Ethics, End‐of‐Life, and Organ Retrieval

Ethics, End‐of‐Life, and Organ Retrieval

Lewis J. Kaplan, MD1,2

1 Division of Trauma, Surgical Critical Care and Emergency Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA

2 Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, USA

  1. An elderly woman is brought to the emergency department from her nursing home with obvious septic shock. She is intubated, sedated, fluid resuscitated, and placed on a norepinephrine infusion. The patient’s sole surviving relative is her daughter. When the daughter arrives, she indicates that her mother would not want the care she is currently receiving and would instead wish to pursue comfort care. Which of the following principles is the care team using in pursuing the daughter’s statement of her mother’s wishes for comfort care?

    1. Substituted judgment
    2. Distributive justice
    3. Ethical parity
    4. Non‐malfeasance
    5. Respect

    Since the patient is intubated, sedated, and cannot state her desires, one must obtain outside input. Using a family member who can articulate the patient’s desires is appropriate. Accepting that family member’s input is termed substituted judgment. Distributive justice is the principle that applies the concept of justice across several individuals or groups of individuals instead of a single person. Ethical parity implies the equally appropriate application of ethical principles across different cultures and circumstances. Non‐malfeasance indicates a lack of wrongdoing by a public official, often in a financial undertaking. Respect is linked with the concept of autonomy but does not address accepting another’s representation of what individuals’ wishes would be if they were only able to share them.

    Answer: A

    Thompson IE (1987) Fundamental ethical principles in healthcare. British Medical Journal 295, 1461–5.

  2. A 67‐year‐old man has a potentially resectable colon cancer and has a tumor type that is thought to be favorably responsive to chemotherapy administration. After a lengthy discussion with you, his surgeon, he declines operative therapy, as well as chemotherapy. What principle is being utilized in his decision to decline indicated and potentially life‐saving therapy?

    1. Nonrational thinking
    2. Deontology
    3. Autonomy
    4. Munificence
    5. Principlism

    This question addresses the role of patient autonomy in medical decision‐making. Autonomy is a key principle in Western medical ethics, which preserves a patient’s ability to engage in self‐determination with regard to goals of therapy, as well as diagnostic or therapeutic undertakings. If the physician believes that the patient has appropriate decisional capacity and understands the implications of the decisions being made, then respecting their informed and autonomous decision to decline medically indicated therapy is appropriate. Nonrational thinking is decision‐making based on obedience, imitation, feeling, desire, intuition, or habit. Deontology is rules‐based decision‐making. Munificence is generosity in giving and does not apply here. Principlism, generally a Western approach, embraces beneficence, non‐maleficence, and autonomy, as well as justice, and as such is too broad an answer.

    Answer: C

    Limentani AE (1999) The role of ethical principles in health care and the implications for ethical codes. Journal of Medical Ethics 25, 394–8.

    Kilbride MK, Joffe S (2018) The new age of patient autonomy: implications for the patient‐physician relationship. JAMA ; 320 (19), 1973–4.

  3. A 24‐year‐old motorcyclist arrives with a severe traumatic brain injury (TBI) and within 48 hours has an examination and supportive investigations consistent with brain death. Which of the following strategies is associated with the greatest likelihood that his familys legally authorized representative will consent to organ donation on his behalf?

    1. A structured interview with an organ donation recipient and family
    2. Approach and consent obtained by the physician and nurse care team
    3. Approach and consent by the organ procurement surgeon
    4. Combined approach by the care team and organ procurement network team
    5. Combined approach by nursing, social service, and chaplaincy representatives

    One of the challenges in organ procurement has been obtaining consent from the legally authorized representative of a potential donor patient. Components cited as contributing to failure in obtaining consent include lack of consistent messaging between clinicians; lack of readily understood language; lack of understanding of organ donation in general; concerns regarding costs of organ donation; concerns regarding mutilation; and faith‐based concerns or objections. Perhaps the most readily addressable set of concerns are those that impact clear and consistent communication. A prefamily “huddle” consisting of physicians, nurses, and representatives of the organ procurement organization to discuss the best approach for a given family has been demonstrated to significantly improve consent rates. Other members of the care team may also participate in the “huddle” as appropriate. Engaging a donor recipient and family is ideal for recipients and their families but not necessarily the donor family. The organ procurement surgeon is ethically constrained from participating in the consent process due to a conflict of interest. Similarly, the care team members are constrained from participating in organ procurement for the same reason.

