Martha L. Twaddle, M.D., F.A.C.P., F.A.A.H.P.M., Tina J. Hieken, M.D., Mona Tareen, M.D.
1 A 93-year-old woman is seen after a fall at home with complaints of right leg and wrist pain. She also gives a history of anorexia and 40-lb weight loss. On physical examination she is cachectic and has a large necrotic tumor in her left breast with significant drainage and odor. She admits to its presence but prefers to deflect questions about the history of the breast lesion. You assess her Karnofsky performance status (KPS) score to be 40% and palliative performance status (PPS) score to be 40%. Radiographs reveal a right wrist fracture and metastases to her pelvis and femur with a nondisplaced hip fracture. As you discuss goals with the patient and her daughter, the patient states that she does not want “you to make a fuss” and her goals are “to be comfortable” and “to not be a burden.” She denies any depression and feels “blessed for having such a wonderful life.” Which one of the following is the best course of action?
A You tell the patient and her daughter that the median survival with stage IV breast cancer is about 2 years and recommend preoperative chemotherapy followed by a mastectomy and radiation therapy.
B You speak privately with the daughter, who desires that her mother undergo surgery and chemotherapy. You declare the patient incompetent because you think that she is depressed and look to her daughter to serve as a designated power of attorney for health care (DPAHC).
C You recommend radiation therapy because this may help decrease the pain of the bone metastases and recommend a single fraction as opposed to a 2-week course.
D You recommend no surgical intervention given her goals to not pursue other treatment.
E You recommend that the patient undergo whole-body computed tomography (CT), positron emission tomography, and magnetic resonance imaging (MRI) of the brain to formulate a treatment plan.
Ref.: 1-7
Comments
This patient’s goals of care are most consistent with a palliative approach to management. Given the extent of disease and her age, this approach is reasonable. The Karnofsky performance scale was developed in 1949 by Dr. Karnofsky as a means to measure and reflect a cancer patient’s quality of life as reflected by functionality. A KPS score of 100% reflects no complaints and no evidence of disease, 50% requires help often and frequent medical care, and 0% is death. The palliative performance status provides a functional assessment of ambulation, activity, cognition, self-care, and oral intake and is used as a tool in prognosis with a scale similar to the KPS (100% is normal, 0% death). Evaluation for depression and decision-making capacity is of key importance to ascertain that the patient clearly understands the consequences of her decisions, is consistent in her decision making, and is not depressed. Even patients with mild cognitive impairment may have decision-making capacity. Physicians do not determine whether a patient is “competent” because that is a legal decision. If the patient is decisional, the DPAHC is not active. The patient’s goals suggest care focused primarily on comfort. Thus, chemotherapy, nonpalliative surgery, and radiotherapy, as well as an extensive radiologic work-up in this patient in whom metastatic disease is already apparent, are not indicated. Wound care for the breast lesion, pain management for the bone metastases, and a palliative care evaluation to facilitate a complex symptom management and discharge plan are recommended. A toilette mastectomy or partial mastectomy may be considered for local control of bleeding, odor, and infection, even in the presence of metastatic disease. Reduced-fraction radiation therapy will facilitate symptom management and minimize the duration of treatment.
Answer
C
2 A 48-year-old man has a recent increase in abdominal girth, 20-lb weight loss, jaundice, and confusion. He has no other significant past medical history and was working until 1 week earlier. His wife provides the history and states that the patient has had persistent complaints of abdominal and back pain unrelieved by acetaminophen or ibuprofen. His current KPS score is 40% and his PPS score is 30%. After further testing, pancreatic cancer with gastric outlet obstruction is diagnosed. Because he is symptomatic with pain and encephalopathy, you speak to his wife. She is very anxious and tells you that they have two children 6 and 8 years of age who are unaware of their father’s diagnosis and the extent of his disease. All of the following are true except:
A At the time of diagnosis, only 20% of patients with pancreatic cancer will have resectable disease.
B Laparoscopic gastrojejunostomy can provide effective palliation of symptoms.
C Celiac neurolysis has been demonstrated to help in pain management.
