A. Patient autonomy is a highly valued guiding ethical principle in U.S. medicine.

Adult patients with decision-making capacity can and may choose to accept or refuse medical therapies. If a patient’s decision-making capacity is questionable, a psychiatrist should evaluate the patient. Decision-making capacity contains four essential elements; understanding, appreciation, reasoning, choice. Competence is a legal term and thus should be limited in use.

B. Autonomy is best preserved by involving the patient in medical decision making whenever possible. Obtaining informed consent for procedures and therapies is an ethical responsibility of the treating physician (see Chapter 1). Rarely, a patient’s condition and emergent circumstances may prevent the discussion involved in the informed consent process. Many critically ill patients cannot make medical decisions because of the gravity of their illness or because of sedative/analgesic medications used to diminish suffering. In these circumstances, an advance directive and/or surrogate may be helpful.

1. An advance directive, commonly called a living will, is a legal document specifying the types of treatment that the patient wishes to receive or reject should future need arise and often includes a designated surrogate. Most hospitals require documentation upon admission that clarifies the wishes for limitations of life-sustaining treatment. For example, a patient with terminal cancer may desire placement of a central venous access for chemotherapy but will refuse resuscitation in the event of a cardiac or respiratory arrest. The limitation of life-sustaining treatment orders especially with respect to do not resuscitate (DNR) and do not intubate (DNI) must be considered prior to each anesthetic.

2. In addition to or in the absence of an advance directive, a patient may designate a surrogate (health care proxy or durable power of attorney for health care) who has the legal charge to execute the patient’s wishes should he or she become unable to do so. The surrogate offers substituted judgment for the patient, providing decisions that the patient would make if capable. If the patient has not designated a surrogate before becoming unable to make medical decisions, the next of kin may become the de facto surrogate. In some circumstances where no family is living or available, a trusted friend may act as the patient’s surrogate. The durable power of attorney for health care may or may not be responsible for financial decisions based upon the wishes of the patient.

3. In emergency situations, physicians may need to act in the best interest of the patient until the patient’s wishes, either directly from the patient or from an advance directive, can be elucidated.

4. A court-appointed legal guardian may be necessary in rare instances in which no family member or friend is able to make decisions in the best interest of the patient.

C. Conflict is best resolved via ongoing discussion with the individuals involved. The anesthetist must recognize and respect cultural differences that influence a patient’s decisions. Irresolvable conflict among family members, health care team members, or between the family and the medical care team often is best addressed by the institutional ethics committee (see below).

D. The institutional ethics committee is generally composed of a group of health care professionals trained in medical ethics.

1. The purpose of the ethics committee is to provide education, advice, and consultation to promote resolution of ethical conflicts. The ethics committee offers an objective analysis of the patient’s case and uses basic ethical principles to guide the health care team, patient, and family to a consensus about the therapeutic course.

2. An ethics consult may be requested by physicians, nurses, other health care professionals or staff members, patients, and patients’ families/friends, and the ethics committee should be easily accessible to all those involved in the case. This diminishes inequalities of power present in the hospital environment and promotes a climate of respect for all viewpoints.

3. When the ethics committee is requested to consult on a case, the question to be answered or the nature of the conflict should be clearly stated. The patient’s condition and prognosis should be documented. Members of the ethics committee may help organize and/or attend a family meeting to facilitate decision making.

4. In rare situations in which irreconcilable differences exist between the physician and the patient and/or family, care of the patient may be transferred to another accepting attending physician. It is even more extraordinary for ethical conflicts to reach resolution by judicial intervention.

E. The pediatric patient deserves special consideration when ethical issues are confronted. Legally, such decisions are deferred to the parents. Ethically, the child may participate in these decisions depending on his or her developmental level and decision-making capacity. If the child is too immature to participate in decisions, parents are relied upon to make decisions in the best interest of the child, incorporating family values as well as weighing the benefit versus burden of the planned therapy. Pediatric anesthetists must be sensitive to individual family dynamics and parenting styles when approaching such discussions.

F. Jehovah’s Witness’ belief is that the bible prohibits consumption of blood and that blood that has been removed is unclean. Patients who are Jehovah’s Witnesses generally do not accept transfusions of blood products. However, each Jehovah’s witnesses must be assessed individually. Some patients will accept blood subfractions or products made from recombinant DNA. Similarly, some individuals will accept autotransfused blood, chest tube-salvaged autologous blood, dialysis or cardiopulmonary bypass return as it is possible for blood to remain in contiguous circulation with the vasculature by allowing a constant connection of the tubing withdrawing the blood from the patient with the transfusion tubing. Special considerations regarding homologous transfusion may apply if the patient is a minor, is incompetent, or has responsibilities for dependents, and in certain emergency circumstances when the patient’s wishes are not yet known. Law and judicial practices vary from state to state, requiring that health care practitioners be familiar with their particular state’s statutes or seek advise from hospital legal counsel. Careful documentation of preoperative discussions, informed consent, and agreement of the entire operating room team to honor the patient’s wishes and not transfuse even in the event of an unexpected blood loss are mandatory. Legal precedent generally supports patient autonomy regarding the acceptance of transfusion.