    Answer: D

    Rady MY, Verheijde JL, McGregor JL (2010) Scientific, legal and ethical challenges of end‐of‐life organ procurement in emergency medicine. Resuscitation 81 (9), 1061–2.

    Witjes M, Kruijff PE, Haase‐Kromwijk BJ, van der Hoeven JG, Jansen NE, Abdo WF (2019) Physician experiences with communicating organ donation with the relatives: a Dutch nationwide evaluation on factors that influence consent rates. Neurocritical Care 31 (2), 357–64.

  4. The ethical and humane treatment of prisoners of war (POW) by physicians is specifically addressed by which of the following:

    1. Hastings Center report
    2. Nuremberg proceedings
    3. North Atlantic Treaty Organization
    4. World Health Organization
    5. Geneva Conventions

    The ethical treatment of POWs is explored in detail within the Geneva Conventions. The tenets are embraced and further articulated within a variety of military field manuals as well. Physicians are specifically constrained from being active combatants but are expected to be able to defend themselves and the patients for whom they actively provide care. The Geneva Convention also prohibits the deliberate attack of medical care providers and the torture of prisoners. Provision of nourishment, medical and surgical care, and humane holding conditions are also explicitly required within the document. The Hastings Center mission is to address fundamental ethical issues in the areas of health, medicine, and the environment as they impact individuals, communities, and societies. This center focuses ethical issues addressing end‐of‐life, public health, and new and emerging technology. Periodic reports are generated on these topics, but not treatment of POWs. The Nuremberg Proceedings addressed war crimes. NATO is a collection of allied countries with similar aims and who have signed mutual aid and intent treaties. The WHO is an organization that addresses world health issues. NATO and the WHO both endorse the Geneva Conventions.

    Answer: E

    Carter BS (1994) Ethical concerns for physicians deployed to operation desert storm. Military Medicine 159 (1), 55–9.

    Barilan YM, Asman O (2017) Research ethics, military medical ethics, and the challenges of international law. The American Journal of Bioethics 17 (10), 53–5.

  5. If one argues that principles and moral rules are not absolutely binding, but are instead prima facie, this means that the principles and moral rules are:

    1. Self‐evident and are context independent when rendering moral judgment
    2. Duties that are binding unless in conflict with an equal or stronger duty
    3. Unable to be equally applied across the same circumstance in different cultures
    4. Only able to be understood within the context of virtue ethics and behavior
    5. Rooted in Western culture and interwoven within the rules for social behavior

    Prima facie means that principles and moral rules are duties that are binding unless in conflict with an equal or stronger duty. In this way, prima facie recognizes that principles may come into conflict with one another and that there is a context‐sensitive nature to principles that may not translate from one culture to another. Therefore, prima facie allows one to allow contextual influences to help shape a moral judgment, instead of strictly adhering to a single set of rules. Thus, a need for overall balance is embedded in the concept of prima facie. Virtue ethics asserts that decision‐maker characteristics are reflected in their behavior, and ethics may be interpolated from a behavior set. This type of ethics implies that virtuous behavior is a type of moral excellence.

    Answer: B

    Limentani AE (1999) The role of ethical principles in health care and the implications for ethical codes. Journal of Medical Ethics 25, 394–8.

    Jones A. (2020) Principlism in medicine–a philosopher’s view. Medicine. 48 (10), 637–9.

  6. Which of the following ethical principles may be used as a justification for performing scientific and medical research?

    1. Non‐maleficence
    2. Distributed justice
    3. Beneficence
    4. Autonomy
    5. Pluralism

    Beneficence is acting for the greater good and implies a sense of moral and ethical correctness in the assignation of good to a particular behavior or activity. Research may be justified using this concept in that the discovery of new knowledge may be applied to others with similar conditions to enable recovery, survival, or mitigate the consequences of that particular, as well as other related, illnesses. Non‐maleficence is different in that it constrains one from willfully doing harm. Distributed justice implies equality in a particular element in either equal share, or in proportion to need, effort, contribution, or merit. Autonomy relates to an individual’s right to self‐determination. Pluralism is the philosophy that it is desirable and beneficial to have several distinct ethnic, religious, or cultural groups thrive within a single society. Pluralism also holds that no single explanatory or belief system may reliably and definitively account for all the phenomena of life. In this way, pluralism supports many different ethical viewpoints and contextually specific moral judgments.

