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The Right Choice? Mixed feelings about a recent informed consent court decision
On June 20, 2017, the Supreme Court of Pennsylvania ruled on a case that may have significant implications for surgical informed consent.
Although the legal complexities of the case might be interesting to some, what got my attention was the question of whether a surgeon can delegate the informed consent discussion with a patient to someone else.
A few weeks later, the patient had a phone conversation with Dr. Tom’s physician assistant (PA) who answered several additional questions Ms. Shinal had about the surgery. Approximately one month later, the patient met with the same PA and had a preoperative history and physical examination and the informed consent form was signed.
About 2 weeks after that, the patient had an open craniotomy with total resection of the tumor. Unfortunately, the procedure was complicated by bleeding that resulted in stroke, brain injury, and partial blindness. Ms. Shinal and her husband sued Dr. Toms for malpractice, and included in the suit was a claim that Dr. Toms failed to obtain informed consent from Ms. Shinal.
At the original trial, the jury was instructed by the judge to consider information given to Ms. Shinal both by Dr. Toms and his PA as included in the informed consent process. The jury found in favor of Dr. Toms and the patient then appealed to the Pennsylvania Superior Court which upheld the decision. The case was then appealed to the Pennsylvania Supreme Court, which specifically addressed the issue of whether the informed consent discussion must be performed by the surgeon or can be delegated to others.
Several groups, including the American Medical Association, filed briefs in the case supporting Dr. Tom’s claim that the information that is conveyed in the informed consent process is what is important rather than exactly who provides that information to the patient. For many, this case seemed to be relatively straightforward. The surgeon had discussed the operation with the patient, she had agreed, and then in several additional conversations with the surgeon’s PA, the patient’s additional questions had been answered and the patient had willingly signed the informed consent document.
However, in a surprise to many, the Pennsylvania Supreme Court decision stated that “a physician may not delegate to others his or her obligation to provide sufficient information in order to obtain a patients’ informed consent. Informed consent requires direct communication between physician and patient and contemplates a back-and-forth, face-to-face exchange, which might include questions that the patient feels the physician must answer personally before the patient feels informed and becomes willing to consent. The duty to obtain the patient’s informed consent belongs solely to the physician.” Based on this finding, the case was sent back to the trial court for a new trial.
Although legal scholars may debate the legal basis of this opinion and the ramifications for future cases, I am more interested in the ethical issues that it raises. Although, in recent decades, I have become increasingly accustomed to the idea of medical care by teams, there is something almost nostalgic about this decision. It suggests to me that at least four of the seven Pennsylvania Supreme Court justices believe that there is something so special about surgical informed consent that it must involve a direct conversation between the patient and the surgeon.
This view seems ever more foreign in an environment in which we increasingly talk about processes of care and systems errors rather than individual relationships and individual responsibility. Although the supremely hierarchical concept of the surgeon as the “captain of the ship” has largely been replaced by the team approach, it is nevertheless true that, in an elective case, the patient would not be in the operating room but for the relationship and trust that the patient has in the surgeon.
As I contemplate this court case, I see how it may add to the challenges of providing surgical care to patients and how it may further the delays to see some surgeons. However, it also reemphasizes for me that informed consent for surgery is less about the information that is transferred to the patient and much more about the relationship in which a patient places his or her trust in the surgeon. The emphasis that this court ruling places on the direct relationship between a surgeon and a patient is a refreshing reminder of the personal responsibility that surgeons have for their patients’ outcomes.
Dr. Angelos is the Linda Kohler Anderson Professor of Surgery and Surgical Ethics, chief of endocrine surgery, and associate director of the MacLean Center for Clinical Medical Ethics at the University of Chicago.
On June 20, 2017, the Supreme Court of Pennsylvania ruled on a case that may have significant implications for surgical informed consent.
Although the legal complexities of the case might be interesting to some, what got my attention was the question of whether a surgeon can delegate the informed consent discussion with a patient to someone else.
A few weeks later, the patient had a phone conversation with Dr. Tom’s physician assistant (PA) who answered several additional questions Ms. Shinal had about the surgery. Approximately one month later, the patient met with the same PA and had a preoperative history and physical examination and the informed consent form was signed.
About 2 weeks after that, the patient had an open craniotomy with total resection of the tumor. Unfortunately, the procedure was complicated by bleeding that resulted in stroke, brain injury, and partial blindness. Ms. Shinal and her husband sued Dr. Toms for malpractice, and included in the suit was a claim that Dr. Toms failed to obtain informed consent from Ms. Shinal.
At the original trial, the jury was instructed by the judge to consider information given to Ms. Shinal both by Dr. Toms and his PA as included in the informed consent process. The jury found in favor of Dr. Toms and the patient then appealed to the Pennsylvania Superior Court which upheld the decision. The case was then appealed to the Pennsylvania Supreme Court, which specifically addressed the issue of whether the informed consent discussion must be performed by the surgeon or can be delegated to others.
Several groups, including the American Medical Association, filed briefs in the case supporting Dr. Tom’s claim that the information that is conveyed in the informed consent process is what is important rather than exactly who provides that information to the patient. For many, this case seemed to be relatively straightforward. The surgeon had discussed the operation with the patient, she had agreed, and then in several additional conversations with the surgeon’s PA, the patient’s additional questions had been answered and the patient had willingly signed the informed consent document.
However, in a surprise to many, the Pennsylvania Supreme Court decision stated that “a physician may not delegate to others his or her obligation to provide sufficient information in order to obtain a patients’ informed consent. Informed consent requires direct communication between physician and patient and contemplates a back-and-forth, face-to-face exchange, which might include questions that the patient feels the physician must answer personally before the patient feels informed and becomes willing to consent. The duty to obtain the patient’s informed consent belongs solely to the physician.” Based on this finding, the case was sent back to the trial court for a new trial.
Although legal scholars may debate the legal basis of this opinion and the ramifications for future cases, I am more interested in the ethical issues that it raises. Although, in recent decades, I have become increasingly accustomed to the idea of medical care by teams, there is something almost nostalgic about this decision. It suggests to me that at least four of the seven Pennsylvania Supreme Court justices believe that there is something so special about surgical informed consent that it must involve a direct conversation between the patient and the surgeon.
This view seems ever more foreign in an environment in which we increasingly talk about processes of care and systems errors rather than individual relationships and individual responsibility. Although the supremely hierarchical concept of the surgeon as the “captain of the ship” has largely been replaced by the team approach, it is nevertheless true that, in an elective case, the patient would not be in the operating room but for the relationship and trust that the patient has in the surgeon.
As I contemplate this court case, I see how it may add to the challenges of providing surgical care to patients and how it may further the delays to see some surgeons. However, it also reemphasizes for me that informed consent for surgery is less about the information that is transferred to the patient and much more about the relationship in which a patient places his or her trust in the surgeon. The emphasis that this court ruling places on the direct relationship between a surgeon and a patient is a refreshing reminder of the personal responsibility that surgeons have for their patients’ outcomes.
Dr. Angelos is the Linda Kohler Anderson Professor of Surgery and Surgical Ethics, chief of endocrine surgery, and associate director of the MacLean Center for Clinical Medical Ethics at the University of Chicago.
On June 20, 2017, the Supreme Court of Pennsylvania ruled on a case that may have significant implications for surgical informed consent.
Although the legal complexities of the case might be interesting to some, what got my attention was the question of whether a surgeon can delegate the informed consent discussion with a patient to someone else.
A few weeks later, the patient had a phone conversation with Dr. Tom’s physician assistant (PA) who answered several additional questions Ms. Shinal had about the surgery. Approximately one month later, the patient met with the same PA and had a preoperative history and physical examination and the informed consent form was signed.
About 2 weeks after that, the patient had an open craniotomy with total resection of the tumor. Unfortunately, the procedure was complicated by bleeding that resulted in stroke, brain injury, and partial blindness. Ms. Shinal and her husband sued Dr. Toms for malpractice, and included in the suit was a claim that Dr. Toms failed to obtain informed consent from Ms. Shinal.
At the original trial, the jury was instructed by the judge to consider information given to Ms. Shinal both by Dr. Toms and his PA as included in the informed consent process. The jury found in favor of Dr. Toms and the patient then appealed to the Pennsylvania Superior Court which upheld the decision. The case was then appealed to the Pennsylvania Supreme Court, which specifically addressed the issue of whether the informed consent discussion must be performed by the surgeon or can be delegated to others.
Several groups, including the American Medical Association, filed briefs in the case supporting Dr. Tom’s claim that the information that is conveyed in the informed consent process is what is important rather than exactly who provides that information to the patient. For many, this case seemed to be relatively straightforward. The surgeon had discussed the operation with the patient, she had agreed, and then in several additional conversations with the surgeon’s PA, the patient’s additional questions had been answered and the patient had willingly signed the informed consent document.
However, in a surprise to many, the Pennsylvania Supreme Court decision stated that “a physician may not delegate to others his or her obligation to provide sufficient information in order to obtain a patients’ informed consent. Informed consent requires direct communication between physician and patient and contemplates a back-and-forth, face-to-face exchange, which might include questions that the patient feels the physician must answer personally before the patient feels informed and becomes willing to consent. The duty to obtain the patient’s informed consent belongs solely to the physician.” Based on this finding, the case was sent back to the trial court for a new trial.
Although legal scholars may debate the legal basis of this opinion and the ramifications for future cases, I am more interested in the ethical issues that it raises. Although, in recent decades, I have become increasingly accustomed to the idea of medical care by teams, there is something almost nostalgic about this decision. It suggests to me that at least four of the seven Pennsylvania Supreme Court justices believe that there is something so special about surgical informed consent that it must involve a direct conversation between the patient and the surgeon.
This view seems ever more foreign in an environment in which we increasingly talk about processes of care and systems errors rather than individual relationships and individual responsibility. Although the supremely hierarchical concept of the surgeon as the “captain of the ship” has largely been replaced by the team approach, it is nevertheless true that, in an elective case, the patient would not be in the operating room but for the relationship and trust that the patient has in the surgeon.
As I contemplate this court case, I see how it may add to the challenges of providing surgical care to patients and how it may further the delays to see some surgeons. However, it also reemphasizes for me that informed consent for surgery is less about the information that is transferred to the patient and much more about the relationship in which a patient places his or her trust in the surgeon. The emphasis that this court ruling places on the direct relationship between a surgeon and a patient is a refreshing reminder of the personal responsibility that surgeons have for their patients’ outcomes.
Dr. Angelos is the Linda Kohler Anderson Professor of Surgery and Surgical Ethics, chief of endocrine surgery, and associate director of the MacLean Center for Clinical Medical Ethics at the University of Chicago.
The right choice? Surgical ethics and the history of surgery
In the almost 30 years since I started surgical residency, the attention to ethical issues in surgery has dramatically changed. Although surgeons still faced ethical dilemmas decades ago, there was little specific attention paid to highlighting these ethical issues in the past. Today, for many reasons, specific attention to the ethical issues in the care of surgical patients is a widespread phenomenon. We see articles in surgical journals about ethical issues and it is commonplace to find sessions devoted to various surgical ethics topics at many surgical society meetings. The American College of Surgeons is even publishing a textbook of surgical ethics in the upcoming months.
This contemporary attention to ethics in surgery seems to be a recent phenomenon. One of my senior colleagues, in commenting on how much more specific attention we pay to ethical issues today, once jokingly stated that he had trained in surgery “before there was ethics.” Although we laughed at the idea that there was a time before ethics, my own experience and my discussions with many retired surgeons, including my father, have led me to believe that things are very different today than several decades ago. I thought that although there were certainly ethically challenging cases in the past that demanded surgeons to make tough choices, such cases I thought were unlikely to be called out as ethics cases.
According to the short publication, the address was given to the Meath Hospital and County Dublin Infirmary at the “opening of the session” on Monday, Oct. 8, 1894. Dr. Stokes’ words on that date seem to have been addressed primarily to medical students, but many of the topics he touched upon resonate with ongoing ethical issues in the care of patients today.
