Schwartz's Principles of Surgery ABSITE and Board Review, 9th Ed.

CHAPTER 48. Ethics, Palliative Care, and Care at the End of Life

BASIC SCIENCE QUESTIONS

1. Which of the following is one of the four guiding principles of bioethics in the principlist approach?

A. Adherence to the law

B. Autonomy

C. Good communication

D. Obtaining all information before making a decision

Answer: B

Biomedical ethics is the system of analysis and deliberation dedicated to guiding surgeons toward the ‘good’ in the practice of surgery. One of the most influential ethical ‘systems’ in the field of biomedical ethics is the principlist approach as articulated by Beauchamp and Childress. In this approach to ethical issues, moral dilemmas are deliberated by using four guiding principles: autonomy, beneficence, nonmaleficence, and justice. (See Schwartz 9th ed., p 1753, 55, and Fig. 48-1.)

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FIG. 48-1. The four principles of the care-based paradigm.

2. Which of the following is one of the four elements of informed consent?

A. All family members must be informed of the options available

B. The physician must document that the patient has the capacity to decide

C. The patient must sign a legal consent form

D. The legal consent form must be signed by a witness

Answer: B

Adequate informed consent entails at least four basic elements: a) The physician documents that the patient or surrogate has the capacity to make a medical decision; (b) The surgeon discloses to the patient details regarding the diagnosis and treatment options sufficiently for the patient to make an informed choice; (c) The patient demonstrates understanding of the disclosed information before (d) authorizing freely a specific treatment plan without undue influence.

The patient or the patient’s surrogate is the only one who must be informed of the options available.

Although signing a legal consent form has become standard, it is not required to document informed consent. (See Schwartz 9th ed., p 1756.)

CLINICAL QUESTIONS

1. An unconscious accident victim is hypotensive from intra-abdominal hemorrhage and needs an emergency laparotomy. His identity is unknown and, therefore, no family is available. Which of the following should be done?

A. Nothing; it is illegal to operate on a patient without consent

B. The surgeon should document the need for the surgery in the chart and proceed

C. Three doctors should document the need for the surgery in the chart and the surgeon should then proceed

D. A court order for surgery should be obtained prior to proceeding

Answer: B

Emergency consent requires the surgeon to consider if and how possible interventions might save a patient’s life, and if successful, what kind of disability might be anticipated. Surgical emergencies are one of the few instances where the limits of patient autonomy are freely acknowledged, and surgeons are empowered by law and ethics to act promptly in the best interests of their patients according to the surgeon’s judgment. Most applicable medical laws require physicians to provide the standard of care to incapacitated patients, even if it entails invasive procedures without the explicit consent of the patient or surrogate. If at all possible, surgeons should seek the permission of their patients to provide treatment, but when emergency medical conditions render patients unable to grant that permission, and when delay is likely to have grave consequences, surgeons are legally and ethically justified in providing whatever surgical treatment the surgeon judges necessary to preserve life and restore health.

It would be unethical to withhold surgery from this patient.

The concept of a “three doctor” documentation is not legally or ethically required in this situation, nor is a court order. (See Schwartz 9th ed., p 1756.)

2. A 3-year-old patient with a severe splenic injury is admitted to the ICU. Clinically, a transfusion is indicated. The parents are adamant that their religion forbids transfusions and threaten to sue the doctor if blood is transfused. The best course of action is

A. Do not transfuse the patient, but use alternatives if available

B. Try to reason with the family and obtain permission for transfusion

C. Contact the hospital legal counsel and proceed with transfusion

D. Proceed with transfusion after documenting the indication in the chart

Answer: C

Certain religious practices can present difficulties in treating minor children in need of life-saving blood transfusions; however, case law has made clear the precedent that parents, regardless of their held beliefs, may not place their minor children at mortal risk. In such a circumstance, the physician should seek counsel from the hospital medicolegal team, as well as from the institutional ethics team. Legal precedent has, in general, established that the hospital or physician can proceed with providing all necessary care for the child. (See Schwartz 9th ed., p 1757.)