    Answer: C

    Limentani AE (1999) The role of ethical principles in health care and the implications for ethical codes. Journal of Medical Ethics 25, 394–8.

    Beauchamp TL, Childress JF (eds) (2009) Principles of Biomedical Ethics , 6th edn, Oxford University Press, New York.

  7. A patient with metastatic colorectal cancer, with symptomatic bony and brain metastases, is critically ill in the ICU with sepsis and impending acute respiratory failure. As the intensivist, you have a discussion with the patient regarding his goals of care. He states that although he is aware that he has only a limited time to live based on his malignancy, he wishes to receive intubation, mechanical ventilation, and CPR if he has a pulmonary or cardiac arrest. His wife is on her way to the ICU but has not yet arrived. As the intensivist, you do not believe that those therapies are reasonable to pursue for this patient. The next most appropriate course of action is to:

    1. Accept the patients decisions to respect his autonomy
    2. Enter a DNR/DNI order to respect your autonomy
    3. Contact the hospital legal/risk management department
    4. Discuss with the wife and accept her substituted judgment
    5. Convene an ethics committee consultative visit

    This patient is critically ill and has brain metastasis. Therefore, his judgment may be compromised, and he may not be able to appropriately interpret the consequences of his decisions. Moreover, as it is an emergency situation, asking a patient to articulate goals of therapy may be viewed as coercive. Furthermore, since you do not believe that intubation will help the patient achieve a reasonable goal, it is appropriate to discuss goals of therapy with an individual who is not physiologically compromised and with impending respiratory failure. The next most appropriate individual is his wife. Were she not alive, then an adult child would be the next most appropriate individual. Others may have a legally authorized representative empowered by a durable healthcare power of attorney designation. Still others have a court appointed conservator when there are no kin to help make healthcare decisions—or when those who are present are unwilling or incapable of making such decisions. Accepting the goals as articulated by the most appropriate individual as those of the patient is known as substituted judgment. Substituted judgment relies on the perspective that the goals being related are those that the patient would most likely share with the care team if they were able to do so. The clinician must be careful to ensure that the goals do not instead reflect what the individual stating the goals wants for the patient, but rather what the patient would want for his or herself. Respecting autonomy also implies that the patient is competent to render a decision. Entering a DNR/DI order to respect your autonomy is inappropriate and violates the patient’s right to self‐determination—either autonomously or via substituted judgment. Hospital agencies including Clinical Ethics Committees generally act slowly to render a rapid decision regarding care, but are very helpful when there is the luxury of time to have an outside agency (not the primary healthcare team), review the case, and share input regarding difficult ethical decisions.

    Answer: D

    Mazur DJ (2006) How successful are we at protecting preferences? Consent, informed consent, advance directives and substituted judgment. Medical Decision Making 26 (2), 106–9.

    Seckler AB, Meier DE, Mulvihill M, Paris BE (1991) Substituted judgment: how accurate are proxy predictors? Annals of Internal Medicine 115 (2), 92–8.

    Kayser J, Kaplan LJ (2020) Conflict management in the intensive care unit: a concise definitive review. Critical Care Medicine 48 (9), 1349–57.

  8. While on call at night in the ICU, one of the surgeons brings up a patient from the OR after performing an adhesiolysis and small bowel resection for a smallbowel obstruction. The operation reportedly went smoothly. As the surgeon is discussing the patient with you in the ICU, it is clear to you that the surgeons breath smells of alcohol and the surgeon appears to be intoxicated. Your most appropriate course of action is to:

    1. Have a private conversation with the surgeon once the surgeon is sober
    2. Do nothing as you do not have laboratory evidence of intoxication
    3. Immediately contact the surgeons Chairman with your concerns
    4. Disenfranchise the surgeon from the patients care due to incompetence

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Dec 15, 2022 | Posted by in CRITICAL CARE | Comments Off on Ethics, End‐of‐Life, and Organ Retrieval

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