L. S. Sparber1, A. B. Warman2, W. Doscher1,4,5 1Northwell Health System North Shore LIJ,Department Of Surgery, Division Of Vascular Surgery,New Hyde Park, NY, USA 2Columbia University,School Of Professional Studies Dept Of Bioethics,New York, NY, USA 4Northwell Health System North Shore LIJ,Department Of Medicine, Division Of Ethics,New Hyde Park, NY, USA 5Hofstra University,School Of Medicine,Hempstead, NY, USA
Introduction: There is a paucity of published studies that have focused on the role of ethics consultations when patients refuse life saving amputations. Duty based ethics suggest that clinicians guide interventions through proportionality and the duty to the patient to restore health when possible and ease suffering when not. Quality of life implications and functional outcomes should be considered. This pilot study sought to examine the ethical issues that arise when patients facing loss of limb and ultimately life refuse surgical interventions.
Methods: Between July 2009 and June 2016, a retrospective study of all ethics consultations was performed. Demographic and clinical data was collected. There were 1,038 limb amputations performed. Seven patients (0.7%) requiring limb amputations required Ethics consultations. The overall median age was 53 years. Two (28.6%) of the patients were female. One patient was pediatric. The average length of stay until clinical ethics was consulted was 18.7 days. Descriptive statistical analysis was utilized to evaluate variations in patient capacity as well as goals of care variations in advanced planning decisions.
Results: The primary outcome was successful mediation of the initial ethical consultation. The time frame from initial consult to surgical intervention was days to months. Of the seven patients, four (57.1%) patients did not have capacity initially. One patient regained capacity. Surgical interventions included below the knee amputation (14.3%); above the knee amputation (28.6%); transmetatarsal amputation (14.3%); debridement (14.3%); multiple limb amputations (28.6%). The secondary outcome was death during incident hospitalization (42.9%).
Conclusion: It is acknowledged that there is a bias towards patients with disabilities, but some may argue that many of the difficulties those with disabilities face are put in place by society at large and are not inherent to their disabilities. What is important is the patient’s perspective of what is good or beneficial for them. The clinician should be able to participate without bias in the shared decision-making process as well as assist the surrogate in the process when the patient does not have capacity. Treatment considerations should be weighed in light of best interests, benefits, burdens and risk to the patient’s authentic self. The consultation service can assist the team navigate through these ethical concerns. Additional studies are required to validate the findings of this small study.