Orit Nahtomi Shick
Anaesthesia as a practice many times gives the anaesthesiologist the opportunity to sit and relax while the surgeon is in the front-line dealing with the patient and family. But more and more as medicine changes and we gain the role of perioperative physicians we find ourselves in the front, the first ones to deal with a patient, and we become part of the decision-making team when a patient is very sick and there are dilemmas and hard decisions to make.
In the previous newsletter Dr Gurman spoke about tasks that are contradictory to our conscience and our ethical principles. In the annual meeting of the Israel Society of Anesthesiologists in November 2018 there was a session about the ethical dilemmas of the anaesthesiologists and the borders of responsibilities we have for the patients.
Dr Shai Fein talked about ethical principles and their embodiment in the anaesthesia treatment. Ethics in general, as he quoted, is ‘The discipline dealing with what is good and bad and with moral duty and obligation’. In ethics we have to deal with professionalism that embeds in it a body of theory and skills, acceptance of duty, and adherence to common codes of value and conduct. Anaesthesia ethical codes were published by the American Society of Anesthesiologists in 2003 and were last amended in 2018.1
The everyday dilemmas we face many times are global patient priorities. For example, who should we send first to the operating room? We have to prioritize patients and our decisions will affect their autonomy and right to know, but we cannot share with the patients the decision-making process. We have to weigh our decision between beneficence to each patient and justice and be true to ourselves and the patients in the decisions we make.
Economic questions are part of our decision making too. We should weigh patient beneficence against the hospital’s financial consequences.
In making these everyday decisions we have to go through 4 stages: The first is to recognize the problem, the facts, legal issues, and moral parameters. The second is to define the possible ways of action through implementation of moral principles to each way. The third is deciding which way to act and to define the justifications for our decision. The fourth is to define the objections to our way and the moral conflicts.
In the second half of this session I talked about the patients’ rights and informed consent.
As mentioned, usually we are not alone in front of the patient and it is more like a threesome. It is a relationship between the patient, the surgeon, and the anaesthesiologist. The patient should always be at the centre of decisions and we should treat them with respect, keep their dignity, and give them the proper treatment professionally, in medical quality and in human relationship. The first step is the patient consent, and for that we have to make sure that the patient has the capacity to consent.
A patient with capacity to consent should fulfil 4 major components: the first is the ability to understand the information given. The second is to retain and ‘hold’ what is said. The third is to process the information and come up with a decision. The fourth is communicating the decision to others.
From our perspective we have to make sure we keep the patient’s autonomy and justice, and we should weigh the beneficence of a treatment against the non-maleficence of not giving the treatment. The best way to approach it is in a rational way of thinking that will lead to the best result under the circumstances.2
In the paediatric population the adolescent group is a challenge. The threesome is the surgeon, the anaesthesiologist, and the parents, but the child could be old enough to understand and decide for them self and should be at the centre. They should be part of the conversation about their operation and part of the decision-making process.
Looking at the literature there are very few studies about informed consent in paediatric patients, and even fewer that examined child anxiety, preferences, understanding, and child refusal.3 The studies put the parents at the centre of investigation, and only one study, 15 years ago, specifically involved interviews with paediatric patients.4 Obviously, there is a place for much more investigation and attention to children in future studies on the subject.
In cases that are high risk for surgery and the patient does not have the full capacity to understand, we should bear in mind a quote by Hippocrates saying we should ‘refuse to treat those who are overmastered by their disease’. We should go ahead with the surgery only after speaking very thoroughly with the patient and a surrogate decision maker about the risks and benefits of the surgery, and risks and benefits of not doing the surgery, and documented the conversation and decisions in the patient records.
To conclude, in modern medicine and limited health resources many countries go towards ‘realistic medicine’. The principles are changing towards shared decision making, building a personalized approach to care, reducing harm and waste, managing risk better, and becoming improvers and innovators. We should pay more attention to patient wishes and encourage patients to have directives of care that will help us in difficult times to make the most appropriate recommendations about treatment for the specific patient according to his opinions, beliefs, emotions, and religion.
- org. Standards and guidelines/Guidelines for the ethical practice of anesthesiology. Available at https://www.asahq.org/standards-and-guidelines/guidelines-for-the-ethical-practice-of-anesthesiology
- Beauchamp TL, Childress JF. Principles of Biomedical Ethics. 4th ed. New York: Oxford University Press; 2014.
- Feinstein MM, Pannunzio AE, Lobell S, Kodish E. Anesth Analg2018;127(6):1398-405.
- Tait AR, Voepel-Lewis T, Malviya S. Anesthesiology2003;98:609–14.