D Acute thromboembolic disease, a common complication of advanced pancreatic cancer, is best managed with a heparin bridge to oral anticoagulation.
E Specialized support services for children and the spouse may be of great psychological benefit earlier in the course of diagnosis and treatment.
Ref.: 8-12
Comments
Although the majority of patients with cancer of the pancreas have advanced disease not amenable to surgical resection when initially seen, much can be done to improve the symptoms and thus quality of life. For patients with good performance status and a life expectancy of several months, laparoscopic gastrojejunostomy can provide effective palliation of the obstruction and allow the patient to eat. Metoclopramide may also improve any associated dysmotility. Pain is a common problem with cancer of the pancreas and can be difficult to manage, particularly if there are concomitant dysmotility issues. Endoscopic ultrasound-guided celiac plexus block is greater than 70% effective in managing the pain related to pancreatic cancer and is a reasonable option for pain management. For patients with acute thromboembolic disease, a common complication of pancreatic cancer secondary to a hypercoagulable state, studies demonstrate a significant decrease in recurrent thromboembolic events in patients treated with low-molecular-weight heparin as opposed to oral anticoagulation. In addition, management of oral anticoagulation is complicated by the malnutrition and liver dysfunction that typically accompany pancreatic cancer. Supportive care services introduced early in the care of patients (and their families) helps address the psychosocial and spiritual stresses of the illness and their ramifications on all family members.
Answer
D
3 A patient scheduled for surgery on her left lower extremity awakens from surgery to find her right leg bandaged and her left leg untouched. Which of the following is true regarding wrong-site surgery?
A The rate of wrong-site surgeries has decreased substantially since the 2004 Institute of Medicine (IOM) initiatives.
B The patient should receive prompt, full disclosure of the error and an apology from the surgeon.
C A sufficient apology typically consists of saying “I’m sorry that this happened.”
D Exposure of the error successfully mitigates against the risk of a patient suing.
E The Joint Commission’s National Patient Safety Goals apply only to hospital settings.
Ref.: 13-18
Comments
Adverse events are defined by the IOM as “harm that is the result of the process of health care rather than the patient’s underlying disease.” A medical error is an adverse event that could have been prevented, and thus its risk or occurrence warrants changes in procedures, systems, practice, or products. The IOM defines a medical error as “failure of a planned action to be completed as intended, or the use of a wrong plan to achieve an aim.” The Joint Commission Board of Commissioners approved the Universal Protocol for Preventing Wrong Site, Wrong Procedure and Wrong Person Surgery in July 2003, and it became effective July 1, 2004, for all accredited hospitals, ambulatory surgery suites, and office-based surgical facilities. The protocol seeks to prevent these errors through active and robust strategies involving the surgical team and the patient (or representative). The three components include preoperative verification of the patient’s and team’s expectations of the procedure to be performed, operative site marking that is visible when the patient is draped for all right and left or multiple-site procedures, and a final time-out before the procedure begins to facilitate reverification. The occurrence of wrong-site surgery is exceeding rare (1 per 112,994 non–spine-related operations in one series) but, interestingly, has not declined since the Joint Commission’s protocol was put into effect in 2004. The occurrence of a wrong-site surgery would constitute a “sentinel event” to be voluntarily reported to the Joint Commission with a root cause analysis and action plan accompanying the report. The Joint Commission maintains a database on sentinel events.
The medical profession’s historical response to errors and adverse outcomes has been to deny and defend. Currently, the widespread consensus is that patients should receive a prompt, thorough disclosure of the error and a sincere apology. Apology in this context indicates that one should admit responsibility, show remorse, offer explanation, and make reparations. Historically, surgeons have been less apt to disclose error than have physicians in other disciplines. Research indicates that the absence of disclosure motivates many medical malpractice lawsuits and that disclosure and full apology may actually decrease liability and maintain support of true patient-centered care. However, this mitigation is not 100%. Many states have adopted laws that such disclosure is inadmissible as evidence of liability.
