no significant relation-ships to disclose. Ira J. Kodner has no significant relationships todisclose.

Objective

The learning objectives provided by this complicated ethical challengeinvolve a morbidly obese patient who has undergone a bariatricprocedure and develops serious, but potentially reversible, postoperativecomplications. The medical/surgical team wants to continue care and alegally designated surrogate wants the withdrawal of life support. Thelearning objectives include (1) understanding the importance of themedical/surgical facts and potential curability versus irreversibility ofsevere complications; (2) learning the importance of true ‘‘informedconsent’’ obtained from the patient pre-operatively; (3) understandingthe limitations of a ‘‘surrogate decision maker’’; and (4) understandingthe complexity of ‘‘withdrawal of life support,’’ especially when there isdisagreement among the surgical team, the medical intensivists, thesurrogate, and the patient’s own informed consent.

American College of SurgeonsDivision of Education

d for publication January 15, 2010.

requests: Ira J. Kodner, MD, FACS, Department of Sur-shington University School of Medicine, 26 Portland

t. Louis, MO 63131. E-mail: IJKodner@aol.com.

2010;147:441-5.

60/$ - see front matter

Mosby, Inc. All rights reserved.

016/j.surg.2010.01.012

A 49-YEAR-OLD MORBIDLY OBESE WOMAN with multiplecomorbidities underwent an open Roux-en-y gastricbypass operation. On postoperative day 2, she devel-oped signs of peritonitis and was taken to the oper-ating room for an exploratory laparotomy, whereshe was found to have a dilated and necrotic colon.

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442 Murphy et al

She underwent resection of the ischemic right colonwith construction of an end ileostomy and a mucousfistula from a viable rectum. Her postoperativecourse was complicated by wound breakdown andthe development of an intra-abdominal abscessthat required percutaneous drain placement. Sheremained on mechanical ventilation in the surgicalintensive care unit (SICU) and eventually required atracheostomy. Throughout her postoperativecourse, she required extensive intravenous (IV)fluid resuscitation and vasopressor support to main-tain her blood pressure.

On postoperative day 13, a conference was heldwith the family to reassess the goals of care. Priorto the operation, the patient had appointed hersister as power of attorney and had signed a healthcare directive. This directive specified that, in theevent of an unlikely recovery, she preferred toforego all life-sustaining measures including artifi-cial hydration, nutrition, surgery, cardiopulmonaryresuscitation, antibiotics, dialysis, mechanical ven-tilation, and ‘‘all other �life-prolonging� medical orsurgical procedures that are merely intended tokeep me alive without reasonable hope of improv-ing my condition, or curing my illness or injury.’’During the meeting, the family expressed addi-tional concerns that the patient would not havewanted to live with an open abdominal wound andan ileostomy, especially as she would not havewanted to undergo complicated dressing changes.

Although she continued to suffer from sepsis,there was a known source of infection that wasbeing treated with IV antibiotics and drainage.During the next 2 days, the patient began to showsigns of improvement and her vasopressor require-ments decreased. The ICU team made preliminaryplans to begin weaning sedation and ventilatorsupport. The family, however, decided that theywanted to redirect care and withdraw life-sustain-ing measures. The ethical problem facing thesurgical team was whether to comply with thefamily’s request to withdraw life support and redi-rect care given the potential for curing the patient.

THE ETHICAL DILEMMA

The surgeon faced the following options indetermining whether to redirect care in thispatient:

1. Agree to withdraw life-sustaining measures and redi-

rect care to comfort-only measures, knowing that

this would cause death.

2. Refuse to redirect care and continue to supply respi-

ratory support, IV fluids, antibiotics, and dressing

changes.

3. Request the involvement of other members of the pa-

tient’s care team.

4. Reverse sedation and ask the patient how she would

like to proceed.

