Ethical Issues in the Surgical ICU

Marshall Beckman, John Weigelt, Jameel Ali and Richard M. Bell

Chapter Overview

Technological advances in life sustaining devices with the attendant capability of prolonging life, complexity of diseases, comorbidities, differences in societal mores in the intensive care unit (ICU) patients all present major challenges to care givers in this increasingly complex environment. The surgical patient is also unique because treatment options are frequently invasive with potential for significant variations in outcome including iatrogenic harm. These factors demand a well-established infrastructure within the surgical ICU to address the inevitable ethical issues that arise. While variable in composition, the bioethics committee should have wide representation from medical staff, nurses, bioethicist, social worker, members of the clergy and lay people to help resolve issues. A totally transparent and free communication system is necessary among physicians, patients, family members, and ICU staff. Such communication allows voicing of concerns regarding choices of care, and potential outcome. One goal should be an attempt to bridge the gap between expectations and reality and the ability to modify plans in an ever changing care environment. Another ethical consideration in this communication is respecting cultural and religious sensibilities, acting with empathy in the best interest of the patient while providing understanding and a sense of deep caring for all individuals involved.

In this chapter, in order to assist the intensivist and staff caring for these patients we will briefly discuss general principles of biomedical ethics, their relation to rights, responsibilities, and the law. We will also discuss specific common ethical issues in the Surgical ICU and how these bioethics principles are applied to these issues.

Brief History, Hippocrates, Nuremburg, Belmont Commission 13,18

As we have become more sophisticated in medicine, we have had further commentary on long held tenets of what is right and what is wrong as we deliver surgical critical care. Hippocrates (c. 460 B.C.), who is often referred to as the Father of Western Medicine, is well-known to for his Hippocratic Oath. It is a variation of this oath that medical students recite as they finish undergraduate medical education. This oath has morphed to make the first priority of a physician to not do harm.

This concept of no harm was surely tested during the reign of the Nazis in Europe during World War II. The Nuremberg Code resulted from the atrocities committed by physicians in Nazi Germany. This code is the first set of principles that guides research on human subjects that is recognized on an international basis (Flanagan).

After the controversial Tuskegee Syphilis Study, the National Commission for the Protection of Human Subjects in Biomedical and Behavioral Research, which is commonly referred to as the Belmont Report, was formed. This report, published in 1978, identified three principles for human subject research: “Respect for persons”, “beneficence”, and “justice”. These principles dove tail into the four principles of Beauchamp and Childress in their book Principles of Biomedical Ethics, 2001. The principles are autonomy, beneficence, non-maleficence, and justice.

General Principles of Biomedical Ethics Applied to the Critical Care Environment^{2,13,14,17,18}

(1) Autonomy: This refers to the right of the patient to decide for himself free from influence by others, how and what care is delivered. Many have regarded this principle to have the highest priority among the four principles. This notion of higher priority is not espoused by the original authors of these principles. The patient must have a clear understanding of the situation in order to make decisions. There is a fine line between education and informing the patient, which is a major function of the physician, and unduly influencing the patient through unjustified bias on the part of the physician. Part of that education is aimed at bridging the gap between the patient’s expectation and “reality” based on reliable scientific data. The right of the patient to decide also requires that the patient has the capacity to decide. In the ICU environment the patient may lack decisional capacity secondary to their level of cognition, level of consciousness, nature of injury etc. or metabolic derangements. Additionally, a patient’s condition may hinder his/her ability to recognize the capacity to decide. Recognized mental competence testing may assist in resolving the situation. When a decision is made and the patient lacks the capacity to decide, there are several options.