Answer
B
4 An 85-year-old man with a history of hypertension, peripheral vascular disease, and hyperlipidemia who was living independently at home was taken to the emergency department after being found unresponsive on the kitchen floor by his sister. On examination, his right pupil is fixed at 7 mm and his left pupil at 5 mm; both are unresponsive. The oculocephalic maneuver (doll’s eyes) is negative. There is a positive but weak corneal reflex on the left; it is absent on the right. The patient gags with insertion of an endotracheal tube and demonstrates extensor posturing in both upper extremities when intubated for airway protection. CT demonstrates a large right temporal-parietal intracerebral hemorrhage, a right frontal subdural hematoma, intraventricular hemorrhage, and a 2-cm midline shift. The patient is unmarried, has no children, but does have five siblings. There is no advance directive available. You decide:
A That urgent neurosurgical intervention is warranted because the patient may regain function even though he has only lower brainstem reflexes.
B To obtain a neurology consultation and let the neurologist deal with decision making.
C To hold a family meeting as soon as possible to explain the patient’s poor prognosis with the goal of determining what treatment the patient would have wanted via substituted judgment.
D To admit the patient to the intensive care unit (ICU) and treat the aspiration pneumonia and urinary tract infection with the intention of performing a tracheostomy and placing a percutaneous endoscopic gastrostomy tube after a family meeting to obtain consent.
E To initiate a morphine drip.
Ref.: 19-23
Comments
“Breaking the bad news” regarding a poor prognosis is the responsibility of every physician, and the ability to provide this intervention is an acquired skill that requires knowledge and practice. The most commonly followed procedure is Buckman’s SPIKES method. Early communication facilitates earlier recognition of the prognosis by the family and is more likely to establish a cooperative, patient-centered plan of care. Although certainty about outcomes may be unclear early in an ICU stay, families find information helpful in anticipating outcomes and making decisions. Family meetings facilitate communication and improve family satisfaction, clinical decision making, and the psychological well-being of the family. In families who perceive communication to be inadequate, symptoms of post-traumatic stress disorder are more likely to develop. Ideally, patients choose their surrogate decision makers. However, the presence of a health care proxy via an advance directive is not always present despite all 50 states having legislation authorizing the appointment of such. The next of kin customarily serves in this role with the expectation that the decisions will be based on substituted judgment, that being what the patient would want if able to provide directives.
Answer
C
5 A 67-year-old woman with a history of severe chronic obstructive pulmonary disease is admitted on an emergency basis to the hospital from home. She has been admitted for pneumonia and respiratory failure four times in the last 6 months; her last hospitalization was complicated by a protracted time in the ICU in which she required biphasic positive airway pressure. She also has chronic renal insufficiency with anemia that is exacerbating her primary lung disease and controlled non–insulin-dependent diabetes mellitus. On this admission, in addition to her severe dyspnea and fever, acute emphysematous cholecystitis develops. The patient has given a “do not resuscitate” (DNR) order as part of her advance directive. She is currently considered decisional despite her serious condition; she understands that she is seriously ill, that she may soon require intubation given her progressive respiratory failure, and that she will need surgery in the very near future, depending on her response to antibiotics and supportive therapies. The patient states that she does not wish to be intubated now or resuscitated if she should die now or later in surgery. You decide:
A To intubate her because this is a potentially reversible condition from which she can fully recover.
B To call her husband because he is her surrogate and ask him for permission to move ahead with intubation as well as rescinding the DNR order.
C To respect her wishes and elect to not intubate her given her advance directives, yet continue to provide antibiotics and supportive care to facilitate possible recovery.
D To call her primary physician and ask him to reverse her DNR order so that you can move ahead with what is best for her.
E To proceed with surgery.