3. A patient with carcinomatosis is requiring large amounts of morphine by PCA (averaging 15 mg/hr). Her pain is very poorly controlled and the pain service feels she will need at least 20mg/hr for adequate control. The pharmacy questions the dose since it is high enough to cause respiratory arrest. The appropriate course of action is

A. Cancel the order and continue with her previous dose

B. Compromise by increasing the dose, but not as much as planned

C. Keep the order for 20 mg/hr

D. Change to bolus morphine from the PCA

Answer: C

In deliberating the issue of withdrawing vs. withholding life-sustaining therapies, the principle of ‘double effect’ is often mentioned. According to the principle of ‘double effect,’ a treatment (e.g., opioid administration in the terminally ill) that is intended to help and not harm the patient (i.e., relieve pain) is ethically acceptable even if an unintended consequence (side effect) of its administration is to shorten the life of the patient (e.g., by respiratory depression). Under the principle of double effect, a physician may withhold or withdraw a life-sustaining therapy if the surgeon’s intent is to relieve suffering, not to hasten death. The classic formulation of double effect has four elements (Fig. 48-2). (See Schwartz 9th ed., p 1758.)

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FIG. 48-2. The four elements of the double effect principle: 1) The good effect is produced directly by the action and not by the bad effect. 2) The person must intend only the good effect, even though the bad effect may be foreseen. 3) The act itself must not be intrinsically wrong, or needs to be at least neutral. 4) The good effect is sufficiently desirable to compensate for allowing the bad effect.

4. Which of the following is an indication for palliative care consultation?

A. Any patient with a life-threatening diagnosis

B. Counseling of physicians and staff after losing a colleague under their care

C. Anticipation of painful procedures or other therapies

D. Psychologic distress

Answer: B

Although not often used, palliative care teams provide bereavement support for physicians and staff after losing a patient.

Palliative care is primarily focused on end of life care. The diagnosis of a disease, anticipation of pain, or psychologic stress are not per se indications for a palliative care consultation.

Nathan Cherny, another pioneer of palliative care, echoes these themes in his definition of palliative care: ‘[it] is concerned with three things: the quality of life, the value of life, and the meaning of life.’ Therefore, it is existence, not death, that is the focus of palliative care. (See Schwartz 9th ed., p 1759, and Table 48-1.)

TABLE 48-1 Indications for palliative care consultation


Patients with conditions that are progressive and life-limiting, especially if characterized by burdensome symptoms, functional decline, and progressive cognitive deficits

Assistance in clarification or reorientation of patient/family goals of care

Assistance in resolution of ethical dilemmas

Situations in which patient/surrogate declines further invasive or curative treatments with stated preference for comfort measures only

Patients who are expected to die imminently or shortly after hospital discharge

Provision of bereavement support for patient care staff, particularly after loss of a colleague under care


5. A patient with terminal cancer who is sleeping >50% of the day and requires some assistance with activities of daily living has approximately how long to live?

A. Unknown, it could be months to years

B. Months

C. Weeks

D. Days

Answer: C

For example, patients with advanced metastatic cancer who are resting/sleeping for 50% or more of normal waking hours and require some assistance with activities of daily living (ADL) have a projected survival of weeks, and patients who are essentially bedfast and dependent for ADL have a projected survival of days to a week or two at best. Table 48-2 shows a simple prognostic tool to aid clinicians in recognizing patients nearing the end of life. (See Schwartz 9th ed., p 1762.)

TABLE 48-2 Simple prognostication tool in advanced illness (especially cancer)

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6. The primary treatment for dyspnea (“air hunger”) in a dying patient is

A. Supplemental oxygen by a non-rebreather mask

B. Cooling the room

C. Opioids

D. Anxiolytic agents

Answer: C

The primary treatment of dyspnea (air hunger) in the dying is opioids, which should be cautiously titrated to increase comfort and reduce tachypnea to a range of 15 to 20 breaths/min. Air movement across the face generated by a fan can sometimes be quite helpful. If this is not effective, empiric use of supplemental O2 by nasal cannula (2 to 3 L/min) may bring some subjective relief, independent of observable changes in pulse oximetry. Supplemental O2 should be humidified to avoid exacerbation of dry mouth. Typical starting doses of an immediate release opioid for breathlessness should be one half to two thirds of a starting dose of the same agent for cancer pain. For patients already on opioids for pain, a 25 to 50% increment in the dose of the current immediate release agent for breakthrough pain often will be effective in relieving breathlessness. (See Schwartz 9th ed., p 1762, 63.)


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