When addressing the innovative ideas of antisepsis, Dr. Stokes wrote: “…it might be that in the minds of some zealous operators, it may have had a tendency to beget an overweening confidence in the powers of our art. The result has been that the ethical principles which should always guide us in our operative work have, at times, I think, been neglected, and operations undertaken that, in the present state of our knowledge, have, I fear, overleaped the pale of legitimate surgery.” In these sentences, Dr. Stokes is addressing the worry that overconfident surgeons might recommend operations that may put their patients at significant risk. Here, he is addressing an issue that remains problematic today as surgeons must often temper their enthusiasm for an innovative operation in the context of the potential complications that the patient will be put at risk for.
Later, Dr. Stokes goes on to use the term “surgical ethics” for perhaps the first time in the surgical literature when he writes: “A consideration of surgical ethics that frequently exercises the mind of the operating surgeon is the question of the principles that should guide him in dealing with cancerous growths. The question as to what constitutes justification in dealing with them in an operative way is ever present and surrounded with difficulty, as the result of such interference must end in weal or woe, satisfaction or regret to the patient as to the operator.” Although the language is somewhat different, Dr. Stokes is challenging surgeons to address a central question in the care of every patient with cancer:
Do the risks of the operation outweigh the potential benefits to the patient?
Although this question is central to all surgical decision making, Dr. Stokes’ specific attention to this question in relation to cancer surgery is a reflection of the understanding, even in the 1890s, that cancers most frequently led to death with or without aggressive surgical intervention. Although patients commonly are willing to put themselves at significant risk for even a small chance of benefit when the alternative is death, surgeons must carefully weigh risks and benefits when deciding when to offer surgery to such vulnerable patients.
The words of Sir William Stokes seem strangely modern in their emphasis on surgeon judgment. The question of “what should we offer to our patient?” is one that apparently is not new. The overarching question of whether the risks outweigh the benefits of innovative operations or challenging cancer procedures are as relevant to surgeons today as they were to a thoughtful surgeon in 1894. The questions that Dr. Stokes raised could have been lifted directly from the M & M discussion at any number of surgical departments today. This early work in surgical ethics should remind us of the importance of carefully considering when we should offer risky surgery to vulnerable patients who often believe that surgery is their only option for cure.
Dr. Angelos is the Linda Kohler Anderson Professor of Surgery and Surgical Ethics; chief, endocrine surgery; and associate director of the MacLean Center for Clinical Medical Ethics at the University of Chicago.
In the almost 30 years since I started surgical residency, the attention to ethical issues in surgery has dramatically changed. Although surgeons still faced ethical dilemmas decades ago, there was little specific attention paid to highlighting these ethical issues in the past. Today, for many reasons, specific attention to the ethical issues in the care of surgical patients is a widespread phenomenon. We see articles in surgical journals about ethical issues and it is commonplace to find sessions devoted to various surgical ethics topics at many surgical society meetings. The American College of Surgeons is even publishing a textbook of surgical ethics in the upcoming months.
This contemporary attention to ethics in surgery seems to be a recent phenomenon. One of my senior colleagues, in commenting on how much more specific attention we pay to ethical issues today, once jokingly stated that he had trained in surgery “before there was ethics.” Although we laughed at the idea that there was a time before ethics, my own experience and my discussions with many retired surgeons, including my father, have led me to believe that things are very different today than several decades ago. I thought that although there were certainly ethically challenging cases in the past that demanded surgeons to make tough choices, such cases I thought were unlikely to be called out as ethics cases.
According to the short publication, the address was given to the Meath Hospital and County Dublin Infirmary at the “opening of the session” on Monday, Oct. 8, 1894. Dr. Stokes’ words on that date seem to have been addressed primarily to medical students, but many of the topics he touched upon resonate with ongoing ethical issues in the care of patients today.
When addressing the innovative ideas of antisepsis, Dr. Stokes wrote: “…it might be that in the minds of some zealous operators, it may have had a tendency to beget an overweening confidence in the powers of our art. The result has been that the ethical principles which should always guide us in our operative work have, at times, I think, been neglected, and operations undertaken that, in the present state of our knowledge, have, I fear, overleaped the pale of legitimate surgery.” In these sentences, Dr. Stokes is addressing the worry that overconfident surgeons might recommend operations that may put their patients at significant risk. Here, he is addressing an issue that remains problematic today as surgeons must often temper their enthusiasm for an innovative operation in the context of the potential complications that the patient will be put at risk for.
Later, Dr. Stokes goes on to use the term “surgical ethics” for perhaps the first time in the surgical literature when he writes: “A consideration of surgical ethics that frequently exercises the mind of the operating surgeon is the question of the principles that should guide him in dealing with cancerous growths. The question as to what constitutes justification in dealing with them in an operative way is ever present and surrounded with difficulty, as the result of such interference must end in weal or woe, satisfaction or regret to the patient as to the operator.” Although the language is somewhat different, Dr. Stokes is challenging surgeons to address a central question in the care of every patient with cancer:
Do the risks of the operation outweigh the potential benefits to the patient?
Although this question is central to all surgical decision making, Dr. Stokes’ specific attention to this question in relation to cancer surgery is a reflection of the understanding, even in the 1890s, that cancers most frequently led to death with or without aggressive surgical intervention. Although patients commonly are willing to put themselves at significant risk for even a small chance of benefit when the alternative is death, surgeons must carefully weigh risks and benefits when deciding when to offer surgery to such vulnerable patients.
The words of Sir William Stokes seem strangely modern in their emphasis on surgeon judgment. The question of “what should we offer to our patient?” is one that apparently is not new. The overarching question of whether the risks outweigh the benefits of innovative operations or challenging cancer procedures are as relevant to surgeons today as they were to a thoughtful surgeon in 1894. The questions that Dr. Stokes raised could have been lifted directly from the M & M discussion at any number of surgical departments today. This early work in surgical ethics should remind us of the importance of carefully considering when we should offer risky surgery to vulnerable patients who often believe that surgery is their only option for cure.
Dr. Angelos is the Linda Kohler Anderson Professor of Surgery and Surgical Ethics; chief, endocrine surgery; and associate director of the MacLean Center for Clinical Medical Ethics at the University of Chicago.
In the almost 30 years since I started surgical residency, the attention to ethical issues in surgery has dramatically changed. Although surgeons still faced ethical dilemmas decades ago, there was little specific attention paid to highlighting these ethical issues in the past. Today, for many reasons, specific attention to the ethical issues in the care of surgical patients is a widespread phenomenon. We see articles in surgical journals about ethical issues and it is commonplace to find sessions devoted to various surgical ethics topics at many surgical society meetings. The American College of Surgeons is even publishing a textbook of surgical ethics in the upcoming months.
This contemporary attention to ethics in surgery seems to be a recent phenomenon. One of my senior colleagues, in commenting on how much more specific attention we pay to ethical issues today, once jokingly stated that he had trained in surgery “before there was ethics.” Although we laughed at the idea that there was a time before ethics, my own experience and my discussions with many retired surgeons, including my father, have led me to believe that things are very different today than several decades ago. I thought that although there were certainly ethically challenging cases in the past that demanded surgeons to make tough choices, such cases I thought were unlikely to be called out as ethics cases.
According to the short publication, the address was given to the Meath Hospital and County Dublin Infirmary at the “opening of the session” on Monday, Oct. 8, 1894. Dr. Stokes’ words on that date seem to have been addressed primarily to medical students, but many of the topics he touched upon resonate with ongoing ethical issues in the care of patients today.
When addressing the innovative ideas of antisepsis, Dr. Stokes wrote: “…it might be that in the minds of some zealous operators, it may have had a tendency to beget an overweening confidence in the powers of our art. The result has been that the ethical principles which should always guide us in our operative work have, at times, I think, been neglected, and operations undertaken that, in the present state of our knowledge, have, I fear, overleaped the pale of legitimate surgery.” In these sentences, Dr. Stokes is addressing the worry that overconfident surgeons might recommend operations that may put their patients at significant risk. Here, he is addressing an issue that remains problematic today as surgeons must often temper their enthusiasm for an innovative operation in the context of the potential complications that the patient will be put at risk for.
Later, Dr. Stokes goes on to use the term “surgical ethics” for perhaps the first time in the surgical literature when he writes: “A consideration of surgical ethics that frequently exercises the mind of the operating surgeon is the question of the principles that should guide him in dealing with cancerous growths. The question as to what constitutes justification in dealing with them in an operative way is ever present and surrounded with difficulty, as the result of such interference must end in weal or woe, satisfaction or regret to the patient as to the operator.” Although the language is somewhat different, Dr. Stokes is challenging surgeons to address a central question in the care of every patient with cancer:
Do the risks of the operation outweigh the potential benefits to the patient?
Although this question is central to all surgical decision making, Dr. Stokes’ specific attention to this question in relation to cancer surgery is a reflection of the understanding, even in the 1890s, that cancers most frequently led to death with or without aggressive surgical intervention. Although patients commonly are willing to put themselves at significant risk for even a small chance of benefit when the alternative is death, surgeons must carefully weigh risks and benefits when deciding when to offer surgery to such vulnerable patients.
The words of Sir William Stokes seem strangely modern in their emphasis on surgeon judgment. The question of “what should we offer to our patient?” is one that apparently is not new. The overarching question of whether the risks outweigh the benefits of innovative operations or challenging cancer procedures are as relevant to surgeons today as they were to a thoughtful surgeon in 1894. The questions that Dr. Stokes raised could have been lifted directly from the M & M discussion at any number of surgical departments today. This early work in surgical ethics should remind us of the importance of carefully considering when we should offer risky surgery to vulnerable patients who often believe that surgery is their only option for cure.
Dr. Angelos is the Linda Kohler Anderson Professor of Surgery and Surgical Ethics; chief, endocrine surgery; and associate director of the MacLean Center for Clinical Medical Ethics at the University of Chicago.
Conflicts and the ethical practice of surgery
Once a month in my department, we focus on a case with challenging ethical considerations for part of the discussion at the M & M conference.
Earlier this week, my colleagues and I heard about an unfortunate 87-year-old man, who had been living independently when he developed a partial bowel obstruction. His wife had died over 10 years earlier and, although he lived alone, he had two sons and a daughter who lived close to him and regularly looked in on him and helped him to keep up his small home.
The ethical challenge presented at M & M was the difficulty of determining what was the “best” treatment for this patient and how that decision was reached. The surgical team explained to the patient and his family that there were two broad possibilities for his treatment: definitive resection of the primary tumor or palliative options. In order for him to have a colon resection, the cardiologists felt that he would need coronary artery bypass grafting before surgery. To pursue this course of treatment, they wanted him to have a diverting colostomy before the heart surgery. Then, after a period of recovery from the heart surgery, he could have a colon resection with takedown of the colostomy.
Alternatively, the palliative option of a colonic stent followed by external beam radiation to the lesion was offered. The surgical team tried to present the options in an evenhanded manner so as not to paint either option as being significantly worse. However, even with a definitive resection, the surgeons did not believe that they could cure the patient and they explained this to him and his family.
The patient seemed to have the capacity to make the choice and, although he had originally wanted “everything” done, when he was transferred to our hospital and when presented with these choices, he stated that the palliative option seemed better for him. He told the surgical team that he did not want to have heart surgery, and he did not want to risk dying with a colostomy.
At the end of the family meeting, the surgical team felt that the patient had made a reasonable decision, and they were comfortable with his choice. However, the following day, the patient’s daughter called demanding another meeting with the surgical team. She had been at the family meeting the prior day and stated that, in her opinion, the surgical team had “pushed” the patient to accept the palliative option and that she was not certain that he really had the capacity to make decisions for himself.
During the subsequent meeting with the family, the daughter was the primary spokesperson, but the two sons also seemed in agreement with her assessment that the patient lacked capacity. She stated that the patient was transferred to our medical center in order to allow him to get the treatments that he needed, and now, in her opinion, the surgical team was not pursuing the “best” treatment. She was upset and repeatedly expressed this sentiment.