Ref.: 3, 24-29
Comments
Patients have the right to refuse treatments, even those that are likely to be beneficial and have a reasonable chance to remediate or resolve a serious condition. This patient has an advance directive and has had time to reflect on her values, draw conclusions based on her past experiences, and make decisions regarding future care. Despite her current condition, she maintains decision-making capacity (she is consistent in her directives, she understands her illness and her prognosis without specific treatments, and she is able to draw to a conclusion). Her care would include providing support to her husband regarding her decisions, adding small doses of hydromorphone for dyspnea given her impaired creatinine clearance, and planning a family meeting to discuss surgery. Involving her husband and primary care physician is appropriate, but not to change or overrule the patient’s advance directive. Reversal of a DNR order preoperatively remains a tremendous challenge for institutions. Position papers of the American College of Surgeons, the Association of Operating Room Nurses, and the American Society of Anesthesiologists speak strongly against policies requiring automatic cancellation of existing DNR orders for patients undergoing anesthesia based on the principle of patient autonomy. Careful attention to the decision-making process and identification of the health care proxy are very important when this is done. The goals of care may need to be further negotiated as the patient receives supportive interventions. The outcome may not what the physician believes is “best” yet may be consistent with what the patient desires. The patient may indicate that she wishes to pursue surgery with some parameters regarding the extent of perioperative interventions. Supportive care interventions include treatment of the infection and relief of the abdominal pain with intravenous analgesics. Morphine should be avoided given the patient’s renal failure to circumvent the accumulation of morphine-6-glucoronide and its side effects. Preferred analgesics for patients with advanced renal disease and renal failure include hydromorphone, fentanyl, and methadone. Given her multiple comorbid conditions, she is at high risk for delirium and should be reassessed frequently for the onset of global confusion, progressive sleep abnormalities, and agitation.
Answer
C
6 A 58-year-old African-American woman with stage IV colon cancer has been admitted multiple times for pneumonia and recurrent partial bowel obstruction over the past month. She is now in the ICU with peritonitis, gram-negative sepsis, acute renal failure, and a suspected bowel perforation. When the patient was decisional, she had expressed to her family that she wanted “everything done” and that “God will cure me.” Her mother and sister are frequently at the bedside and express a range of emotions, including anger. Her sister cannot understand why “you aren’t doing anything to help her!” In particular, the sister, acting as the patient’s surrogate decision maker, is insistent that you move forward with surgery to repair the bowel and states this is necessary for religious reasons. The next best step in your approach to this patient is to:
A Consult the palliative care service to hold a family meeting to discuss the goals and prognosis before instituting hemodialysis or operating on the patient.
B Operate because of the patient’s and family’s goals and their religious beliefs after the sister signs fully informed consent.
C Tell the patient and the family that surgery in her case is futile care and sign off the case.
D Call the hospital risk management department.
E Delay surgical intervention and avoid confrontation with the family until full discussion of the case with the patient’s clergy can take place.
Ref.: 9, 20, 23, 24, 28, 30-33
Comments
Surgeons are faced with patient and family member requests for what may be called “futile” care, although this term is best avoided in family discussions because it implies a value judgment. Clearly, this family does not think that treatment is futile, and discussion may be eclipsed by the meaning of a word as opposed to focusing on the issues. The surgeon is confronted with a request for care that is unlikely to benefit the patient, who appears to be dying, and complicated by the family’s expressions of anger and their stated religious beliefs. A palliative care team or ethics consultation is beneficial in this situation; these services have been shown to improve symptom control, enhance patient and family satisfaction, lower costs, and even increase organ donations. Ideally, the surgeon provides primary palliative care and does not abdicate resolution of the issue but actively collaborates with the consultants. The surgeon has a responsibility to explain the clinical situation, the options for care, and the probable outcomes of each option. A second opinion may be offered. Religious traditions may affect decisions about treatment and withholding and withdrawing of life-prolonging care. The medical team should make “reasonable accommodation” for such beliefs. In this case, the family is asking for treatment of no benefit and probable harm, thereby potentially accelerating death. Involving chaplaincy or a member of the patient’s religious community can be of value but is not a substitute for direct discussion with the family. Studies show that African Americans tend to prefer life-prolonging measures. They may see death as a struggle to overcome or to deny and suffering as something spiritual to be endured; this may be at odds with a palliative care approach. Honest open communication, compassion, and respect can align the surgeon with the family so that the surgeon is seen as an advocate seeking to do what is best for the patient. Alerting risk management services is often advisable but is not the most pressing priority.