DISCUSSION

Option 1: Agree to withdraw life-sustainingmeasures and redirect care to comfort-only mea-sures. The patient understood the risks of thisoperation and had appointed a durable power ofattorney (DPA) to make medical decisions in theevent that she became incapacitated. Decisionalcapacity requires that a patient have the ability tounderstand relevant information, appreciate themedical situation and its potential consequences,communicate a choice, and engage in a rationalchoice based on her own values in relation to therecommendations of the physician.1 Our patientlacked capacity because she was unconscious andcould not communicate her choice. Her surrogatedecision maker had the responsibility of makingdecisions that would be consistent with what thepatient would have chosen for herself if she hadnot lacked capacity. Furthermore, we had evidenceof the patient’s preferences as she signed a healthcare directive that stated specifically which treat-ments she wished to forego in the event of an un-likely recovery. Failure to comply with the requestto withdraw support could have been viewed as aviolation of the patient’s autonomy.

There is a limit to a patient’s autonomy, how-ever, and it must be balanced with the goals ofmedical treatment. In the preoperative setting, it iscritical to provide the patient with informed con-sent and to also address the patient’s expectationsof the surgical care. In knowing what are thepatient’s desired outcome and expectations ofthe operation, we can more accurately approachissues of redirection of care. In cases where thepatient has a DPA, it is also necessary for thepatient to have an ongoing dialog with the DPA sothat the latter is also aware of the potentialoutcomes of and collective expectations regardingthe surgical therapy and how much suffering thepatient is willing to bear for a desired outcome. Inthis case, the decision to undergo bariatric surgeryrested on the patient’s assumption that, subse-quent to her operation, she would be healthierand would have a better quality of life. It is possiblethat if only returned to her baseline health status,she would not have wanted to undergo prolongedtreatment and that she might have been willing tosuffer through a prolonged recovery in exchangefor better health in the long run. These important

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issues should have been addressed between thepatient and surgeon and the DPA.

One key problem in this scenario was determin-ing whether there was reasonable hope for herrecovery. If her recovery were extremely improba-ble, then redirection of care would be in line withher stated preferences. At the time of this di-lemma, she had been in the ICU for almost 2weeks and had experienced a complicated course.Her obesity and hypertension had put her at riskfor increased surgical complications, and her co-morbidities were likely to continue to complicateher recovery. If she did survive the sepsis, herquality of life would have been impacted, likelytemporarily, by repeated, messy, and painful dress-ing changes and ostomy care as well as by thechange in self-image effected by an ileostomy.

The major problem with this option is thatmembers of the medical/surgical team might notbe comfortable with withdrawing life support in apatient who seems to be improving. Some mightview this as an act of murder. It is critical that thesurgeon and other physicians involved be able toframe this decision in a way with which they arecomfortable. Otherwise, it will be difficult formembers of the care team to accept the decision.If the surgeon does not feel comfortable with thisline of action, then he/she can request an ethicsconsult; an experienced ethicist could help ex-plain the ethical basis for a course of action.

Option 2: Refuse to redirect care and continueto supply respiratory support, IV fluids, antibiotics,and wound care. As the patient had expressedpreviously her desire not to be sustained on lifesupport, this option hinged on the likelihood ofher recovery. Jonsen et al1 suggest that the follow-ing four key factors be addressed when makingethical decisions in a clinical context: medical indi-cations, patient preferences, quality of life, andcontextual features. In this case, the patient wassuffering from respiratory failure secondary to sep-sis, which is usually an acute and potentially revers-ible problem. The source of infection had beenidentified, and she was receiving appropriate anti-microbial therapy. She had recently begun to showclinical signs of improvement. If ventilator supportwere continued, along with antibiotics and abscessdrainage, it was possible that she could recoverfrom her sepsis.

Furthermore, if she recovered from her sepsis,she would likely require wound care, but thiswould also likely have been a temporary situation,and eventually, she should have been able toresume her normal life activities. The strongestargument against the redirection of care in this

situation was that the patient was suffering fromacute and potentially reversible problems. If shedid survive with continued support, then she waslikely to recover to her previous level of function-ing. Her quality of life was likely to be impactedinitially by dressing changes and the presence ofan ileostomy, but this too was likely to be tempo-rary, because her ileostomy could be taken downeventually with continuity restored in the future.Although she had underlying medical conditionsthat impacted her situation, neither obesity norhypertension represented a terminal conditionthat would imminently hasten her death. Herhealth care directive was to be used in a situationin which she was ‘‘persistently unconscious orthere is no reasonable expectation of [her] recov-ery from seriously incapacitating or terminal illnessor condition.’’ Because she was only unconsciousbecause of sedation provided for her comfort, andthere was a reasonable expectation of her recovery,continued care was not necessarily a violation ofher advance directive or autonomy.

