Medical indications
Patient preferences
The principles of beneficence and nonmaleficence
The principle of respect for autonomy
1. What is the patient’s medical problem? history? diagnosis? prognosis?
1. Is the patient mentally capable and legally competent? Is there evidence of incapacity?
2. Is the problem acute, chronic, critical, emergent, or reversible?
2. If competent, what is the patient stating about preferences for treatment?
3. What are the goals of treatment?
3. Has the patient been informed of benefits and risks, understood this information, and given consent?
4. What are the probabilities of success?
4. If incapacitated, who is the appropriate surrogate? Is the surrogate using appropriate standards for decision-making?
5. What are the plans in case of therapeutic failure?
5. Has the patient expressed prior preferences, e.g., advance directives?
6. In sum, how can this patient be benefited by medical and nursing care, and how can harm be avoided?
6. Is the patient unwilling or unable to cooperate with medical treatment? If so, why?
7. In sum, is the patient’s right to choose being respected to the extent possible in ethics and law?
Quality of life
Contextual features
The principles of beneficence and nonmaleficence and respect for autonomy
The principles of loyalty and fairness
1. What are the prospects, with or without treatment, for a return to normal life?
1. Are there family issues that might influence treatment decisions?
2. What physical, mental, and social deficits are the patient likely to experience if treatment succeeds?
2. Are there provider (physicians and nurses) issues that might influence treatment decisions?
3. Are there biases that might prejudice the provider’s evaluation of the patient’s quality of life?
3. Are there financial and economic factors?
4. Is the patient’s present or future condition such that his or her continued life might be judged undesirable?
4. Are there religious or cultural factors?
5. Is there any plan and rationale to forego treatment?
5. Are there limits on confidentiality?
6. Are there plans for comfort and palliative care?
6. Are there problems of allocation of resources?
7. How does the law affect treatment decisions?
8. Is clinical research or teaching involved?
9. Is there any conflict of interest on the part of the providers or the institution?
1.
Medical indications
2.
Patient preferences
3.
Quality of life
4.
Contextual features, defined as the social, economic, legal, and administrative context in which the case occurs
Most ethical conflicts can be resolved by falling back on the medical indications that represent the medical facts of the case. This information, plus the second category of patient preferences, almost always will lead the clinical surgeon to a resolution of the ethical problem. If the ethical dilemma results from conflicts among the patient, the family, the health-care team, or institutional policy, then adequate resolution may become dependent on applying analysis of the additional categories, quality of life, and the array of contextual feature.
Specific Dilemmas of Colon and Rectal Surgery
Special Considerations for Colon and Rectal Surgeons
Colorectal surgeons frequently are confronted with ethical dilemmas. These may include issues such as:
Screening, preventive measures, understanding genetic predisposition to disease, and even the need for what has come to be called preemptive surgery
Challenges of respecting confidentiality and requesting genetic counseling to deal with the long-term aspects involving not only the patient but also the family members
Quality-of-life issues as body image and impairment of sexual function
Differentiating acceptable surgical innovation from truly investigative ventures that require research protocols and institutional approval
Categories of Patient Encounters
Severe Emergency: Life in Immediate Jeopardy
An example would be a critically ill person brought in from a severe motor vehicle accident.
Urgent: Serious Problem Needing Surgery
An example would be a patient brought in with peritonitis.
When there is some but not much time, the presence of a surrogate and clearly described advance directives would be extremely helpful.
Semi-elective: Will Probably Need Surgery
An example would be a patient with known extensive intra-abdominal cancer who presents with a significant, unresolving intestinal obstruction.
Determination of decisional capacity, the existence of advance directives, or the presence of a reliable surrogate is very important.
Autonomy/Decision-Making Capacity/Competency
General Concepts
Autonomy Versus Paternalism: Trust Is the Bridge
Individual freedom (autonomy) is one of the basic tenets of modern bioethics and implies that a person should be free to make his or her own decisions.
Paternalism involves the physician acting on what he or she thought was good for the patient, whether or not the patient agreed.
Patients often significantly rely on physicians for guidance through complicated choices, often where life itself is on the line.
The key to accomplishing this is based on the principle of trust.
Refusal of Treatment
Ethical dilemmas usually occur when there is disagreement among the patient, the family, and the health-care team.
The courts have, however, identified four state interests that override the refusal or termination of medical treatment on behalf of competent and incompetent persons, including:
The preservation of human life
The protection of the interests of innocent third persons
The prevention of suicide
The maintenance of the integrity of the medical profession
Each competent patient has a right to refuse treatment, even if the results of such refusal will be their death.
