L. Torregrosa1, E. Rueda2 1Xaverian University – San Ignacio Hospital, Bogotá, Colombia 2Institute of Bioethics, Xaverian University, Bogotá
Introduction:
Determining the futility of a particular intervention is not just an empirical medical assessment. Unfortunately, almost nothing in physicians´ medical training prepares them to make appropriate decisions in cases in which medical futility is at stake. The study of medical sciences doesn’t let physicians to know how to cope with those clinical situations either.
Making surgical decisions in situations in which a significant benefit for the patient is unclear should be a central issue to surgical teams especially when they are engaged in postgraduate training. In order to prepare surgeons to make better decisions in cases in which the benefit of gastrostomy tube placement is unclear, we develop a decision tool focused on the patient’s point of view about the acceptability of the procedure in his/her own case.
Methods:
Traditionally, the decision to place a gastrostomy tube is focused mainly on patients in terminal phases of their diseases (last phases of cancer, dementia, anorexia-cachexia syndrome, permanent vegetative states) who cannot satisfy nutritional requirements by oral intake of food or nutritional supplements. This situation, that residents face frequently during surgical training, provides an ideal scenario for learning how to move beyond a narrow physiological way of understanding benefit to a broader concept of clinical benefit (based on the patient`s perspective).
On the grounds of a theory of human capabilities (M. Nussbaum – A. Sen) we developed an open-ended questionnaire to register what a potential patient for the procedure would consider valuable in his/her case. The questionnaire was used during each clinical encounter between the physician (resident) and the patient (or his/her surrogate decision maker) to improve decision making on whether a gastrostomy tube should be placed. Perceptions of the members of the General Surgical team at Hospital San Ignacio about the utility of the tool were evaluated as well.
Results:
The physicians (attendings and residents) of the General Surgery Service and the Nutritional Support Team perceived that this tool improved their decisions on whether a gastrostomy tube should be offered. General capacity of those teams to address medical futility regarding different cases was also improved.
Conclusions:
Since our tool integrates both medical and non-medical dimensions within the decision making process on whether a gastrostomy tube should be placed, it contributes to improve ethical reasoning among physicians (including residents) on the potential futility of such procedure (or others), and guides the resident through the ethical reasoning when the overall clinical benefit of a surgical intervention is uncertain.
The “human capabilities approach” (A. Sen, M. Nussbaum) was productively integrated into the decision making on the acceptability of this procedure. Actually, the surgical team assessed this bed-side tool as useful to facilitate decision making in cases in which the overall clinical benefit of placing a gastrostomy tube is uncertain.