The surgery team was understandably concerned with this turn of events. They had undertaken their evaluation with constant reassessment of the likely impact of the treatment options on the patient’s quality of life. They had tried to explain the options fully to the patient and involved his family in the discussion. In short, the surgical team had done their best to pursue high-quality ethical care by utilizing shared decision making. Despite spending significant time with the patient and his family, there was now conflict. The patient wanted to pursue a course of treatment that the surgical team felt was appropriate, but the family disagreed and wanted to make the decisions for the patient and pursue a more aggressive approach.
For many physicians, especially the residents who were actively involved in caring for this patient, this outcome – namely, significant conflict with the family and the family feeling that the patient should not be allowed to make his own decisions – seemed to be exactly what the careful attention to the ethical dimension of surgical practice tries to avoid.
Even though most of us try to avoid conflicts with patients and their families, optimal ethical practice does not always result in a consensus of opinions and that lack of conflict. As physicians, we can try to follow all of the ethical guidelines of extensive communication and shared decision making, yet we may still wind up with unhappy patients and families.
The goal of ethical practice should not be to avoid conflicts, but, rather, to treat patients in the manner that helps them to achieve what they value most.
In this present case, what could the surgical team do moving forward? Sometimes conflicts can be solved with additional information. A psychiatry consultation might be helpful to gain an opinion on whether the patient has the capacity to make decisions. Additionally, an ethics consultation might be valuable to gain an outside view to help the family understand the potential merits of a palliative approach. Although this case raises ethical concerns for the surgical team, the conflicts that resulted ought not be seen as a failure of the discussions surrounding the patient’s goals for his treatment.
Most of us prefer to avoid conflicts with patients and their families, but our ultimate goal in the ethical practice of surgery cannot be consensus. Rather, it should be to do the best we can to provide care that helps the patient achieve his or her goals. Unfortunately, we may do everything possible to provide high quality ethical care to patients and conflict still result. However, we cannot use resulting conflict as a reason to avoid the many discussions needed to communicate the options accurately to our patients and their families.
Dr. Angelos is the Linda Kohler Anderson Professor of Surgery and Surgical Ethics, chief of endocrine surgery, and associate director of the MacLean Center for Clinical Medical Ethics at the University of Chicago.
Once a month in my department, we focus on a case with challenging ethical considerations for part of the discussion at the M & M conference.
Earlier this week, my colleagues and I heard about an unfortunate 87-year-old man, who had been living independently when he developed a partial bowel obstruction. His wife had died over 10 years earlier and, although he lived alone, he had two sons and a daughter who lived close to him and regularly looked in on him and helped him to keep up his small home.
The ethical challenge presented at M & M was the difficulty of determining what was the “best” treatment for this patient and how that decision was reached. The surgical team explained to the patient and his family that there were two broad possibilities for his treatment: definitive resection of the primary tumor or palliative options. In order for him to have a colon resection, the cardiologists felt that he would need coronary artery bypass grafting before surgery. To pursue this course of treatment, they wanted him to have a diverting colostomy before the heart surgery. Then, after a period of recovery from the heart surgery, he could have a colon resection with takedown of the colostomy.
Alternatively, the palliative option of a colonic stent followed by external beam radiation to the lesion was offered. The surgical team tried to present the options in an evenhanded manner so as not to paint either option as being significantly worse. However, even with a definitive resection, the surgeons did not believe that they could cure the patient and they explained this to him and his family.
The patient seemed to have the capacity to make the choice and, although he had originally wanted “everything” done, when he was transferred to our hospital and when presented with these choices, he stated that the palliative option seemed better for him. He told the surgical team that he did not want to have heart surgery, and he did not want to risk dying with a colostomy.
At the end of the family meeting, the surgical team felt that the patient had made a reasonable decision, and they were comfortable with his choice. However, the following day, the patient’s daughter called demanding another meeting with the surgical team. She had been at the family meeting the prior day and stated that, in her opinion, the surgical team had “pushed” the patient to accept the palliative option and that she was not certain that he really had the capacity to make decisions for himself.
During the subsequent meeting with the family, the daughter was the primary spokesperson, but the two sons also seemed in agreement with her assessment that the patient lacked capacity. She stated that the patient was transferred to our medical center in order to allow him to get the treatments that he needed, and now, in her opinion, the surgical team was not pursuing the “best” treatment. She was upset and repeatedly expressed this sentiment.
The surgery team was understandably concerned with this turn of events. They had undertaken their evaluation with constant reassessment of the likely impact of the treatment options on the patient’s quality of life. They had tried to explain the options fully to the patient and involved his family in the discussion. In short, the surgical team had done their best to pursue high-quality ethical care by utilizing shared decision making. Despite spending significant time with the patient and his family, there was now conflict. The patient wanted to pursue a course of treatment that the surgical team felt was appropriate, but the family disagreed and wanted to make the decisions for the patient and pursue a more aggressive approach.
For many physicians, especially the residents who were actively involved in caring for this patient, this outcome – namely, significant conflict with the family and the family feeling that the patient should not be allowed to make his own decisions – seemed to be exactly what the careful attention to the ethical dimension of surgical practice tries to avoid.
Even though most of us try to avoid conflicts with patients and their families, optimal ethical practice does not always result in a consensus of opinions and that lack of conflict. As physicians, we can try to follow all of the ethical guidelines of extensive communication and shared decision making, yet we may still wind up with unhappy patients and families.
The goal of ethical practice should not be to avoid conflicts, but, rather, to treat patients in the manner that helps them to achieve what they value most.
In this present case, what could the surgical team do moving forward? Sometimes conflicts can be solved with additional information. A psychiatry consultation might be helpful to gain an opinion on whether the patient has the capacity to make decisions. Additionally, an ethics consultation might be valuable to gain an outside view to help the family understand the potential merits of a palliative approach. Although this case raises ethical concerns for the surgical team, the conflicts that resulted ought not be seen as a failure of the discussions surrounding the patient’s goals for his treatment.
Most of us prefer to avoid conflicts with patients and their families, but our ultimate goal in the ethical practice of surgery cannot be consensus. Rather, it should be to do the best we can to provide care that helps the patient achieve his or her goals. Unfortunately, we may do everything possible to provide high quality ethical care to patients and conflict still result. However, we cannot use resulting conflict as a reason to avoid the many discussions needed to communicate the options accurately to our patients and their families.
Dr. Angelos is the Linda Kohler Anderson Professor of Surgery and Surgical Ethics, chief of endocrine surgery, and associate director of the MacLean Center for Clinical Medical Ethics at the University of Chicago.
Once a month in my department, we focus on a case with challenging ethical considerations for part of the discussion at the M & M conference.
Earlier this week, my colleagues and I heard about an unfortunate 87-year-old man, who had been living independently when he developed a partial bowel obstruction. His wife had died over 10 years earlier and, although he lived alone, he had two sons and a daughter who lived close to him and regularly looked in on him and helped him to keep up his small home.
The ethical challenge presented at M & M was the difficulty of determining what was the “best” treatment for this patient and how that decision was reached. The surgical team explained to the patient and his family that there were two broad possibilities for his treatment: definitive resection of the primary tumor or palliative options. In order for him to have a colon resection, the cardiologists felt that he would need coronary artery bypass grafting before surgery. To pursue this course of treatment, they wanted him to have a diverting colostomy before the heart surgery. Then, after a period of recovery from the heart surgery, he could have a colon resection with takedown of the colostomy.
Alternatively, the palliative option of a colonic stent followed by external beam radiation to the lesion was offered. The surgical team tried to present the options in an evenhanded manner so as not to paint either option as being significantly worse. However, even with a definitive resection, the surgeons did not believe that they could cure the patient and they explained this to him and his family.
The patient seemed to have the capacity to make the choice and, although he had originally wanted “everything” done, when he was transferred to our hospital and when presented with these choices, he stated that the palliative option seemed better for him. He told the surgical team that he did not want to have heart surgery, and he did not want to risk dying with a colostomy.
At the end of the family meeting, the surgical team felt that the patient had made a reasonable decision, and they were comfortable with his choice. However, the following day, the patient’s daughter called demanding another meeting with the surgical team. She had been at the family meeting the prior day and stated that, in her opinion, the surgical team had “pushed” the patient to accept the palliative option and that she was not certain that he really had the capacity to make decisions for himself.
During the subsequent meeting with the family, the daughter was the primary spokesperson, but the two sons also seemed in agreement with her assessment that the patient lacked capacity. She stated that the patient was transferred to our medical center in order to allow him to get the treatments that he needed, and now, in her opinion, the surgical team was not pursuing the “best” treatment. She was upset and repeatedly expressed this sentiment.
The surgery team was understandably concerned with this turn of events. They had undertaken their evaluation with constant reassessment of the likely impact of the treatment options on the patient’s quality of life. They had tried to explain the options fully to the patient and involved his family in the discussion. In short, the surgical team had done their best to pursue high-quality ethical care by utilizing shared decision making. Despite spending significant time with the patient and his family, there was now conflict. The patient wanted to pursue a course of treatment that the surgical team felt was appropriate, but the family disagreed and wanted to make the decisions for the patient and pursue a more aggressive approach.
For many physicians, especially the residents who were actively involved in caring for this patient, this outcome – namely, significant conflict with the family and the family feeling that the patient should not be allowed to make his own decisions – seemed to be exactly what the careful attention to the ethical dimension of surgical practice tries to avoid.
Even though most of us try to avoid conflicts with patients and their families, optimal ethical practice does not always result in a consensus of opinions and that lack of conflict. As physicians, we can try to follow all of the ethical guidelines of extensive communication and shared decision making, yet we may still wind up with unhappy patients and families.
The goal of ethical practice should not be to avoid conflicts, but, rather, to treat patients in the manner that helps them to achieve what they value most.
In this present case, what could the surgical team do moving forward? Sometimes conflicts can be solved with additional information. A psychiatry consultation might be helpful to gain an opinion on whether the patient has the capacity to make decisions. Additionally, an ethics consultation might be valuable to gain an outside view to help the family understand the potential merits of a palliative approach. Although this case raises ethical concerns for the surgical team, the conflicts that resulted ought not be seen as a failure of the discussions surrounding the patient’s goals for his treatment.
Most of us prefer to avoid conflicts with patients and their families, but our ultimate goal in the ethical practice of surgery cannot be consensus. Rather, it should be to do the best we can to provide care that helps the patient achieve his or her goals. Unfortunately, we may do everything possible to provide high quality ethical care to patients and conflict still result. However, we cannot use resulting conflict as a reason to avoid the many discussions needed to communicate the options accurately to our patients and their families.
Dr. Angelos is the Linda Kohler Anderson Professor of Surgery and Surgical Ethics, chief of endocrine surgery, and associate director of the MacLean Center for Clinical Medical Ethics at the University of Chicago.
The Surgical M&M Conference: Balancing a Blame-Free Environment with Individual Responsibility
The traditional Surgical Morbidity and Mortality Conference that I remember so well from my residency days has changed. Not everything has changed, however. Usually the most senior resident involved still presents the case along with a discussion of the operation performed and the complication. There is invariably a discussion of the central question, “What should have been done differently?” Residents still occasionally get nervous before presenting a case as I did years ago, and there is still the occasional disagreement over how a surgical issue was handled. But there are subtle differences notable in the M&M discussions of today.
Rather than focusing on who did something wrong, there is today more often a focus on the “systems issues” in the case. In other words, if a pneumothorax was missed after a central line placement, the discussion today is much more commonly focused on the systems that should have been in place to ensure that such an abnormality was noted and acted upon. In years past, the focus was squarely on identifying which resident shirked his or her responsibility to review the film.