If this course of action is chosen, it threatens todestroy trust between the physician and familymembers and thereby seriously jeopardize thedoctor--patient relationship. Risk managementmight play a role in this scenario, as there mightbe legal consequences of failing to comply withthe requests of the DPA. It might become nec-essary to question the judgment of the surrogateif she herself lacks decision-making capacity,2 hasa gross conflict of interest, and is making deci-sions that are clearly contrary to the patient’s ex-pressed wishes and/or best interest withoutsubstantial evidence, or if there is evidence thatthe patient is being abused in some manner bythe surrogate.

Option 3: Request the involvement of othermembers of the patient’s care team. In decisionsregarding the withdrawal of care, it is important toinvolve all members of the care team as well as thepatient’s family members. If there is a conflictbetween the attending physician and the DPA, andthe DPA wants to make a decision quickly, it iscritical to determine why the DPA wishes to with-draw care at that moment in time. Is there some-thing that the DPA does not understand? Hasthere been a miscommunication? Are there othermotives guiding his decision making? Are thereunderlying issues of which the primary surgeryteam is unaware? These are questions that can beaddressed by involving the SICU physicians,nurses, social workers, and chaplains. If everyonecannot be in agreement about the course ofaction, then it is important for everyone to at least

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have an understanding of the issues at hand andrealize why certain decisions are being made.

In involving other members of the team, it isalso important to identify the individuals in whomthe DPA has the most trust. Although those whoinspire the greatest degree of trust are not alwaysthose with the greatest authority, they can be instru-mental in determining why the DPA wishes towithdraw care. They can also be helpful in encour-aging family members to consider different options.

The opinion of a second physician can also besolicited in regard to the likelihood of recovery. Ifa second physician agrees that, based on clinicalexperience, recovery is extremely unlikely, thencare at that point can then be redirected. Thiswould represent a situation of probabilistic orquantitative futility in which, based on past expe-rience, the desired outcome (in this case, thepatient’s full recovery) is extremely unlikely tooccur.1 One problem with such assessments, how-ever, is the high degree of variability between phy-sicians. A second (or even third) opinion could,thus, be helpful in this situation. Many healthcare directives require that a second physicianagree that recovery is unlikely before care is with-drawn. The patient in this case, however, electedto appoint 1 physician, rather than 2, to makethis decision.

In addition, this situation was somewhat uniquein that the operating surgeon felt that the patienthad a reasonable chance of recovery if therapywere continued. The DPA, acting as the patient’ssurrogate, however, thought that withdrawal ofcare was what the patient would have wanted inthis situation. If a second physician were consultedwho also felt that recovery was possible, this mighthave given additional support to the treatingphysicians.

Option 4: Reverse sedation and solicit thepatient’s preferences. With our patient, the pa-tient’s DPA was making decisions because thepatient lacked the capacity to make decisionsregarding her care. However, she was not perma-nently unconscious but rather was being sedatedfor comfort. This sedation could have been re-versed by holding medications for long enough toexplain to the patient the medical situation, herlikelihood of recovery, and her subsequent qualityof life and then asking her preference.

Although it might be argued that it would becruel to lift sedation in a patient in the ICU who isbeing sedated for comfort, it is important to realizethat the presence of opiates and pain medicationdoes not negate a person’s decisional capacity.Sedation could thus be lifted while pain

medications were continued. If the patient wishesto redirect care, then comfort care measures canbe introduced. This approach has been usedsuccessfully in the past in similar situations wherethe physicians were not comfortable with thedecisions being made by DPAs.

This is perhaps the most direct way to deal withthe situation, but it is not without consequence. Ifsedation is lifted and the patient wakes up, then itwill still be necessary to assess the decision-makingcapacity of the patient. If sedation is reversed butdecision-making capacity is not restored, how canthe medical team be sure that the transient de-crease in patient comfort was worth the possibilityof including her in the determination of herfuture care? The reversal of sedation may alsocast suspicion on the decision-making capacity ofthe DPA and must, therefore, be carefully ex-plained. An ethics consult could be of great utilityin assisting the medical team in explaining to theDPA why sedation was reversed.

