Resident Readiness General Surgery 1st Ed.

A Surgical Intern in a Moral Dilemma

Peter Angelos, MD, PhD, FACS and Debra A. DaRosa, PhD

You have been on the surgical oncology service for the past 2 weeks. During that time, you have been involved in the care of a 45-year-old gentleman who has had a pancreaticoduodenectomy performed for pancreatic carcinoma. The patient has had a number of complications associated with leaks from his operation and has required percutaneous drainage. His pathology report has come back that shows positive nodes as well as a positive margin. Based on this information, you know that his overall prognosis is poor. The patient has confided in you his desire not to have his life artificially prolonged unnecessarily. Nevertheless, as he has deteriorated and required intubation and pressors for his sepsis, his family has proceeded with a very aggressive course of treatment in accordance with the recommendations of the surgical attending. You believe that perhaps the patient’s wishes have been discounted by the family and the attending surgeon.

1. How should you approach this issue?

2. Who would be the appropriate person with whom to raise your concerns?

3. Do you believe your primary allegiance is to the service or to the patient for whom you have participated in care?

4. If you believe that the care being rendered is contrary to the patient’s wishes, when is it appropriate to withdraw from this patient’s case?

MORALITY IN THE SURGICAL INTERN

Answers

1. As a junior member of the surgical team caring for the patient, it can be easy to lose track of the fact that the resident actually has a relationship with the patient and, as a result, responsibilities to the patient. The complicating factor, however, is that your relationship with your patient is not in isolation, but rather is present because of the relationship that the patient has with the attending surgeon. In an elective situation such as this, the patient has made the choice to have the attending surgeon operate on him. The relationship between the attending surgeon and the patient certainly arose prior to the relationship between the resident and the patient. As a result, the issues that are concerning you may have already been addressed preoperatively with the patient or postoperatively with the patient’s family.

2. For the reasons noted above relating to the relationship between the attending surgeon and the patient, as a resident, you should communicate your concerns to the attending surgeon. This is best done as a private discussion between you and the attending surgeon and not in the presence of the other members of the team or in front of the family. Although frank discussions and a vigorous debate of alternative approaches to a complex patient’s care should occur in any teaching environment, ethical issues may be particularly emotionally charged for all involved and are best done privately. In such a context, the resident’s concerns can clearly be expressed as being focused on the patient’s interests and not misinterpreted as being a challenge to the attending surgeon’s ethics or judgment.

3. For the reasons noted in question #1, the relationship between the resident and patient must always be seen in the broader context of the relationship between the attending surgeon and the patient. For the reasons noted in question #2 above, the discussion between resident and attending surgeon about sensitive issues such as what is in the patient’s best interests should be done in private. You must not forget that your ability to effectively function as part of the surgical team and render good patient care is predicated on your ability not only to be proactive in rendering patient care but also to ensure ongoing communication and understanding between you and your attending supervisor, and the other health care professionals on the team.

4. No one should be expected to carry out what he or she perceives as an immoral or unethical action, no matter what “orders” might have been given. Certainly, in a situation such as described above, a difference of opinion about what a patient “would have wanted” is often so subjective that it would not normally be the sort of major issue for which a resident would withdraw from participating in the patient’s care. However, when faced with a clear and significant breach of ethics (eg, if the resident were to feel that going along with the attending surgeon would lead to significant harm to the patient), then the resident should respectfully withdraw from the patient’s care. Furthermore, if a resident perceives any health care provider is a danger to the patient or himself or herself, the resident should report it to the program director or other trusted individual positioned in an educational leadership role.

TIPS TO REMEMBER

Image The attending surgeon and patient established a relationship prior to the resident–patient relationship. Therefore, resident concerns or disagreements in patient care should be communicated in private to the attending.

Image If a resident has a major moral conflict with some aspect of a patient’s care that cannot be resolved even after communicating with an attending, the resident should respectfully withdraw from the patient’s care.

Image Residents should communicate concerns or ethical conflicts with their program director, a trusted mentor, or other member of the educational leadership team.