This current “blame-free” environment is the hallmark of a “learning organization” that aims to use the review process to improve performance. Mistakes are viewed as opportunities for learning and improving the system. And the nonpunitive analysis goes a long way toward improving morale among the residents and certainly encourages teamwork and identification of mechanisms to avoid errors within a hospital or service. These are all good things. But I worry that perhaps there is a tendency to go too far with avoiding individual responsibility.
Sometimes it is easy to talk about things “just happening” in large medical systems of today. Many surgeons are accustomed to dictating operative reports in the passive voice. For example, I find myself routinely stating, “the patient was prepped and draped,” “an incision was made,” and “exposure was obtained.” All these statements suggest that things happened and, perhaps “mistakes were made,” but there is little attribution to a specific actor. Unfortunately, it can be easy to also talk about patient care in a similarly abstract manner in which it is hard to identify who did what to whom.
The central question, I believe, is whether this new focus on the system and the team is ultimately better for patient care. We do want all members of the operating room team, for example, to feel responsible for speaking up when something does not seem right. We want every person involved in a patient’s care to feel comfortable with stopping an incorrect intervention. Surgeons, in particular, should not be upset by having the medical student question which side of the patient is being operated upon. Hierarchy should never stand in the way of speaking up to avoid an error being made. Nevertheless, we must not completely eliminate the sense of personal responsibility that each individual caregiver should feel toward ensuring the well-being of the patient.
In 1937, Chicago surgeon Max Thorek, M.D., wrote a pioneering book entitled, Surgical Errors and Safeguards. Dr. Thorek wrote, “While it is human to err, it is inhuman not to try, if possible, to protect those who entrust their lives into our hands from avoidable failures and danger.” I believe that this philosophy continues to be embodied in the Surgical M&M conference.
One of the central components of the M&M discussion has not changed. After all of the discussion about systems and corporate responsibility, I believe that the most common statement that I have heard from the treating surgeon is, “My error was that I should have done ... ” Although some observers might see this ascription of the individual role of the surgeon to be anachronistic, I believe that it captures the reality of the situation that even though patients are operated upon by teams, it is most commonly an individual relationship with a specific surgeon that has prompted the patient to go ahead with the surgery. We must not lose sight of the importance of that individual relationship and the responsibility that the individual surgeon has in influencing patient choice. In many ways, although the tenor of the Surgical M&M conference has changed the old question of “What could I have done differently?” remains of central importance to ensuring that surgeons take responsibility for their patients’ well-being.
Dr. Angelos is an ACS Fellow; the Linda Kohler Anderson Professor of Surgery and Surgical Ethics; chief, endocrine surgery; and associate director of the MacLean Center for Clinical Medical Ethics at the University of Chicago.
The traditional Surgical Morbidity and Mortality Conference that I remember so well from my residency days has changed. Not everything has changed, however. Usually the most senior resident involved still presents the case along with a discussion of the operation performed and the complication. There is invariably a discussion of the central question, “What should have been done differently?” Residents still occasionally get nervous before presenting a case as I did years ago, and there is still the occasional disagreement over how a surgical issue was handled. But there are subtle differences notable in the M&M discussions of today.
Rather than focusing on who did something wrong, there is today more often a focus on the “systems issues” in the case. In other words, if a pneumothorax was missed after a central line placement, the discussion today is much more commonly focused on the systems that should have been in place to ensure that such an abnormality was noted and acted upon. In years past, the focus was squarely on identifying which resident shirked his or her responsibility to review the film.
This current “blame-free” environment is the hallmark of a “learning organization” that aims to use the review process to improve performance. Mistakes are viewed as opportunities for learning and improving the system. And the nonpunitive analysis goes a long way toward improving morale among the residents and certainly encourages teamwork and identification of mechanisms to avoid errors within a hospital or service. These are all good things. But I worry that perhaps there is a tendency to go too far with avoiding individual responsibility.
Sometimes it is easy to talk about things “just happening” in large medical systems of today. Many surgeons are accustomed to dictating operative reports in the passive voice. For example, I find myself routinely stating, “the patient was prepped and draped,” “an incision was made,” and “exposure was obtained.” All these statements suggest that things happened and, perhaps “mistakes were made,” but there is little attribution to a specific actor. Unfortunately, it can be easy to also talk about patient care in a similarly abstract manner in which it is hard to identify who did what to whom.
The central question, I believe, is whether this new focus on the system and the team is ultimately better for patient care. We do want all members of the operating room team, for example, to feel responsible for speaking up when something does not seem right. We want every person involved in a patient’s care to feel comfortable with stopping an incorrect intervention. Surgeons, in particular, should not be upset by having the medical student question which side of the patient is being operated upon. Hierarchy should never stand in the way of speaking up to avoid an error being made. Nevertheless, we must not completely eliminate the sense of personal responsibility that each individual caregiver should feel toward ensuring the well-being of the patient.
In 1937, Chicago surgeon Max Thorek, M.D., wrote a pioneering book entitled, Surgical Errors and Safeguards. Dr. Thorek wrote, “While it is human to err, it is inhuman not to try, if possible, to protect those who entrust their lives into our hands from avoidable failures and danger.” I believe that this philosophy continues to be embodied in the Surgical M&M conference.
One of the central components of the M&M discussion has not changed. After all of the discussion about systems and corporate responsibility, I believe that the most common statement that I have heard from the treating surgeon is, “My error was that I should have done ... ” Although some observers might see this ascription of the individual role of the surgeon to be anachronistic, I believe that it captures the reality of the situation that even though patients are operated upon by teams, it is most commonly an individual relationship with a specific surgeon that has prompted the patient to go ahead with the surgery. We must not lose sight of the importance of that individual relationship and the responsibility that the individual surgeon has in influencing patient choice. In many ways, although the tenor of the Surgical M&M conference has changed the old question of “What could I have done differently?” remains of central importance to ensuring that surgeons take responsibility for their patients’ well-being.
Dr. Angelos is an ACS Fellow; the Linda Kohler Anderson Professor of Surgery and Surgical Ethics; chief, endocrine surgery; and associate director of the MacLean Center for Clinical Medical Ethics at the University of Chicago.
The traditional Surgical Morbidity and Mortality Conference that I remember so well from my residency days has changed. Not everything has changed, however. Usually the most senior resident involved still presents the case along with a discussion of the operation performed and the complication. There is invariably a discussion of the central question, “What should have been done differently?” Residents still occasionally get nervous before presenting a case as I did years ago, and there is still the occasional disagreement over how a surgical issue was handled. But there are subtle differences notable in the M&M discussions of today.
Rather than focusing on who did something wrong, there is today more often a focus on the “systems issues” in the case. In other words, if a pneumothorax was missed after a central line placement, the discussion today is much more commonly focused on the systems that should have been in place to ensure that such an abnormality was noted and acted upon. In years past, the focus was squarely on identifying which resident shirked his or her responsibility to review the film.
This current “blame-free” environment is the hallmark of a “learning organization” that aims to use the review process to improve performance. Mistakes are viewed as opportunities for learning and improving the system. And the nonpunitive analysis goes a long way toward improving morale among the residents and certainly encourages teamwork and identification of mechanisms to avoid errors within a hospital or service. These are all good things. But I worry that perhaps there is a tendency to go too far with avoiding individual responsibility.
Sometimes it is easy to talk about things “just happening” in large medical systems of today. Many surgeons are accustomed to dictating operative reports in the passive voice. For example, I find myself routinely stating, “the patient was prepped and draped,” “an incision was made,” and “exposure was obtained.” All these statements suggest that things happened and, perhaps “mistakes were made,” but there is little attribution to a specific actor. Unfortunately, it can be easy to also talk about patient care in a similarly abstract manner in which it is hard to identify who did what to whom.
The central question, I believe, is whether this new focus on the system and the team is ultimately better for patient care. We do want all members of the operating room team, for example, to feel responsible for speaking up when something does not seem right. We want every person involved in a patient’s care to feel comfortable with stopping an incorrect intervention. Surgeons, in particular, should not be upset by having the medical student question which side of the patient is being operated upon. Hierarchy should never stand in the way of speaking up to avoid an error being made. Nevertheless, we must not completely eliminate the sense of personal responsibility that each individual caregiver should feel toward ensuring the well-being of the patient.
In 1937, Chicago surgeon Max Thorek, M.D., wrote a pioneering book entitled, Surgical Errors and Safeguards. Dr. Thorek wrote, “While it is human to err, it is inhuman not to try, if possible, to protect those who entrust their lives into our hands from avoidable failures and danger.” I believe that this philosophy continues to be embodied in the Surgical M&M conference.
One of the central components of the M&M discussion has not changed. After all of the discussion about systems and corporate responsibility, I believe that the most common statement that I have heard from the treating surgeon is, “My error was that I should have done ... ” Although some observers might see this ascription of the individual role of the surgeon to be anachronistic, I believe that it captures the reality of the situation that even though patients are operated upon by teams, it is most commonly an individual relationship with a specific surgeon that has prompted the patient to go ahead with the surgery. We must not lose sight of the importance of that individual relationship and the responsibility that the individual surgeon has in influencing patient choice. In many ways, although the tenor of the Surgical M&M conference has changed the old question of “What could I have done differently?” remains of central importance to ensuring that surgeons take responsibility for their patients’ well-being.
Dr. Angelos is an ACS Fellow; the Linda Kohler Anderson Professor of Surgery and Surgical Ethics; chief, endocrine surgery; and associate director of the MacLean Center for Clinical Medical Ethics at the University of Chicago.
The right choice? Too little too soon?
The case being presented at Surgical Morbidity and Mortality Conference was all too familiar to many of the surgeons in the auditorium. After extensive discussions with the surgeon, an elderly man had undergone a risky operation. Although the operation had gone well, the patient had several setbacks in the first 48 hours requiring a second trip to the operating room. The patient was back in the surgical ICU fully ventilated on minimal pressors less than 24 hours after leaving the operating room the second time when the patient’s two sons and a daughter approached the surgeon to talk about the plan moving forward.
This was not a surprising turn of events since the patient’s wife had died several years earlier and he was in close contact with his children. They all lived in the area and had been present in the waiting room during both of his trips to the operating room. In accordance with the accepted standards for surrogate decision making, since the patient was not able to make decisions for himself, the appropriate surrogates were the two sons and a daughter. What was surprising to the surgeon was that now, less than 24 hours after leaving the operating room, the children were unanimous in their request that the patient’s life-supporting measures be stopped. Although there was no written advance directive, all the children felt strongly that their father would not have been wanted to be kept alive through “artificial means.”
This request created a series of quandaries for the attending surgeon. First, the surgeon felt that the patient had fully understood the small risks of complications and he had wanted to proceed with the operation despite understanding these risks. Second, the surgeon fully believed that the patient had a good chance for a complete recovery after surgery despite the complication. Based on the belief that the current requirement for intubation and ventilation was a temporary one, the surgeon felt that to withdraw support of the patient for a reversible problem so soon after surgery would be evidence of her not respecting the patient’s specifically stated wishes that he wanted to have surgery and recover from it.
The ensuing M&M discussion focused on a series of important questions. Had the patient fully understood the risks of the operation? His surgeon felt that he had, and she believed that the patient would not have wanted her to “give up” so soon after the operation. Someone asked whether the surgeon should have been willing to perform a high-risk operation on an elderly patient without having had the sons and daughter present to participate in the preoperative discussions. Such a scenario might have avoided the circumstance of the surgeon having a different understanding of the patient’s wishes than was currently being expressed by the sons and daughter. However, the logistics of requiring a competent adult patient who is living independently to bring his sons and daughter to the consultation before the surgeon was willing to operate seemed problematic.
It became clear that from the surgeon’s point of view (as well as from the majority of us at the M&M conference) that when the patient agreed to have the operation, he was not only agreeing to the surgery but also to the necessary perioperative care to allow him to recover. On the other hand, the family (who were now the appropriate surrogate decision makers) believed that the operation was over and all further treatments were open to discussion and should be evaluated based on what they believed their father’s wishes would have been.
