L. Sparber1, A. Warman3, R. McLeod-Sordjan1,5, V. Patel4,5, R. Barrera4,5, W. Doscher1,4,5 1Northwell Health System – Long Island Jewish Medical Center,Division Of Medical Ethics – Department Of Medicine,New Hyde Park, NY, USA 3Duke University,Durham, NORTH CAROLINA, USA 4Northwell Health System – Long Island Jewish Medical Center,Department Of Surgery,New Hyde Park, NY, USA 5Hofstra University School Of Medicine,Hempstead, NY, USA
Introduction: Due to modern resuscitative technologies, critically ill patients undergoing major emergent operations frequently survive to face a post-surgical quality of life quite different than their pre-morbid state. Post-surgical increased morbidity requires the surgical team to communicate harms and benefits of continued interventions in a time sensitive manner. Multidisciplinary meetings including caregivers, the patient, the clinical team, palliative care, clinical ethicists, social work, nursing and chaplaincy can facilitate surrogate decisions regarding goals of care. This pilot study sought to describe the ethical framework necessary to guide medical decision making when patients and caregivers face unexpected near-fatal sequela after surgical intervention.
Methods: Between July 2011 and June 2016, a retrospective study of all ethics consultations was performed. Demographic and clinical data was collected. 22 SICU patients had Ethics consultations. Of those 22 patients, 14 (63.6%) patients were in multi-system organ failure post-operatively. The overall median age was 68 years. Six (42.8%) of the patients were female. The average length of stay until clinical ethics was consulted was 28.4 days. Descriptive statistical analysis was utilized to evaluate variations in ethical dilemmas as well as goals of care variations in advanced planning decisions.
Results: The primary outcome was successful mediation of the initial reason the ethical consultation was called. Major ethical dilemmas included mediation of goals of care (85.7%); withdrawal of life sustaining treatments (57.1%) as well as identifying an appropriate surrogate decision maker (14.3%). The secondary outcome was death during incident hospitalization (71.4%, N = 10). Two (14.2 %) patients were discharged but subsequently died on average 60 days after discharge. Two (14.2 %) patients remained alive to hospital discharge. 85.7% (12) of patients at onset of surgical intervention had capacity. Six (42.8%) patients had Health Care Proxy documents. Eight (57.1%) patients had surrogates who were family, while one (7.1%) patient had an assigned legal guardian. Three (21.4%) patients had capacity/restored capacity during their hospital stay.
Conclusion: Patients and their surrogates frequently experience significant distress when patients initially survive high risk interventions but then suffer declining quality of life during the post-operative recovery period. Additionally, when the patient experiences incapacity post-operatively either due to chemical sedation or physiologic distress, the burden of surrogate decision making may not necessarily accurately reflect the patient’s autonomous choice. It is imperative to recognize this ethical dilemma to be able to reconcile the conundrum that “surgical success” is not equivalent to “high quality of life.” Additional studies are required to validate the findings of this small study.