La Paradoja

SURGICAL ETHICS CHALLENGES

Complying with advance directives in the operating room
James W. Jones, MD, PhD,a and Laurence B. McCullough, PhDb An ambulance brings an unconscious 41-year-old man to the emergency department after an automobile accident. Emergency computed tomography shows rupture of the liver, spleen, and superior mesenteric artery. He is being prepared for surgery when hisbusiness partner arrives with what he claims is the patient’s signed advance directive, specifying that in the event of cardiac arrest, the patient wishes that no resuscitative measures be taken. During surgery, the patient suffers an acute hypotensive episode and arrests. Your proper response is which of the following? A. B. C. D. E. Do not resuscitate. Resuscitate and continue the operation. Limityour resuscitative efforts to closed chest massage. Consult the business partner. Ignore the advance directive. Though grievously injured, this patient can recover with timely and competent surgical care. His intraoperative arrest is a correctable complication of fluid management, likely not the culminating event of an inevitably terminal illness or injury. Intraoperative resuscitation maintainshomeostasis, and patient recovery in such cases is routine, as opposed to the overall 15% success rate of cardiopulmonary resuscitation.2 The patient’s refusal of cardiopulmonary resuscitation in the advance directive may ethically be understood to apply in the context of these poor success rates, which include not just death but survival with a greatly diminished quality of life. The advancedirective’s election of Choice A, no resuscitation, was very likely formulated without consideration of functional conditions in the operating room, and would furthermore deny the patient the benefits for which he was originally brought to the operating room. Choice B is fully consistent with the goals of surgery and is a necessary and proper response for a patient whose condition does not activate theauthority of a living will. Some ethicists argue that advance directives containing do-not-resuscitate instructions should be as applicable inside the operating room as in the intensive care unit.3 Others have argued that the conditions of surgery blur the distinctions between resuscitation and maintenance of homeostasis,2 or that many physicians routinely dismiss advance directives, or thatpatients seldom understand the processes of surgical care. Attempting to straddle these issues by limiting the procedural options of the resuscitation efforts (Choice C) strengthens neither the physician’s ethical posture nor his clinical effectiveness and is inconsistent with the goals of surgery and conditions under which the advance directive has clinical authority. The business partner is not thenext of kin and has no legal standing as a surrogate decision-maker unless he has been named as an agent in a durable medical power of attorney. Furthermore, the patient’s own views have been articulated in the advance directive, which would stand as the last available expression of his wishes if it otherwise qualified. Choice D is therefore not available. Ignoring the advance directive, Choice E,which legend holds is a common tactic among physicians who find such instructions odious, is not acceptable. Notwithstanding, the surgeon is obligated to evaluate the directive in 199

B is the most ethically sound option. The “living will” advance directive is defined by most statutes and hospital policies as the medical instructions of a terminally ill or injured patient who can no longercommunicate his immediate wishes.1 Living wills typically concentrate on end-of-life issues, particularly withdrawing or withholding efforts to sustain a life that cannot be saved or restored to a functional level acceptable to the patient. They may conversely express the wish that all available lifesustaining efforts be fully implemented until death is spontaneous. A “terminal illness or injury” is...