What should be done when the surgeon’s responsibility to respect what she believes the patient’s wishes were are in conflict with the surrogate decision makers? Unfortunately, there is no clear answer to this question. The closer in time one is to the operation, the more the patient’s initial decision to proceed with surgery seemingly should hold sway. The further away from the operation, the more the family members’ interpretation of the patient’s wishes should guide decisions about treatments.
The surgeon in this case seemed to have reached an excellent compromise with the family. Based on the belief that the need for intubation and ventilation was short term, the surgeon convinced the family to allow aggressive treatment for 48 hours. She had expressed to the family that she felt she had a responsibility to their father to try to get him safely through this early part of the recovery. After the 48-hour time-limited trial, the surgeon and the family would meet again to discuss his status. If there had been improvements, then the same aggressive treatments would be continued in the hopes that the patient would soon be able to make his own decisions. Alternatively, if there was not improvement over the next 2 days, the surgeon agreed that further interventions would all be reassessed in accordance with what the family believed would have been their father’s wishes.
Although the patient ultimately did not recover, the surgeon felt that she had lived up to her responsibility to respect her patient’s decision to have surgery, while not completely ignoring the family’s wishes. The family also felt that the surgeon had been respectful of their own interpretation of their father’s goals and values. Sometimes in the ethical care of surgical patients, there is not a right and a wrong answer, but a series of compromises that we all hope will lead to the best outcome for our patients.
Dr. Angelos is an ACS Fellow; the Linda Kohler Anderson Professor of Surgery and Surgical Ethics; chief, endocrine surgery; and associate director of the MacLean Center for Clinical Medical Ethics at the University of Chicago.
The case being presented at Surgical Morbidity and Mortality Conference was all too familiar to many of the surgeons in the auditorium. After extensive discussions with the surgeon, an elderly man had undergone a risky operation. Although the operation had gone well, the patient had several setbacks in the first 48 hours requiring a second trip to the operating room. The patient was back in the surgical ICU fully ventilated on minimal pressors less than 24 hours after leaving the operating room the second time when the patient’s two sons and a daughter approached the surgeon to talk about the plan moving forward.
This was not a surprising turn of events since the patient’s wife had died several years earlier and he was in close contact with his children. They all lived in the area and had been present in the waiting room during both of his trips to the operating room. In accordance with the accepted standards for surrogate decision making, since the patient was not able to make decisions for himself, the appropriate surrogates were the two sons and a daughter. What was surprising to the surgeon was that now, less than 24 hours after leaving the operating room, the children were unanimous in their request that the patient’s life-supporting measures be stopped. Although there was no written advance directive, all the children felt strongly that their father would not have been wanted to be kept alive through “artificial means.”
This request created a series of quandaries for the attending surgeon. First, the surgeon felt that the patient had fully understood the small risks of complications and he had wanted to proceed with the operation despite understanding these risks. Second, the surgeon fully believed that the patient had a good chance for a complete recovery after surgery despite the complication. Based on the belief that the current requirement for intubation and ventilation was a temporary one, the surgeon felt that to withdraw support of the patient for a reversible problem so soon after surgery would be evidence of her not respecting the patient’s specifically stated wishes that he wanted to have surgery and recover from it.
The ensuing M&M discussion focused on a series of important questions. Had the patient fully understood the risks of the operation? His surgeon felt that he had, and she believed that the patient would not have wanted her to “give up” so soon after the operation. Someone asked whether the surgeon should have been willing to perform a high-risk operation on an elderly patient without having had the sons and daughter present to participate in the preoperative discussions. Such a scenario might have avoided the circumstance of the surgeon having a different understanding of the patient’s wishes than was currently being expressed by the sons and daughter. However, the logistics of requiring a competent adult patient who is living independently to bring his sons and daughter to the consultation before the surgeon was willing to operate seemed problematic.
It became clear that from the surgeon’s point of view (as well as from the majority of us at the M&M conference) that when the patient agreed to have the operation, he was not only agreeing to the surgery but also to the necessary perioperative care to allow him to recover. On the other hand, the family (who were now the appropriate surrogate decision makers) believed that the operation was over and all further treatments were open to discussion and should be evaluated based on what they believed their father’s wishes would have been.
What should be done when the surgeon’s responsibility to respect what she believes the patient’s wishes were are in conflict with the surrogate decision makers? Unfortunately, there is no clear answer to this question. The closer in time one is to the operation, the more the patient’s initial decision to proceed with surgery seemingly should hold sway. The further away from the operation, the more the family members’ interpretation of the patient’s wishes should guide decisions about treatments.
The surgeon in this case seemed to have reached an excellent compromise with the family. Based on the belief that the need for intubation and ventilation was short term, the surgeon convinced the family to allow aggressive treatment for 48 hours. She had expressed to the family that she felt she had a responsibility to their father to try to get him safely through this early part of the recovery. After the 48-hour time-limited trial, the surgeon and the family would meet again to discuss his status. If there had been improvements, then the same aggressive treatments would be continued in the hopes that the patient would soon be able to make his own decisions. Alternatively, if there was not improvement over the next 2 days, the surgeon agreed that further interventions would all be reassessed in accordance with what the family believed would have been their father’s wishes.
Although the patient ultimately did not recover, the surgeon felt that she had lived up to her responsibility to respect her patient’s decision to have surgery, while not completely ignoring the family’s wishes. The family also felt that the surgeon had been respectful of their own interpretation of their father’s goals and values. Sometimes in the ethical care of surgical patients, there is not a right and a wrong answer, but a series of compromises that we all hope will lead to the best outcome for our patients.
Dr. Angelos is an ACS Fellow; the Linda Kohler Anderson Professor of Surgery and Surgical Ethics; chief, endocrine surgery; and associate director of the MacLean Center for Clinical Medical Ethics at the University of Chicago.
The case being presented at Surgical Morbidity and Mortality Conference was all too familiar to many of the surgeons in the auditorium. After extensive discussions with the surgeon, an elderly man had undergone a risky operation. Although the operation had gone well, the patient had several setbacks in the first 48 hours requiring a second trip to the operating room. The patient was back in the surgical ICU fully ventilated on minimal pressors less than 24 hours after leaving the operating room the second time when the patient’s two sons and a daughter approached the surgeon to talk about the plan moving forward.
This was not a surprising turn of events since the patient’s wife had died several years earlier and he was in close contact with his children. They all lived in the area and had been present in the waiting room during both of his trips to the operating room. In accordance with the accepted standards for surrogate decision making, since the patient was not able to make decisions for himself, the appropriate surrogates were the two sons and a daughter. What was surprising to the surgeon was that now, less than 24 hours after leaving the operating room, the children were unanimous in their request that the patient’s life-supporting measures be stopped. Although there was no written advance directive, all the children felt strongly that their father would not have been wanted to be kept alive through “artificial means.”
This request created a series of quandaries for the attending surgeon. First, the surgeon felt that the patient had fully understood the small risks of complications and he had wanted to proceed with the operation despite understanding these risks. Second, the surgeon fully believed that the patient had a good chance for a complete recovery after surgery despite the complication. Based on the belief that the current requirement for intubation and ventilation was a temporary one, the surgeon felt that to withdraw support of the patient for a reversible problem so soon after surgery would be evidence of her not respecting the patient’s specifically stated wishes that he wanted to have surgery and recover from it.
The ensuing M&M discussion focused on a series of important questions. Had the patient fully understood the risks of the operation? His surgeon felt that he had, and she believed that the patient would not have wanted her to “give up” so soon after the operation. Someone asked whether the surgeon should have been willing to perform a high-risk operation on an elderly patient without having had the sons and daughter present to participate in the preoperative discussions. Such a scenario might have avoided the circumstance of the surgeon having a different understanding of the patient’s wishes than was currently being expressed by the sons and daughter. However, the logistics of requiring a competent adult patient who is living independently to bring his sons and daughter to the consultation before the surgeon was willing to operate seemed problematic.
It became clear that from the surgeon’s point of view (as well as from the majority of us at the M&M conference) that when the patient agreed to have the operation, he was not only agreeing to the surgery but also to the necessary perioperative care to allow him to recover. On the other hand, the family (who were now the appropriate surrogate decision makers) believed that the operation was over and all further treatments were open to discussion and should be evaluated based on what they believed their father’s wishes would have been.
What should be done when the surgeon’s responsibility to respect what she believes the patient’s wishes were are in conflict with the surrogate decision makers? Unfortunately, there is no clear answer to this question. The closer in time one is to the operation, the more the patient’s initial decision to proceed with surgery seemingly should hold sway. The further away from the operation, the more the family members’ interpretation of the patient’s wishes should guide decisions about treatments.
The surgeon in this case seemed to have reached an excellent compromise with the family. Based on the belief that the need for intubation and ventilation was short term, the surgeon convinced the family to allow aggressive treatment for 48 hours. She had expressed to the family that she felt she had a responsibility to their father to try to get him safely through this early part of the recovery. After the 48-hour time-limited trial, the surgeon and the family would meet again to discuss his status. If there had been improvements, then the same aggressive treatments would be continued in the hopes that the patient would soon be able to make his own decisions. Alternatively, if there was not improvement over the next 2 days, the surgeon agreed that further interventions would all be reassessed in accordance with what the family believed would have been their father’s wishes.
Although the patient ultimately did not recover, the surgeon felt that she had lived up to her responsibility to respect her patient’s decision to have surgery, while not completely ignoring the family’s wishes. The family also felt that the surgeon had been respectful of their own interpretation of their father’s goals and values. Sometimes in the ethical care of surgical patients, there is not a right and a wrong answer, but a series of compromises that we all hope will lead to the best outcome for our patients.
Dr. Angelos is an ACS Fellow; the Linda Kohler Anderson Professor of Surgery and Surgical Ethics; chief, endocrine surgery; and associate director of the MacLean Center for Clinical Medical Ethics at the University of Chicago.
The Right Choice? Surgeons, patients, and ethical analysis
In July 2011, I first had the opportunity to write a column on ethics for ACS Surgery News. That article, "Responding to Family/Patient Requests," explored possible responses to the family members’ requests to "do everything" for a critically ill patient. The article was published under the tag line, "The Right Choice."
Since that first article, I have had the opportunity to write 12 additional columns on different ethical issues in the care of surgical patients. The issues have ranged from considerations of informed consent and disclosure of information to the challenges of innovative techniques and scarce resources. Each of these columns has continued to be under the heading "The Right Choice." As I considered what to write about this month, I reviewed my previous articles and I was struck by a worrisome possibility. In the challenging surgical cases presented, is the suggestion that I know "the right choice" actually wrong?
Medical ethics has increasingly become an important topic in medical schools and the clinical care of patients since the late 1970s. Although the medical and surgical care of patients has always had an ethical dimension, it has only been in the last several decades that the ethical issues have been separately identified and analyzed. As the acceptance of surgeons making decisions about what is "best" for their patients has shifted to increasing respect for the patient as an autonomous decision maker, we have seen the importance of understanding patient preferences increase.
At the same time, as medical and surgical care has improved, we now have more options to prolong patients’ lives even when the quality of those lives may be dramatically diminished. These factors have led to the increased consideration of ethical dimensions of decisions that we must help our patients make.
Although many authors have suggested ways to proceed with the ethical analysis of cases, few methods have been as widely adopted as that suggested by Albert Jonsen, Mark Siegler, and William Winslade in their influential book, "Clinical Ethics: A Practical Approach to Ethical Decisions in Clinical Medicine," 7th edition (New York: Lange Clinical Science/McGraw Hill, 2010). These authors suggest that the analysis of a case should include attention to four sets of issues: medical indications, patient preferences, quality of life, and contextual features. By analyzing these issues for a difficult case, we are often able to see where the underlying principles of beneficence, nonmaleficence, respect for patient autonomy, and justice may be at odds.
