- Email: [email protected]
Complying with advance directives in the operating room
SURGICAL ETHICS CHALLENGES
Complying with advance directives in the operating room James W. Jones, MD, PhD,a and Laurence B. McCullough, PhDb
An ambulance brings an unconscious 41-year-old man to the emergency department after an automobile accident. Emergency computed tomography shows rupture of the liver, spleen, and superior mesenteric artery. He is being prepared for surgery when his business partner arrives with what he claims is the patient’s signed advance directive, specifying that in the event of cardiac arrest, the patient wishes that no resuscitative measures be taken. During surgery, the patient suffers an acute hypotensive episode and arrests. Your proper response is which of the following? A. B. C. D. E.
Do not resuscitate. Resuscitate and continue the operation. Limit your resuscitative efforts to closed chest massage. Consult the business partner. Ignore the advance directive.
B is the most ethically sound option. The “living will” advance directive is defined by most statutes and hospital policies as the medical instructions of a terminally ill or injured patient who can no longer communicate his immediate wishes.1 Living wills typically concentrate on end-of-life issues, particularly withdrawing or withholding efforts to sustain a life that cannot be saved or restored to a functional level acceptable to the patient. They may conversely express the wish that all available lifesustaining efforts be fully implemented until death is spontaneous. A “terminal illness or injury” is understood to mean that death is inevitable within a short time regardless of medical intervention. The living will provisions of advance directives should not govern physicians’ clinical responses when the patient’s clinical status does not meet these criteria. From the Department of Surgery, University of Missouri,a and the Center for Medical Ethics and Health Policy, Baylor College of Medicine.b Correspondence: James W. Jones, MD, PhD, University of Missouri, Department of Surgery (M580), One Hospital Dr, Columbia MO 65212 (e-mail: [email protected]). J Vasc Surg 2002;36:199-200. Copyright © 2002 by The Society for Vascular Surgery and The American Association for Vascular Surgery. 0741-5214/2002/$35.00 ⫹ 0 24/1/125383 doi:10.1067/mva.2002.125383
Though grievously injured, this patient can recover with timely and competent surgical care. His intraoperative arrest is a correctable complication of fluid management, likely not the culminating event of an inevitably terminal illness or injury. Intraoperative resuscitation maintains homeostasis, and patient recovery in such cases is routine, as opposed to the overall 15% success rate of cardiopulmonary resuscitation.2 The patient’s refusal of cardiopulmonary resuscitation in the advance directive may ethically be understood to apply in the context of these poor success rates, which include not just death but survival with a greatly diminished quality of life. The advance directive’s election of Choice A, no resuscitation, was very likely formulated without consideration of functional conditions in the operating room, and would furthermore deny the patient the benefits for which he was originally brought to the operating room. Choice B is fully consistent with the goals of surgery and is a necessary and proper response for a patient whose condition does not activate the authority of a living will. Some ethicists argue that advance directives containing do-not-resuscitate instructions should be as applicable inside the operating room as in the intensive care unit.3 Others have argued that the conditions of surgery blur the distinctions between resuscitation and maintenance of homeostasis,2 or that many physicians routinely dismiss advance directives, or that patients seldom understand the processes of surgical care. Attempting to straddle these issues by limiting the procedural options of the resuscitation efforts (Choice C) strengthens neither the physician’s ethical posture nor his clinical effectiveness and is inconsistent with the goals of surgery and conditions under which the advance directive has clinical authority. The business partner is not the next of kin and has no legal standing as a surrogate decision-maker unless he has been named as an agent in a durable medical power of attorney. Furthermore, the patient’s own views have been articulated in the advance directive, which would stand as the last available expression of his wishes if it otherwise qualified. Choice D is therefore not available. Ignoring the advance directive, Choice E, which legend holds is a common tactic among physicians who find such instructions odious, is not acceptable. Notwithstanding, the surgeon is obligated to evaluate the directive in 199
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200 Jones and McCullough
light of the patient’s clinical condition to establish its pertinence. As noted, the qualities necessary to establish the authority of an advance directive, ie, a terminal condition not susceptible to reversal with medical care, are not present, and the physician is not governed by the terms of the document. In such cases, the chart should reflect why the surgeon is not implementing the directive.