In our patient’s case, because there was alreadya plan in place to wean sedation and ventilatorsupport, the family could have been encouraged towait an additional day or 2 to determine whetherthe patient’s condition improved or to if thepatient woke up enough to voice her own prefer-ences. The family was concerned that there was acritical window for this decision. They felt that ifthe patient were allowed to wake up, or if hercondition improved, that it would no longer bepossible to withdraw care. If the patient werecompetent, however, she could still refuse life-sustaining treatment on the principle of autonomy,even though this decision would eventually resultin her death. In this scenario, her death wouldhave been the result of underlying sepsis ratherthan the action of a physician. Previous courtdecisions have upheld the right of competentpatients to refuse IV fluids, nutrition, and antibi-otics even if it will likely result in their death.3

ETHICS BOTTOM LINE

This complicated case highlights the difficultiesin assessing the goals of care in the SICU setting. Itraises the question of futility and asks at what pointan intervention should be deemed unlikely to resultin the recovery of a patient. Who should decide thatan intervention is unlikely to be successful? Whatshould be done in the presence of a clear power ofattorney and health care directive when physiciansand family members disagree about the likelihoodand desirability of outcomes?

This case was complicated even more by thetransfer of care with shift changes, which is

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common in the current medical environment.Although the operating surgeon remains the pri-mary physician for the patient, a team of intensivistscares for the patient while he or she is in the SICU.The patient is thus cared for by several attendingsand numerous residents. The handoff of care is aknown vulnerable point in patient care, and therisk to the patient increases with the number ofphysicians involved in care.4 Frequent handoffsintroduce additional opportunities for error anddisrupt continuity of care. The physician whoultimately may be guiding the family’s end-of-lifedecision making might not be the same physicianwho provided informed consent to the patient.

In approaching ethical issues in the clinicalsetting, it is important that we evaluate all 4 aspectsof a given case, specifically, the medical indications,patient preferences, quality of life, and contextualfeatures.1 Although autonomy plays an importantrole in patient care, it should not be the only ethicalprinciple that guides clinical decision making. Thisis particularly true when a patient’s autonomy con-flicts with the other key principles of beneficence,nonmaleficence, justice, and fairness.

As medical care has shifted away from a pater-nalistic approach toward an approach in whichpatient autonomy is valued increasingly, it is im-portant to realize that the patient--physician rela-tionship should be one of mutual respect andreciprocity. Decision making should be sharedbetween the physician and patient (and by exten-sion, the patient’s surrogate decision makers)rather than being dominated purely by physicianor patient preferences.1,5 It is important to

remember that the ethical obligations of the physi-cian are defined both by the wishes of the patientand the goals of medicine. If a physician feels thata patient’s or surrogate’s request is not in agree-ment with the goals of medical therapy, particu-larly if another ethical principle takesprecedence, then he/she can refuse to complywith the patient/surrogate’s request.1

In a case such as discussed here, in which thereis no easy or obvious correct answer, surgeonsshould be aware of the existence of the dilemmaand of resources available to help guide ethicaldecision making. Many institutions set forth guide-lines and policies for discussing redirection of carein critically ill patients. In addition, the surgeonshould not hesitate to involve other nonphysicianmembers of the team who can provide collateralinformation and provide further insight into theproblem. Finally, an ethics consult would havebeen appropriate in any of the options considered.

REFERENCES

1. Jonsen AR, Siegler M, Winslade WJ. Clinical ethics: a practi-cal approach to ethical decisions in clinical medicine. 6th ed.New York: McGraw-Hill; 2006 p. 227.

2. Bramstedt KA. Questioning the decision-making capacity ofsurrogates. Intern Med J 2003;33:257-9.

3. Luce JM, Alpers A. Legal aspects of withholding and with-drawing life support from critically ill patients in the UnitedStates and providing palliative care to them. Am J Respir CritCare Med 2000;162:2029-32.

4. Dracup K, Morris PE. Passing the torch: the challenge ofhandoffs. Am J Crit Care 2008;17:95-7.

5. Davis MP, Davis DD, Smith ML, Cooper KC. Just whose auton-omy is it? J Clin Oncol 2003;21:67s-9s.