For example, in the case that I discussed in the July 2011 issue, about the 80-year-old woman with extensive gangrenous bowel, a central concern was whether the surgical decision making should be altered by the family member’s request to "do everything you can." In this case, I suggested that requests from surrogate decision makers must be tempered by the realities of the case and the importance of not harming a patient by providing burdensome care that has minimal chance of success.
As I reread that prior article, I am struck by the fact that I suggest a way of thinking about the case and a series of considerations that are important. However, I am not comfortable saying that I have identified the single correct course of action. I believe that although ethical analysis of cases has tremendous value for doctors and patients, there is rarely one right answer. There may be several wrong answers, and there may be several acceptable answers, but there is rarely a single right choice. My goal in these columns that I wrote in the past and hope to write in the future is to raise awareness of the ethical dimensions of the case, to suggest important considerations, and perhaps even to identify some of the ethical principles that may be relevant. But I do not believe that I can identify "the right choice
In the very first edition of "Clinical Ethics" published in 1982, Jonsen, Siegler, and Winslade wrote in the preface, "We do not merely discuss or analyze the ethical problems; we offer counsel about decisions. Lest this be thought presumptuous, we do not consider our counsel the single and final answer. We offer it in the tradition of medical consultation: The consultant may bring to the practitioner’s view of the case not only broader information but another perspective."
I have tried to provide this type of information and perspective in the ACS Surgery News ethics columns and in view of the difficulty of determining the single right answer to many challenging cases, future columns will be found under the new heading, "The Right Choice?" By adding the critical question mark, I hope that readers will be reminded of the need for ongoing discussion of the challenging ethical questions that arise in the care of surgical patients.
Dr. Angelos is the Linda Kohler Anderson Professor of Surgery and Surgical Ethics; chief, endocrine surgery; and associate director, MacLean Center for Clinical Medical Ethics, at the University of Chicago.
In July 2011, I first had the opportunity to write a column on ethics for ACS Surgery News. That article, "Responding to Family/Patient Requests," explored possible responses to the family members’ requests to "do everything" for a critically ill patient. The article was published under the tag line, "The Right Choice."
Since that first article, I have had the opportunity to write 12 additional columns on different ethical issues in the care of surgical patients. The issues have ranged from considerations of informed consent and disclosure of information to the challenges of innovative techniques and scarce resources. Each of these columns has continued to be under the heading "The Right Choice." As I considered what to write about this month, I reviewed my previous articles and I was struck by a worrisome possibility. In the challenging surgical cases presented, is the suggestion that I know "the right choice" actually wrong?
Medical ethics has increasingly become an important topic in medical schools and the clinical care of patients since the late 1970s. Although the medical and surgical care of patients has always had an ethical dimension, it has only been in the last several decades that the ethical issues have been separately identified and analyzed. As the acceptance of surgeons making decisions about what is "best" for their patients has shifted to increasing respect for the patient as an autonomous decision maker, we have seen the importance of understanding patient preferences increase.
At the same time, as medical and surgical care has improved, we now have more options to prolong patients’ lives even when the quality of those lives may be dramatically diminished. These factors have led to the increased consideration of ethical dimensions of decisions that we must help our patients make.
Although many authors have suggested ways to proceed with the ethical analysis of cases, few methods have been as widely adopted as that suggested by Albert Jonsen, Mark Siegler, and William Winslade in their influential book, "Clinical Ethics: A Practical Approach to Ethical Decisions in Clinical Medicine," 7th edition (New York: Lange Clinical Science/McGraw Hill, 2010). These authors suggest that the analysis of a case should include attention to four sets of issues: medical indications, patient preferences, quality of life, and contextual features. By analyzing these issues for a difficult case, we are often able to see where the underlying principles of beneficence, nonmaleficence, respect for patient autonomy, and justice may be at odds.
For example, in the case that I discussed in the July 2011 issue, about the 80-year-old woman with extensive gangrenous bowel, a central concern was whether the surgical decision making should be altered by the family member’s request to "do everything you can." In this case, I suggested that requests from surrogate decision makers must be tempered by the realities of the case and the importance of not harming a patient by providing burdensome care that has minimal chance of success.
As I reread that prior article, I am struck by the fact that I suggest a way of thinking about the case and a series of considerations that are important. However, I am not comfortable saying that I have identified the single correct course of action. I believe that although ethical analysis of cases has tremendous value for doctors and patients, there is rarely one right answer. There may be several wrong answers, and there may be several acceptable answers, but there is rarely a single right choice. My goal in these columns that I wrote in the past and hope to write in the future is to raise awareness of the ethical dimensions of the case, to suggest important considerations, and perhaps even to identify some of the ethical principles that may be relevant. But I do not believe that I can identify "the right choice
In the very first edition of "Clinical Ethics" published in 1982, Jonsen, Siegler, and Winslade wrote in the preface, "We do not merely discuss or analyze the ethical problems; we offer counsel about decisions. Lest this be thought presumptuous, we do not consider our counsel the single and final answer. We offer it in the tradition of medical consultation: The consultant may bring to the practitioner’s view of the case not only broader information but another perspective."
I have tried to provide this type of information and perspective in the ACS Surgery News ethics columns and in view of the difficulty of determining the single right answer to many challenging cases, future columns will be found under the new heading, "The Right Choice?" By adding the critical question mark, I hope that readers will be reminded of the need for ongoing discussion of the challenging ethical questions that arise in the care of surgical patients.
Dr. Angelos is the Linda Kohler Anderson Professor of Surgery and Surgical Ethics; chief, endocrine surgery; and associate director, MacLean Center for Clinical Medical Ethics, at the University of Chicago.
In July 2011, I first had the opportunity to write a column on ethics for ACS Surgery News. That article, "Responding to Family/Patient Requests," explored possible responses to the family members’ requests to "do everything" for a critically ill patient. The article was published under the tag line, "The Right Choice."
Since that first article, I have had the opportunity to write 12 additional columns on different ethical issues in the care of surgical patients. The issues have ranged from considerations of informed consent and disclosure of information to the challenges of innovative techniques and scarce resources. Each of these columns has continued to be under the heading "The Right Choice." As I considered what to write about this month, I reviewed my previous articles and I was struck by a worrisome possibility. In the challenging surgical cases presented, is the suggestion that I know "the right choice" actually wrong?
Medical ethics has increasingly become an important topic in medical schools and the clinical care of patients since the late 1970s. Although the medical and surgical care of patients has always had an ethical dimension, it has only been in the last several decades that the ethical issues have been separately identified and analyzed. As the acceptance of surgeons making decisions about what is "best" for their patients has shifted to increasing respect for the patient as an autonomous decision maker, we have seen the importance of understanding patient preferences increase.
At the same time, as medical and surgical care has improved, we now have more options to prolong patients’ lives even when the quality of those lives may be dramatically diminished. These factors have led to the increased consideration of ethical dimensions of decisions that we must help our patients make.
Although many authors have suggested ways to proceed with the ethical analysis of cases, few methods have been as widely adopted as that suggested by Albert Jonsen, Mark Siegler, and William Winslade in their influential book, "Clinical Ethics: A Practical Approach to Ethical Decisions in Clinical Medicine," 7th edition (New York: Lange Clinical Science/McGraw Hill, 2010). These authors suggest that the analysis of a case should include attention to four sets of issues: medical indications, patient preferences, quality of life, and contextual features. By analyzing these issues for a difficult case, we are often able to see where the underlying principles of beneficence, nonmaleficence, respect for patient autonomy, and justice may be at odds.
For example, in the case that I discussed in the July 2011 issue, about the 80-year-old woman with extensive gangrenous bowel, a central concern was whether the surgical decision making should be altered by the family member’s request to "do everything you can." In this case, I suggested that requests from surrogate decision makers must be tempered by the realities of the case and the importance of not harming a patient by providing burdensome care that has minimal chance of success.
As I reread that prior article, I am struck by the fact that I suggest a way of thinking about the case and a series of considerations that are important. However, I am not comfortable saying that I have identified the single correct course of action. I believe that although ethical analysis of cases has tremendous value for doctors and patients, there is rarely one right answer. There may be several wrong answers, and there may be several acceptable answers, but there is rarely a single right choice. My goal in these columns that I wrote in the past and hope to write in the future is to raise awareness of the ethical dimensions of the case, to suggest important considerations, and perhaps even to identify some of the ethical principles that may be relevant. But I do not believe that I can identify "the right choice
In the very first edition of "Clinical Ethics" published in 1982, Jonsen, Siegler, and Winslade wrote in the preface, "We do not merely discuss or analyze the ethical problems; we offer counsel about decisions. Lest this be thought presumptuous, we do not consider our counsel the single and final answer. We offer it in the tradition of medical consultation: The consultant may bring to the practitioner’s view of the case not only broader information but another perspective."
I have tried to provide this type of information and perspective in the ACS Surgery News ethics columns and in view of the difficulty of determining the single right answer to many challenging cases, future columns will be found under the new heading, "The Right Choice?" By adding the critical question mark, I hope that readers will be reminded of the need for ongoing discussion of the challenging ethical questions that arise in the care of surgical patients.
Dr. Angelos is the Linda Kohler Anderson Professor of Surgery and Surgical Ethics; chief, endocrine surgery; and associate director, MacLean Center for Clinical Medical Ethics, at the University of Chicago.
More than a document: The importance of the informed consent process
In a recent issue of JAMA Surgery, Dr. Jacqueline M. Garonzik-Wang and colleagues presented the results of an important study of missing surgical consent forms at Johns Hopkins Hospital. The authors tallied the absence of a surgical consent form in a patient’s medical record and the resulting delays and other impacts on the surgical services. The authors also surveyed nurses, surgical residents, and surgical faculty regarding their satisfaction with the informed consent process. The results of the study show that cases are often delayed and surgical residents are often pulled away from other activities (e.g., educational conferences) to have new consent forms signed in the preoperative area. In addition, both faculty and residents had concerns about residents obtaining informed consent for major elective procedures.
This is undoubtedly an important study in that it casts light upon an important source of delays and dissatisfaction in the preoperative setting. However, are there additional lessons about informed consent that might be gleaned from this type of analysis?
Moving beyond the study itself, other important issues arise. Consider a patient who comes to the office for evaluation of a symptomatic hernia. Once the surgeon decides that the operation is indicated, the consent process requires a description of the indications (benefits), risks, and alternatives for the patient. Even though the surgeon may be convinced that the benefits of the operation outweigh the risks, the patient still needs to be convinced. Depending on the patient and the procedure being recommended, the time necessary to explain the above to the patient so that he or she is adequately informed and willing to sign the consent form will vary greatly.
In contemporary surgical practice, the determination of when the patient has been adequately informed is made by the patient. At the point that he or she is comfortable enough with the recommendation to proceed to an operation, the informed consent process has reached its conclusion. Only at this point, is the informed consent form even relevant to the discussion. The patient’s signature on the informed consent form is designed to signify the conclusion of the informed consent process.
Although we often mix the signature on the form with the process itself, they are, in fact, markedly different. The informed consent process is an ethical requirement; whereas the signature on the form is a legal requirement. The fact that these two requirements are different can readily be seen from the Mayo Clinic experience. For years, no informed consent forms were even used at the Mayo Clinic! The discussion of the indications, risks, and alternatives was documented in the surgeon’s notes and the fact that the patient showed up for the elective operation could be taken as the evidence of the adequacy of the informed consent process. Although this practice was acceptable to both surgeons and patients for years, the Clinic ultimately changed its practice in response to federal regulations that require the patient’s signature on an informed consent form.
Certainly, there is nothing inherently wrong with the practice of obtaining a signature from a patient on a consent form at the conclusion of the informed consent process. However, the current emphasis on the form itself has had a tendency for the process to be short changed in favor of getting the signature. The fact that both practicing surgeons and surgeons in training often slip into the habit of referring to the process solely by the form can frequently be seen. How often have we or our colleagues talked about "consenting the patient" when we really mean "obtaining informed consent from a patient"?