REFERENCES 1. Youngner SJ, Shuck JM. Advance directives and the determination of death. In: McCullough LB, Jones JW, Brody BA, editors. Surgical ethics. New York: Oxford University Press; 1998. p. 61. 2. Cohen CB, Cohen PJ. Do-not-resuscitate orders in the operating room. N Engl J Med 1991;325:1879-82. 3. Walker RM. DNR in the OR. Resuscitation as an operative risk. JAMA 1991;266:2407-12.
22ND ANNUAL WILLIAM J. VON LIEBIG FOUNDATION AWARD FOR EXCELLENCE IN VASCULAR SURGICAL RESEARCH FOR RESIDENTS, FELLOWS, AND MENTORS— FIRST PLACE: $5,000 (AUTHOR) AND $10,000 (SUPPORTING MENTOR) Additionally, an unlimited number of $2,500 awards will be given for each manuscript achieving a score within the 1.0 to 2.0 range, with $5,000 being awarded to each of their research mentors. PURPOSE • Motivate physicians early in their training to pursue their interest in research • Recognize and support research professionals who supervise this critical function ELIGIBILITY • Author must be a Resident or Fellow on staff at an accredited vascular surgery program in the United States, Canada, or Mexico, with senior collaborators acting in a consultative capacity. • Manuscripts must be postmarked no later than September 3, 2002. Selection results will be conveyed to all applicants by October 31, 2002. RESEARCH REQUIREMENTS • The research may be experimental or clinical in nature, dealing with some fundamental or clinical aspect of vascular surgery. Both basic and clinical research papers are especially encouraged. • The manuscript must be an original, unpublished work (not submitted elsewhere for publication, except to the ACS Surgical Forum). • The submission must be in English and include 1 copy of the typed manuscript and 1 original copy of illustrations (photographic prints or original computer-generated images). The manuscript must also be submitted electronically in Microsoft Word or PDF format on a PC computer disk or e-mailed to [email protected]. All submissions must comply with the Information for Authors of the Journal of Vascular Surgery and include an abstract of 250 words or less. • Accompanying each submission should also be the following: a cover letter from the Resident or Fellow indicating the manuscript is to be considered for “The 22nd Annual William J. von Liebig Foundation Award for Residents, Fellows, and Mentors”; the author’s full curriculum vitae; and a signed letter from the author’s mentor attesting that the author performed all the essential parts of the experimental work reported. SELECTION PROCESS A select committee of vascular surgeons appointed by the Foundation will review the manuscripts submitted. 2002-2003 Committee Members include the following: Colleen M. Brophy, MD, Chairman; Elliot L. Chaikof, MD, PhD; Linda M. Graham, MD; William H. Pearce, MD; Michael Sobel, MD; Jean A. Goggins, PhD, Secretary; and Thomas C. Naslund, MD, SAVS Ex-Officio. The first-prize winner will be a guest of The von Liebig Foundation, and the award will be presented at the annual meeting of the Southern Association for Vascular Surgery on January 15-18, 2003, at The Lowes Ventana Canyon Resort in Tucson, Arizona. Meeting expenses incurred by the winning author will be reimbursed according to the travel policy of the Foundation. The winning manuscript will be submitted to the Journal of Vascular Surgery or another publication of the author’s choosing for consideration for publication. The William J. von Liebig Foundation reserves the right to withhold the granting of the award at the sole discretion of the Award Committee, whose judgment with respect thereto shall be final and conclusive. HISTORY Since the award’s inception in 1982, 90% of previous award recipients have pursued careers in vascular or cardiothoracic surgical research. Thirteen recipients have become Fellows of the American College of Surgeons, three are associate members of the College, and one recipient is a Fellow of the American College of Cardiology. Two previous award winners are recipients of the von Liebig–supported Mentored Clinical Scientist Development Awards, and approximately 50% have become successful peer review funded researchers in vascular surgery. Past award winners include such well known researchers as Colleen Brophy, MD, Howard Greisler, MD, Michael Marin, MD, and Kenneth Ouriel, MD. CONCLUSION It is the desire of the Foundation to encourage the movement of technical innovation and relevant clinical findings from the laboratory to the vascular surgical community. It was Mr von Liebig’s hope that those who pursue this award and those who win it will contribute to the advancement of medical care. Further inquiries may be directed to the Foundation as follows: JEAN A. GOGGINS, PHD, Executive Director The William J. von Liebig Foundation 8889 Pelican Bay Blvd, Suite 403, Naples, Fla 34108 Telephone (239) 513-2229 Facsimile (239) 513-2239 www.vonliebigfoundation.com [email protected]
Complying with advance directives in the operating room James W. Jones, MD, PhD,a and Laurence B. McCullough, PhDb
An ambulance brings an unconscious 41-year-old man to the emergency department after an automobile accident. Emergency computed tomography shows rupture of the liver, spleen, and superior mesenteric artery. He is being prepared for surgery when his business partner arrives with what he claims is the patient’s signed advance directive, specifying that in the event of cardiac arrest, the patient wishes that no resuscitative measures be taken. During surgery, the patient suffers an acute hypotensive episode and arrests. Your proper response is which of the following? A. B. C. D. E.