There are situations where parents or guardians are involved in refusal to accept and allow treatment on behalf of miners.
These are the most common instances where court intervention is sought, and to resolve the problem, the courts must balance the best interests of the child against the desires of the parents.
Telling the Truth/Disclosing Errors
General Concepts
There may be circumstances where telling the whole truth to a patient will have a negative impact on his or her overall well-being.
Truth telling also would apply in situations involving medical mistakes, even those mistakes that are minor and arguably have no detrimental effect on the patient.
Prognosis: Balance Between Giving False Hope and Removing All Hope
Even what is anticipated to be a fairly straightforward operation may have unexpected, adverse results.
Discussing prognosis with our patients and their families is one of the situations, which forces us most carefully to choose our words precisely.
It can be very expeditious for us to use statistics as a form of truth dumping, but such an act can be devastating to a terrified, desperate, and inadequately informed patient who is desperately clinging to any possible hope.
Patients with Impaired Decision-Making Capacity
Examples of patients having impaired decision-making capacity include minors, mentally handicapped persons, those with organic brain disease or in toxic states, and those with psychiatric conditions, including suicidal risk.
Depending on the severity of their disease, they may well be able to participate in much of the decision-making process.
Suicidal Patients
When treating a suicidal patient, the surgeon is faced with a conflict between the ethical principle of beneficence and respect for autonomy.
Relying on the principle of beneficence, surgeons almost always treat the injuries inflicted by suicidal patients despite their expressed intention to die.
The conflict arises when the reasons for suicide appear “good,” such as in the case of the terminally ill cancer patient with severe, uncontrollable pain.
Although some patients might make a rational decision to commit suicide, in most cases the surgeon delivering care must assume that the person’s judgment is impaired and proceed with full indicated, lifesaving measures.
Advance Directives
General Principles: Talking About Death
Often, the issues that are most difficult to address when patients are near the end of life are those that have not been attended to earlier in the patient’s course of treatment.
Advance directives express in written form what the patient’s choices would have been if he or she had decision-making capacity.
There should be advanced informed consent for a myriad of courses of treatment, whether it be related to pain medication, “do not resuscitate orders,” or management, should the individual enter some level of persistent vegetative state.
Advance directives include living wills, durable powers of attorneys, and other written documents.
The Patient Self-Determination Act (PSDA) required that health-care institutions advise and educate patients regarding advance directives, yet only ~20 % of seriously ill patients have advance directives.
Living Will
The signatory indicates what his or her choices would be for medical treatment in the situation where death is imminent and the individual’s wishes are unable to be communicated to the treating physician.
This usually amounts to a “do not resuscitate” order but can also indicate the patient’s wishes concerning the level of pain medication, hydration, and nutrition, which the patient would desire if he or she lapses into a nondecisional condition.
A second physician’s opinion is typically required corroborating a determination of imminent demise.
Durable Power of Attorney
A durable power of attorney for health care specifies a surrogate decision-maker in the event that the patient no longer has the capacity to make medical decisions.
The reason it is called “durable” is to ensure that the signatory knows that it can be revoked and/or changed at any time.
Thus, the patient designates a surrogate decision-maker who should participate in all significant treatment decisions and be kept up to date regarding the patient’s health care.
If there is no durable power of attorney, there is usually a defined hierarchy regarding surrogate decision-makers: spouses, adult children, siblings, etc.
Problems
The surrogate has the legal authority to make a decision but is not aware of what the patient would want.
Using the substitute judgment standard, the surrogate bases a decision on a prior expressed statement of the patient’s preferences or on an in-depth knowledge of the personality of the patient and a willingness to do what the surrogate believes the patient, not the surrogate, would want in that specific situation.
The second standard is that of the best interest of the patient where the surrogate is supposed to do what he believes is in the best interest of the patient.
A further problem is the application of such directives in situations for which they were not intended.
Verbal communication takes precedence over any written advance directive.
If there is any confusion, advance directives limiting treatment should be ignored in favor of prudent medical care.
In such situations, the hospital ethics consultation service can often prove very helpful.
Informed Consent
General Concepts
A patient’s informed consent to a medical or surgical procedure or test is essential.
The physician must give the patient sufficient information to make an intelligent decision before any action is performed.
The nature of the procedure, risks, benefits, and alternatives, including no treatment at all
Permission must be given voluntarily.
Without coercion from the physician or anyone else involved in rendering health care) orRelated posts:
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