The Hopkins study serves to remind us that if we really take the process of obtaining informed consent from surgical patients as ethically important, we must be sure to give it the attention it deserves in our practice. If obtaining informed consent is central to the ethical practice of surgery, then why do we so often depend on the least experienced member of the surgical team to carry out this task right before surgery? Perhaps this practice does not reflect our devaluation of the informed consent process as much as a realization that if a patient scheduled for elective surgery has discussed the operation with the surgeon and has chosen to come to the hospital for the procedure, we can assume that the patient has already had a satisfactory consent process. In this context, the problem of the missing consent form is less an ethical issue than a clerical one that might be solved by eliminating the paper form and depending on technology for a solution.
How might a technological fix help in this situation? Among the possibilities would be to have paper forms signed in the attending surgeon’s office at the time of the informed consent discussion. The form could then be scanned into the electronic medical record. Such an approach should significantly reduce the numbers of missing forms since the electronic version cannot be misplaced. This approach will not, however, solve the problem of the missing consent form if the patient is undecided about surgery when he or she leaves the outpatient visit. In such cases, the patient may not be back to the office or hospital until the day of surgery.
Alternatively, all of the information on the standard informed consent form could be made electronic and after the discussion with the attending surgeon, the electronic version could be signed if the patient is amenable, or printed for the patient to take home if he or she is undecided. If the patient then decides to proceed with surgery, the patient could sign in to a secure website and electronically acknowledge (that is, sign) the electronic consent form. This electronic version could then be reviewed by the preoperative nurse and the patient on the day of surgery. As long as the informed consent process that is dependent on the relationship between the surgeon and patient remains intact, there is no reason why technology might not help us eliminate the problem of the missing consent form.
Garonzik-Wang JM, Brat G, Salazar JH, et al. Missing consent forms in the preoperative area: A single-center assessment of the scope of the problem and its downstream effects. JAMA Surg. Published online July 10, 2013, E1-E4.
Dr. Angelos is an ACS Fellow; the Linda Kohler Anderson Professor of Surgery and Surgical Ethics; chief, endocrine surgery; and associate director of the MacLean Center for Clinical Medical Ethics at the University of Chicago.
In a recent issue of JAMA Surgery, Dr. Jacqueline M. Garonzik-Wang and colleagues presented the results of an important study of missing surgical consent forms at Johns Hopkins Hospital. The authors tallied the absence of a surgical consent form in a patient’s medical record and the resulting delays and other impacts on the surgical services. The authors also surveyed nurses, surgical residents, and surgical faculty regarding their satisfaction with the informed consent process. The results of the study show that cases are often delayed and surgical residents are often pulled away from other activities (e.g., educational conferences) to have new consent forms signed in the preoperative area. In addition, both faculty and residents had concerns about residents obtaining informed consent for major elective procedures.
This is undoubtedly an important study in that it casts light upon an important source of delays and dissatisfaction in the preoperative setting. However, are there additional lessons about informed consent that might be gleaned from this type of analysis?
Moving beyond the study itself, other important issues arise. Consider a patient who comes to the office for evaluation of a symptomatic hernia. Once the surgeon decides that the operation is indicated, the consent process requires a description of the indications (benefits), risks, and alternatives for the patient. Even though the surgeon may be convinced that the benefits of the operation outweigh the risks, the patient still needs to be convinced. Depending on the patient and the procedure being recommended, the time necessary to explain the above to the patient so that he or she is adequately informed and willing to sign the consent form will vary greatly.
In contemporary surgical practice, the determination of when the patient has been adequately informed is made by the patient. At the point that he or she is comfortable enough with the recommendation to proceed to an operation, the informed consent process has reached its conclusion. Only at this point, is the informed consent form even relevant to the discussion. The patient’s signature on the informed consent form is designed to signify the conclusion of the informed consent process.
Although we often mix the signature on the form with the process itself, they are, in fact, markedly different. The informed consent process is an ethical requirement; whereas the signature on the form is a legal requirement. The fact that these two requirements are different can readily be seen from the Mayo Clinic experience. For years, no informed consent forms were even used at the Mayo Clinic! The discussion of the indications, risks, and alternatives was documented in the surgeon’s notes and the fact that the patient showed up for the elective operation could be taken as the evidence of the adequacy of the informed consent process. Although this practice was acceptable to both surgeons and patients for years, the Clinic ultimately changed its practice in response to federal regulations that require the patient’s signature on an informed consent form.
Certainly, there is nothing inherently wrong with the practice of obtaining a signature from a patient on a consent form at the conclusion of the informed consent process. However, the current emphasis on the form itself has had a tendency for the process to be short changed in favor of getting the signature. The fact that both practicing surgeons and surgeons in training often slip into the habit of referring to the process solely by the form can frequently be seen. How often have we or our colleagues talked about "consenting the patient" when we really mean "obtaining informed consent from a patient"?
The Hopkins study serves to remind us that if we really take the process of obtaining informed consent from surgical patients as ethically important, we must be sure to give it the attention it deserves in our practice. If obtaining informed consent is central to the ethical practice of surgery, then why do we so often depend on the least experienced member of the surgical team to carry out this task right before surgery? Perhaps this practice does not reflect our devaluation of the informed consent process as much as a realization that if a patient scheduled for elective surgery has discussed the operation with the surgeon and has chosen to come to the hospital for the procedure, we can assume that the patient has already had a satisfactory consent process. In this context, the problem of the missing consent form is less an ethical issue than a clerical one that might be solved by eliminating the paper form and depending on technology for a solution.
How might a technological fix help in this situation? Among the possibilities would be to have paper forms signed in the attending surgeon’s office at the time of the informed consent discussion. The form could then be scanned into the electronic medical record. Such an approach should significantly reduce the numbers of missing forms since the electronic version cannot be misplaced. This approach will not, however, solve the problem of the missing consent form if the patient is undecided about surgery when he or she leaves the outpatient visit. In such cases, the patient may not be back to the office or hospital until the day of surgery.
Alternatively, all of the information on the standard informed consent form could be made electronic and after the discussion with the attending surgeon, the electronic version could be signed if the patient is amenable, or printed for the patient to take home if he or she is undecided. If the patient then decides to proceed with surgery, the patient could sign in to a secure website and electronically acknowledge (that is, sign) the electronic consent form. This electronic version could then be reviewed by the preoperative nurse and the patient on the day of surgery. As long as the informed consent process that is dependent on the relationship between the surgeon and patient remains intact, there is no reason why technology might not help us eliminate the problem of the missing consent form.
Garonzik-Wang JM, Brat G, Salazar JH, et al. Missing consent forms in the preoperative area: A single-center assessment of the scope of the problem and its downstream effects. JAMA Surg. Published online July 10, 2013, E1-E4.
Dr. Angelos is an ACS Fellow; the Linda Kohler Anderson Professor of Surgery and Surgical Ethics; chief, endocrine surgery; and associate director of the MacLean Center for Clinical Medical Ethics at the University of Chicago.
In a recent issue of JAMA Surgery, Dr. Jacqueline M. Garonzik-Wang and colleagues presented the results of an important study of missing surgical consent forms at Johns Hopkins Hospital. The authors tallied the absence of a surgical consent form in a patient’s medical record and the resulting delays and other impacts on the surgical services. The authors also surveyed nurses, surgical residents, and surgical faculty regarding their satisfaction with the informed consent process. The results of the study show that cases are often delayed and surgical residents are often pulled away from other activities (e.g., educational conferences) to have new consent forms signed in the preoperative area. In addition, both faculty and residents had concerns about residents obtaining informed consent for major elective procedures.
This is undoubtedly an important study in that it casts light upon an important source of delays and dissatisfaction in the preoperative setting. However, are there additional lessons about informed consent that might be gleaned from this type of analysis?
Moving beyond the study itself, other important issues arise. Consider a patient who comes to the office for evaluation of a symptomatic hernia. Once the surgeon decides that the operation is indicated, the consent process requires a description of the indications (benefits), risks, and alternatives for the patient. Even though the surgeon may be convinced that the benefits of the operation outweigh the risks, the patient still needs to be convinced. Depending on the patient and the procedure being recommended, the time necessary to explain the above to the patient so that he or she is adequately informed and willing to sign the consent form will vary greatly.
In contemporary surgical practice, the determination of when the patient has been adequately informed is made by the patient. At the point that he or she is comfortable enough with the recommendation to proceed to an operation, the informed consent process has reached its conclusion. Only at this point, is the informed consent form even relevant to the discussion. The patient’s signature on the informed consent form is designed to signify the conclusion of the informed consent process.
Although we often mix the signature on the form with the process itself, they are, in fact, markedly different. The informed consent process is an ethical requirement; whereas the signature on the form is a legal requirement. The fact that these two requirements are different can readily be seen from the Mayo Clinic experience. For years, no informed consent forms were even used at the Mayo Clinic! The discussion of the indications, risks, and alternatives was documented in the surgeon’s notes and the fact that the patient showed up for the elective operation could be taken as the evidence of the adequacy of the informed consent process. Although this practice was acceptable to both surgeons and patients for years, the Clinic ultimately changed its practice in response to federal regulations that require the patient’s signature on an informed consent form.
Certainly, there is nothing inherently wrong with the practice of obtaining a signature from a patient on a consent form at the conclusion of the informed consent process. However, the current emphasis on the form itself has had a tendency for the process to be short changed in favor of getting the signature. The fact that both practicing surgeons and surgeons in training often slip into the habit of referring to the process solely by the form can frequently be seen. How often have we or our colleagues talked about "consenting the patient" when we really mean "obtaining informed consent from a patient"?
The Hopkins study serves to remind us that if we really take the process of obtaining informed consent from surgical patients as ethically important, we must be sure to give it the attention it deserves in our practice. If obtaining informed consent is central to the ethical practice of surgery, then why do we so often depend on the least experienced member of the surgical team to carry out this task right before surgery? Perhaps this practice does not reflect our devaluation of the informed consent process as much as a realization that if a patient scheduled for elective surgery has discussed the operation with the surgeon and has chosen to come to the hospital for the procedure, we can assume that the patient has already had a satisfactory consent process. In this context, the problem of the missing consent form is less an ethical issue than a clerical one that might be solved by eliminating the paper form and depending on technology for a solution.
How might a technological fix help in this situation? Among the possibilities would be to have paper forms signed in the attending surgeon’s office at the time of the informed consent discussion. The form could then be scanned into the electronic medical record. Such an approach should significantly reduce the numbers of missing forms since the electronic version cannot be misplaced. This approach will not, however, solve the problem of the missing consent form if the patient is undecided about surgery when he or she leaves the outpatient visit. In such cases, the patient may not be back to the office or hospital until the day of surgery.
Alternatively, all of the information on the standard informed consent form could be made electronic and after the discussion with the attending surgeon, the electronic version could be signed if the patient is amenable, or printed for the patient to take home if he or she is undecided. If the patient then decides to proceed with surgery, the patient could sign in to a secure website and electronically acknowledge (that is, sign) the electronic consent form. This electronic version could then be reviewed by the preoperative nurse and the patient on the day of surgery. As long as the informed consent process that is dependent on the relationship between the surgeon and patient remains intact, there is no reason why technology might not help us eliminate the problem of the missing consent form.
Garonzik-Wang JM, Brat G, Salazar JH, et al. Missing consent forms in the preoperative area: A single-center assessment of the scope of the problem and its downstream effects. JAMA Surg. Published online July 10, 2013, E1-E4.
Dr. Angelos is an ACS Fellow; the Linda Kohler Anderson Professor of Surgery and Surgical Ethics; chief, endocrine surgery; and associate director of the MacLean Center for Clinical Medical Ethics at the University of Chicago.
'Don't tell her the diagnosis': Nondisclosure and the surgeon
It goes without saying that good surgical care is based on honesty in informed consent. The ethical basis of telling patients about their conditions and what needs to be done is central to what surgeons do. In this context, a request not to tell a patient a diagnosis is always jarring to me. One of the ethical principles that medicine has most fully embraced in the last few decades has been respect for patient autonomy. This principle is very much in opposition with the previous practice of paternalism in the prior era of medical care in which "the doctor knows best" and doctors made decisions for their patients. As a practicing surgeon today, I feel that there is very little that I know that I cannot disclose to my patient. However, occasionally cases challenge our underlying assumptions.