Do not resuscitate. Resuscitate and continue the operation. Limit your resuscitative efforts to closed chest massage. Consult the business partner. Ignore the advance directive.
B is the most ethically sound option. The “living will” advance directive is defined by most statutes and hospital policies as the medical instructions of a terminally ill or injured patient who can no longer communicate his immediate wishes.1 Living wills typically concentrate on end-of-life issues, particularly withdrawing or withholding efforts to sustain a life that cannot be saved or restored to a functional level acceptable to the patient. They may conversely express the wish that all available lifesustaining efforts be fully implemented until death is spontaneous. A “terminal illness or injury” is understood to mean that death is inevitable within a short time regardless of medical intervention. The living will provisions of advance directives should not govern physicians’ clinical responses when the patient’s clinical status does not meet these criteria. From the Department of Surgery, University of Missouri,a and the Center for Medical Ethics and Health Policy, Baylor College of Medicine.b Correspondence: James W. Jones, MD, PhD, University of Missouri, Department of Surgery (M580), One Hospital Dr, Columbia MO 65212 (e-mail: [email protected]). J Vasc Surg 2002;36:199-200. Copyright © 2002 by The Society for Vascular Surgery and The American Association for Vascular Surgery. 0741-5214/2002/$35.00 ⫹ 0 24/1/125383 doi:10.1067/mva.2002.125383
Though grievously injured, this patient can recover with timely and competent surgical care. His intraoperative arrest is a correctable complication of fluid management, likely not the culminating event of an inevitably terminal illness or injury. Intraoperative resuscitation maintains homeostasis, and patient recovery in such cases is routine, as opposed to the overall 15% success rate of cardiopulmonary resuscitation.2 The patient’s refusal of cardiopulmonary resuscitation in the advance directive may ethically be understood to apply in the context of these poor success rates, which include not just death but survival with a greatly diminished quality of life. The advance directive’s election of Choice A, no resuscitation, was very likely formulated without consideration of functional conditions in the operating room, and would furthermore deny the patient the benefits for which he was originally brought to the operating room. Choice B is fully consistent with the goals of surgery and is a necessary and proper response for a patient whose condition does not activate the authority of a living will. Some ethicists argue that advance directives containing do-not-resuscitate instructions should be as applicable inside the operating room as in the intensive care unit.3 Others have argued that the conditions of surgery blur the distinctions between resuscitation and maintenance of homeostasis,2 or that many physicians routinely dismiss advance directives, or that patients seldom understand the processes of surgical care. Attempting to straddle these issues by limiting the procedural options of the resuscitation efforts (Choice C) strengthens neither the physician’s ethical posture nor his clinical effectiveness and is inconsistent with the goals of surgery and conditions under which the advance directive has clinical authority. The business partner is not the next of kin and has no legal standing as a surrogate decision-maker unless he has been named as an agent in a durable medical power of attorney. Furthermore, the patient’s own views have been articulated in the advance directive, which would stand as the last available expression of his wishes if it otherwise qualified. Choice D is therefore not available. Ignoring the advance directive, Choice E, which legend holds is a common tactic among physicians who find such instructions odious, is not acceptable. Notwithstanding, the surgeon is obligated to evaluate the directive in 199
JOURNAL OF VASCULAR SURGERY July 2002
200 Jones and McCullough
light of the patient’s clinical condition to establish its pertinence. As noted, the qualities necessary to establish the authority of an advance directive, ie, a terminal condition not susceptible to reversal with medical care, are not present, and the physician is not governed by the terms of the document. In such cases, the chart should reflect why the surgeon is not implementing the directive.