An advance directive is one. This document is prepared and signed by the patient during a time when they had the capacity to decide which can be used to guide the decision making process. The patient’s autonomy is thus preserved based on his previous level of mental competence. This appears to be a straight-forward solution to a difficult situation, but it is far from a perfect solution. Often the advance directive document is not specific enough to apply to a medical condition. Most directives designate a specific individual, (Power of Healthcare Attorney), to oversee the decision making process. The lack of a Power of Healthcare Attorney creates a void for decision making. Trying to decide who will be the substitute decision maker is difficult and controversial. Options for this substitute decision maker include a legal representative, a pastor, a member of the family, or even a friend. How this is decided is not easy when agreement among friends and family is not unanimous. Ethical issues can arise as family or friends believe that motives behind a decision are not shared by all. How these differences are mediated are unique to each patient or situation and may need legal involvement. The living will is another document which may contain elements of the Power of Healthcare Attorney as well as directives regarding disposal of assets etc. and would therefore also serve the purpose of the advance directive. More details on the living will are discussed below.

(2) Beneficence: This principle entails the obligation of the physician to do good things on behalf of his patient and to consider the welfare of his patient at all times without being viewed as being too paternalistic and/or manipulative. The risk of conflict between autonomy and beneficence commonly exists and safeguards against this conflict must be practiced by the physician with a clear aim of preserving the patient’s welfare. The balance between risk and benefit is always present when a physician caring for a critically ill patient considers the beneficence principle. One example is that any intervention carries a potential benefit, but also risks. The moral duty of the physician is to ensure that the result is to the overall benefit of the patient.

In spite of the physician adhering to this principle of beneficence, the patient’s perception may be different especially if the patient is reducing the risk and enhancing the benefit. In this situation, the physician must try to engender patient trust emphasizing that the doctor is trying to serve as the patient’s advocate for his/her overall well-being. The earlier a physician can develop patient trust and understanding as well as demonstrate appropriate empathy, the more likely is the patient to accept physician recommendations.

A sense of beneficence and trust will encourage open communication so that the patient does not feel abandoned by the physician. A common scenario in the ICU is how to keep an entire family updated and involved in the patient’s care. Ideally, at each meeting with care providers, all family members should be present. This is usually impossible. One solution is to have a policy for regularly scheduled family updates which are scheduled usually related to patient acuity. Another solution is short updates each day when convenient for a majority of family members and ICU staff and physicians. An additional step, especially with large families, is to have one or two individuals who the family designate as spokespersons to deliver information to the rest of the family. While these options are all applicable, no one solution will solve each family’s needs for communication.

A final help in the field of beneficence is an institutional patient advocate. The institutional designated patient advocate serves the purpose of bringing patient’s concerns to the attention of the treating team. They can be helpful in clarifying issues and reassuring patients. Depending on how they are organized within each institution they may be the ones setting up meetings, routinely communicating with families and even answering specific complaints. These individuals also learn that a frequent cause of complaints is miscommunication. They become very good at interpreting physician’s communication with families and patients in terms they understand. Resolving patient and family complaints helps avoid painful interactions later including legal actions.

(3) Non-maleficence: The principle of non-maleficence emphasizes the physician obligation to avoid doing “bad things”, i.e., things that could potentially harm the patient. So, on the one hand beneficence implies action to encourage good outcomes while the non-maleficence principle focuses on avoiding actions that could do harm. This emanates from the golden principle of “primum non nocere”-first do no harm. These two principles could potentially yield conflicts. In the extreme, if physicians do nothing in order to avoid harm, good interventions with acceptable risks could be omitted to the detriment of the patient. For example a patient with major comorbidities and attendant high risk for postoperative complications may be denied an operative procedure such as appendectomy which could result in an improved outcome. Applying this principle is another risk benefit decision. As a critical care team elects to apply any intervention, a thoughtful review of the expected benefit versus any adverse event should occur. To give a simple example. A simple blood test has risks and benefits. If the test will not change anything, then why place the patient at risk for an invasive procedure as well as a lab error which could lead to further interventions. While simplistic it illustrates the non-maleficence principle.

(4) Justice: There are two components to this principle of Justice which may be in conflict with each other: Individual Justice and Distributive Justice.

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