A few years ago, I saw an 11-year-old girl with a recent diagnosis of papillary thyroid cancer. Before I even saw her, the parents had called my office to be sure that I did not tell her the diagnosis of cancer. I found this request to be troubling. How could I discuss the operation with this child without telling her that she had cancer? Her parents assured me that she knew that she had a thyroid nodule and that on the basis of the biopsy, that she would need a thyroidectomy. The only thing that had not been explained to the child was the diagnosis of thyroid cancer.
Despite my initial concern with this request, in pediatrics, the parents are the decision makers for the child, so that there was no legal reason why the patient needed to be told that she had cancer. Nevertheless, the ethical imperative to include the diagnosis of cancer in the discussion about surgery weighed on me. Despite my initial opposition to being put in the position of not telling the patient of her diagnosis, I decided that I could do nothing more at that point. I hoped to convince the parents to let me share the diagnosis with their daughter at a later time.
When I met my patient, I found her to be a quiet and calm girl who seemed to me to be mature beyond her years. I proceeded to explain the risks of thyroidectomy to the patient and her parents. She seemed to take it all in and asked good questions about the operation and the recovery. She wanted to know how long before she could get back to school and sports. At the end of the consultation, the patient’s mother asked her to wait with her younger sister and her grandmother in the waiting room for a few minutes while the parents spoke to me alone.
Once she had left, the parents expressed their appreciation that I had not told her she had cancer. I told them how impressed I was with her poise and maturity and that although I did not agree with their decision not to tell her the diagnosis, I would certainly go along with it based on the assumption that they knew what would be in her best interests better than I. They seemed relieved that I was willing to go along with their decision. I realized at that point that the ethical arguments in favor of telling the patient of her diagnosis would likely be unconvincing for the parents, so I decided to focus instead on the practical problems with nondisclosure.
I asked the parents to consider that the operative schedule would include the diagnosis of thyroid cancer and that everyone seeing her in the hospital (doctors, nurses, etc.) would know her diagnosis. For all of these reasons, there would be a high likelihood that at some point during her hospital stay, someone would slip, and she would learn of the diagnosis in an uncontrolled manner from someone other than her parents or her doctor. In addition, I suggested that she would likely figure it out anyway even if no one told her. Finally, I asked them to consider the next few years. If they did not tell her the diagnosis of cancer now, at what point would they choose to do so? Certainly, at the point that she turned 18 years old, she would need to know the diagnosis, but would the parents want to hide it from her that long, even if they could?
The parents seemed to have not thought of all of these issues and answered that they fully wanted to tell her, but they were concerned about doing so when they, themselves, were still so upset by the diagnosis. They explained that they planned to tell her when they felt more in control of their own emotions.
Two weeks later, on the morning of surgery, the parents told me how they had explained the diagnosis to their daughter and that she had then explained it to her younger sister. It was clear to me that the assurance that the parents had given to the patient had allowed her to be calm and positive when talking with her younger sister. It is unknown how things might have worked out had the parents not told the patient of her diagnosis when they did, but it was clear to me that the fact that the parents had been able to control some aspects of how the patient learned of her diagnosis had helped them to feel better about a difficult situation. In addition, the patient seemed to be reassured by having explained things to her sister. Although I continue to assume that disclosure is always the best approach, there may be cases, such as this one, in which the timing of the disclosure might allow for a good outcome.
Dr. Angelos is an ACS Fellow, the Linda Kohler Anderson Professor of Surgery and Surgical Ethics; chief, endocrine surgery, and associate director of the MacLean Center for Clinical Medical Ethics at the University of Chicago.
It goes without saying that good surgical care is based on honesty in informed consent. The ethical basis of telling patients about their conditions and what needs to be done is central to what surgeons do. In this context, a request not to tell a patient a diagnosis is always jarring to me. One of the ethical principles that medicine has most fully embraced in the last few decades has been respect for patient autonomy. This principle is very much in opposition with the previous practice of paternalism in the prior era of medical care in which "the doctor knows best" and doctors made decisions for their patients. As a practicing surgeon today, I feel that there is very little that I know that I cannot disclose to my patient. However, occasionally cases challenge our underlying assumptions.
A few years ago, I saw an 11-year-old girl with a recent diagnosis of papillary thyroid cancer. Before I even saw her, the parents had called my office to be sure that I did not tell her the diagnosis of cancer. I found this request to be troubling. How could I discuss the operation with this child without telling her that she had cancer? Her parents assured me that she knew that she had a thyroid nodule and that on the basis of the biopsy, that she would need a thyroidectomy. The only thing that had not been explained to the child was the diagnosis of thyroid cancer.
Despite my initial concern with this request, in pediatrics, the parents are the decision makers for the child, so that there was no legal reason why the patient needed to be told that she had cancer. Nevertheless, the ethical imperative to include the diagnosis of cancer in the discussion about surgery weighed on me. Despite my initial opposition to being put in the position of not telling the patient of her diagnosis, I decided that I could do nothing more at that point. I hoped to convince the parents to let me share the diagnosis with their daughter at a later time.
When I met my patient, I found her to be a quiet and calm girl who seemed to me to be mature beyond her years. I proceeded to explain the risks of thyroidectomy to the patient and her parents. She seemed to take it all in and asked good questions about the operation and the recovery. She wanted to know how long before she could get back to school and sports. At the end of the consultation, the patient’s mother asked her to wait with her younger sister and her grandmother in the waiting room for a few minutes while the parents spoke to me alone.
Once she had left, the parents expressed their appreciation that I had not told her she had cancer. I told them how impressed I was with her poise and maturity and that although I did not agree with their decision not to tell her the diagnosis, I would certainly go along with it based on the assumption that they knew what would be in her best interests better than I. They seemed relieved that I was willing to go along with their decision. I realized at that point that the ethical arguments in favor of telling the patient of her diagnosis would likely be unconvincing for the parents, so I decided to focus instead on the practical problems with nondisclosure.
I asked the parents to consider that the operative schedule would include the diagnosis of thyroid cancer and that everyone seeing her in the hospital (doctors, nurses, etc.) would know her diagnosis. For all of these reasons, there would be a high likelihood that at some point during her hospital stay, someone would slip, and she would learn of the diagnosis in an uncontrolled manner from someone other than her parents or her doctor. In addition, I suggested that she would likely figure it out anyway even if no one told her. Finally, I asked them to consider the next few years. If they did not tell her the diagnosis of cancer now, at what point would they choose to do so? Certainly, at the point that she turned 18 years old, she would need to know the diagnosis, but would the parents want to hide it from her that long, even if they could?
The parents seemed to have not thought of all of these issues and answered that they fully wanted to tell her, but they were concerned about doing so when they, themselves, were still so upset by the diagnosis. They explained that they planned to tell her when they felt more in control of their own emotions.
Two weeks later, on the morning of surgery, the parents told me how they had explained the diagnosis to their daughter and that she had then explained it to her younger sister. It was clear to me that the assurance that the parents had given to the patient had allowed her to be calm and positive when talking with her younger sister. It is unknown how things might have worked out had the parents not told the patient of her diagnosis when they did, but it was clear to me that the fact that the parents had been able to control some aspects of how the patient learned of her diagnosis had helped them to feel better about a difficult situation. In addition, the patient seemed to be reassured by having explained things to her sister. Although I continue to assume that disclosure is always the best approach, there may be cases, such as this one, in which the timing of the disclosure might allow for a good outcome.
Dr. Angelos is an ACS Fellow, the Linda Kohler Anderson Professor of Surgery and Surgical Ethics; chief, endocrine surgery, and associate director of the MacLean Center for Clinical Medical Ethics at the University of Chicago.
It goes without saying that good surgical care is based on honesty in informed consent. The ethical basis of telling patients about their conditions and what needs to be done is central to what surgeons do. In this context, a request not to tell a patient a diagnosis is always jarring to me. One of the ethical principles that medicine has most fully embraced in the last few decades has been respect for patient autonomy. This principle is very much in opposition with the previous practice of paternalism in the prior era of medical care in which "the doctor knows best" and doctors made decisions for their patients. As a practicing surgeon today, I feel that there is very little that I know that I cannot disclose to my patient. However, occasionally cases challenge our underlying assumptions.
A few years ago, I saw an 11-year-old girl with a recent diagnosis of papillary thyroid cancer. Before I even saw her, the parents had called my office to be sure that I did not tell her the diagnosis of cancer. I found this request to be troubling. How could I discuss the operation with this child without telling her that she had cancer? Her parents assured me that she knew that she had a thyroid nodule and that on the basis of the biopsy, that she would need a thyroidectomy. The only thing that had not been explained to the child was the diagnosis of thyroid cancer.
Despite my initial concern with this request, in pediatrics, the parents are the decision makers for the child, so that there was no legal reason why the patient needed to be told that she had cancer. Nevertheless, the ethical imperative to include the diagnosis of cancer in the discussion about surgery weighed on me. Despite my initial opposition to being put in the position of not telling the patient of her diagnosis, I decided that I could do nothing more at that point. I hoped to convince the parents to let me share the diagnosis with their daughter at a later time.
When I met my patient, I found her to be a quiet and calm girl who seemed to me to be mature beyond her years. I proceeded to explain the risks of thyroidectomy to the patient and her parents. She seemed to take it all in and asked good questions about the operation and the recovery. She wanted to know how long before she could get back to school and sports. At the end of the consultation, the patient’s mother asked her to wait with her younger sister and her grandmother in the waiting room for a few minutes while the parents spoke to me alone.
Once she had left, the parents expressed their appreciation that I had not told her she had cancer. I told them how impressed I was with her poise and maturity and that although I did not agree with their decision not to tell her the diagnosis, I would certainly go along with it based on the assumption that they knew what would be in her best interests better than I. They seemed relieved that I was willing to go along with their decision. I realized at that point that the ethical arguments in favor of telling the patient of her diagnosis would likely be unconvincing for the parents, so I decided to focus instead on the practical problems with nondisclosure.
I asked the parents to consider that the operative schedule would include the diagnosis of thyroid cancer and that everyone seeing her in the hospital (doctors, nurses, etc.) would know her diagnosis. For all of these reasons, there would be a high likelihood that at some point during her hospital stay, someone would slip, and she would learn of the diagnosis in an uncontrolled manner from someone other than her parents or her doctor. In addition, I suggested that she would likely figure it out anyway even if no one told her. Finally, I asked them to consider the next few years. If they did not tell her the diagnosis of cancer now, at what point would they choose to do so? Certainly, at the point that she turned 18 years old, she would need to know the diagnosis, but would the parents want to hide it from her that long, even if they could?
The parents seemed to have not thought of all of these issues and answered that they fully wanted to tell her, but they were concerned about doing so when they, themselves, were still so upset by the diagnosis. They explained that they planned to tell her when they felt more in control of their own emotions.
Two weeks later, on the morning of surgery, the parents told me how they had explained the diagnosis to their daughter and that she had then explained it to her younger sister. It was clear to me that the assurance that the parents had given to the patient had allowed her to be calm and positive when talking with her younger sister. It is unknown how things might have worked out had the parents not told the patient of her diagnosis when they did, but it was clear to me that the fact that the parents had been able to control some aspects of how the patient learned of her diagnosis had helped them to feel better about a difficult situation. In addition, the patient seemed to be reassured by having explained things to her sister. Although I continue to assume that disclosure is always the best approach, there may be cases, such as this one, in which the timing of the disclosure might allow for a good outcome.
Dr. Angelos is an ACS Fellow, the Linda Kohler Anderson Professor of Surgery and Surgical Ethics; chief, endocrine surgery, and associate director of the MacLean Center for Clinical Medical Ethics at the University of Chicago.
