Y. Liu1, M. D. Kuzemchak2, C. M. Hammack-Aviran3, J. B. Fanning3, O. D. Guillamondegui2, M. B. Patel2, A. B. Peetz2 2Vanderbilt University Medical Center, Division Of Acute Care Surgery, Department Of Surgery, Section Of Surgical Sciences, Nashville, TN, USA 3Vanderbilt University Medical Center, Center For Biomedical Ethics And Society, Nashville, TN, USA 1Vanderbilt University Medical Center, Vanderbilt University School Of Medicine, Nashville, TN, USA
Introduction: Ethical challenges in healthcare are compounded when clinicians have limited time to reason through options, such as during a major trauma. After serious injury, patient autonomy is often compromised due to fluctuating consciousness and shifting provider focus on surrogates for decision-making. The frequency and type of ethical dilemmas arising in traumatology is unknown. This study aims to better characterize the frequency and type of ethical dilemmas after serious injury. As a descriptive study, our hypothesis is that there is a differential pattern identifiable in trauma-related ethics consultations that is not established in current literature.
Methods: After obtaining IRB approval, all ethics consults regarding trauma patients from January 2014 to January 2021 were reviewed using a qualitative approach from a secure RedCap database developed and managed by a single center ethics consultation service. Representative consult summaries which included ethics issues addressed and consultant’s advisory comments were distributed among researchers who independently generated thematic codes. These were aggregated to create a codebook, which was applied to all consult summaries. Iterative and emergent thematic analyses were done to coding results.
Results: We identified 167 trauma patients within the ethics consult database. Most consults were requested by the social worker (25%) and primary attending physician (20%). The highest requests for an ethics consult were Concerns Regarding Surrogates (66%) and Appropriateness of Clinical Care (49%). Consults were placed to help the clinical team clarify hospital policies (72%), resolve conflicts within the clinical teams or between the team and patient families (37%), and clarify goals of care (31%). Most consults tied queries to a litigious impact (73%). A minority of consults had no clear ethical question but served as a written outlet of emotions for the clinical team (13%).
Conclusion: This qualitative study found clear patterns in trauma-related ethics consultations. Our results identified Surrogate Decision Makers and Appropriateness of Care as the two most common ethical problems in a cohort of trauma patients. Future studies should seek to further elucidate the actual incidence of ethical issues that characterize trauma care across multiple centers, and possibly explore parallel issues in non-trauma acute care surgery. Larger epidemiologic patterns may identify modifiable factors that improve resource allocation (e.g., dedicated palliative care, social workers) toward trauma care.