REFERENCES 1. Youngner SJ, Shuck JM. Advance directives and the determination of death. In: McCullough LB, Jones JW, Brody BA, editors. Surgical ethics. New York: Oxford University Press; 1998. p. 61. 2. Cohen CB, Cohen PJ. Do-not-resuscitate orders in the operating room. N Engl J Med 1991;325:1879-82. 3. Walker RM. DNR in the OR. Resuscitation as an operative risk. JAMA 1991;266:2407-12.
22ND ANNUAL WILLIAM J. VON LIEBIG FOUNDATION AWARD FOR EXCELLENCE IN VASCULAR SURGICAL RESEARCH FOR RESIDENTS, FELLOWS, AND MENTORS— FIRST PLACE: $5,000 (AUTHOR) AND $10,000 (SUPPORTING MENTOR) Additionally, an unlimited number of $2,500 awards will be given for each manuscript achieving a score within the 1.0 to 2.0 range, with $5,000 being awarded to each of their research mentors. PURPOSE • Motivate physicians early in their training to pursue their interest in research • Recognize and support research professionals who supervise this critical function ELIGIBILITY • Author must be a Resident or Fellow on staff at an accredited vascular surgery program in the United States, Canada, or Mexico, with senior collaborators acting in a consultative capacity. • Manuscripts must be postmarked no later than September 3, 2002. Selection results will be conveyed to all applicants by October 31, 2002. RESEARCH REQUIREMENTS • The research may be experimental or clinical in nature, dealing with some fundamental or clinical aspect of vascular surgery. Both basic and clinical research papers are especially encouraged. • The manuscript must be an original, unpublished work (not submitted elsewhere for publication, except to the ACS Surgical Forum). • The submission must be in English and include 1 copy of the typed manuscript and 1 original copy of illustrations (photographic prints or original computer-generated images). The manuscript must also be submitted electronically in Microsoft Word or PDF format on a PC computer disk or e-mailed to [email protected]. All submissions must comply with the Information for Authors of the Journal of Vascular Surgery and include an abstract of 250 words or less. • Accompanying each submission should also be the following: a cover letter from the Resident or Fellow indicating the manuscript is to be considered for “The 22nd Annual William J. von Liebig Foundation Award for Residents, Fellows, and Mentors”; the author’s full curriculum vitae; and a signed letter from the author’s mentor attesting that the author performed all the essential parts of the experimental work reported. SELECTION PROCESS A select committee of vascular surgeons appointed by the Foundation will review the manuscripts submitted. 2002-2003 Committee Members include the following: Colleen M. Brophy, MD, Chairman; Elliot L. Chaikof, MD, PhD; Linda M. Graham, MD; William H. Pearce, MD; Michael Sobel, MD; Jean A. Goggins, PhD, Secretary; and Thomas C. Naslund, MD, SAVS Ex-Officio. The first-prize winner will be a guest of The von Liebig Foundation, and the award will be presented at the annual meeting of the Southern Association for Vascular Surgery on January 15-18, 2003, at The Lowes Ventana Canyon Resort in Tucson, Arizona. Meeting expenses incurred by the winning author will be reimbursed according to the travel policy of the Foundation. The winning manuscript will be submitted to the Journal of Vascular Surgery or another publication of the author’s choosing for consideration for publication. The William J. von Liebig Foundation reserves the right to withhold the granting of the award at the sole discretion of the Award Committee, whose judgment with respect thereto shall be final and conclusive. HISTORY Since the award’s inception in 1982, 90% of previous award recipients have pursued careers in vascular or cardiothoracic surgical research. Thirteen recipients have become Fellows of the American College of Surgeons, three are associate members of the College, and one recipient is a Fellow of the American College of Cardiology. Two previous award winners are recipients of the von Liebig–supported Mentored Clinical Scientist Development Awards, and approximately 50% have become successful peer review funded researchers in vascular surgery. Past award winners include such well known researchers as Colleen Brophy, MD, Howard Greisler, MD, Michael Marin, MD, and Kenneth Ouriel, MD. CONCLUSION It is the desire of the Foundation to encourage the movement of technical innovation and relevant clinical findings from the laboratory to the vascular surgical community. It was Mr von Liebig’s hope that those who pursue this award and those who win it will contribute to the advancement of medical care. Further inquiries may be directed to the Foundation as follows: JEAN A. GOGGINS, PHD, Executive Director The William J. von Liebig Foundation 8889 Pelican Bay Blvd, Suite 403, Naples, Fla 34108 Telephone (239) 513-2229 Facsimile (239) 513-2239 www.vonliebigfoundation.com [email protected]