Answer
A
7 A 52-year-old woman is now at postoperative day 5 after debulking surgery for stage IIIC ovarian cancer. She is passing some flatus, but her recovery is complicated by protracted nausea and vomiting. She has received odansetron, chlorpromazine, and droperidol without improvement in her symptoms, and she continues to complain of nausea, to vomit intermittently, and to require intravenous fluids for hydration. The patient tells you that when her food is brought in and she sits up to eat, her nausea increases significantly and she vomits. Her protracted symptoms are most likely related to:
A Centrally mediated nausea from the smell of the food.
B Bowel dysmotility and edema.
C Stimulation of the vestibular apparatus.
D Manipulation of the uterus and ovaries in surgery.
E Anesthesia.
Ref.: 34-38
Comments
Nausea, like pain, is a complex symptom that requires a thorough history to elucidate the cause and best treatment. Vomiting is controlled by the vomiting center in the brain, which is located in the medulla and serves to process all the stimuli that elicit nausea. The chemoreceptor trigger zone in the floor of the fourth ventricle is outside the blood-brain barrier and can be directly stimulated by changes in blood chemistry, toxins, or pharmaceuticals. Centrally mediated nausea from the cortex is not as well understood but can trigger nausea via smells and learned triggers. Dysmotility from postoperative ileus, bowel edema, decreased peristalsis from opioids, or inflammatory changes in the viscera may also affect the vomiting center via gastrointestinal neurologic mechanisms. There is also a strong correlation between postoperative pain and nausea; improved pain control may concomitantly decrease nausea without direct treatment of the symptoms. An often overlooked type of nausea is vestibular nausea, caused by activation of the vestibular apparatus, which may be triggered by drugs such as opioids, dehydration, and postural changes. Vestibular nausea is more common in women, and those with a previous history of motion sickness may be at increased risk. This patient’s history is significant for nausea after a change in posture. Ondansetron, chlorpromazine, and droperidol address centrally mediated nausea; none will alleviate vestibular nausea, which is best treated by scopolamine applied as a transdermal patch or diphenhydramine.
Answer
C
8 A 66-year-old man is seen 4 months after right thoracotomy and upper lobectomy for stage I adenocarcinoma of his right lung. He appears anxious and depressed, has suffered a 12-lb weight loss, and complains of pain along the area of the healed incision. He describes the pain as a deep pressure with shooting, electrical qualities. He experiences severe pain when his undershirt rubs against the area and says that if the area is rubbed or touched repeatedly, the resultant surge of pain will last for several days. On examination, the thoracotomy incision is well healed, numb, yet markedly dysesthetic to touch. Given his deteriorating condition, the patient is convinced that the cancer has returned and seeks your help. As you counsel the patient, you explain that:
A He would probably benefit from radiation therapy directed to the intercostal area.
B The pain is suggestive of locally recurrent disease secondary to implantation of tumor cells in the incision, and you order CT of the chest.
C His pain is consistent with a post-thoracotomy neuropathic pain syndrome and it should resolve over time without intervention.
D His pain is consistent with a post-thoracotomy neuropathic pain syndrome and prompt treatment with a combination of medications may reduce or remit his pain.
E His pain is suggestive of a centrally mediated phenomenon, and you order an MRI of the brain to evaluate for brain metastases.
Ref.: 39-44
Comments
Neuropathic pain is defined by the International Association for the Study of Pain as “pain initiated or caused by a primary lesion or dysfunction in the nervous system.” It may follow injury to the nervi nervorum or nerve axons in peripheral pain syndromes or be centrally mediated from lesions of the spinal cord or brain. The diagnosis is made principally by eliciting a history of the characteristic dysesthesias, which may be manifested as a searing sensation of heat, electrical shocks, or stabbing pain coupled with abnormal evoked pain. The latter, known as allodynia, is pain caused by nonnoxious stimuli, such as the brush of clothing or a light touch. Hyperalgesia may be present, in which a painful stimulus is greatly exaggerated, or hyperpathia, in which repeated nonpainful stimuli seemingly accumulate and cause an intensified pain response. Neuropathic pain persists after the primary cause has resolved. In this case, healing of the thoracotomy is complete, but the pain persists. In some individuals the pain will not begin until several weeks after surgery. There may be physical findings that accompany the neuropathic pain, such as changes in the color of the skin (pallor or redness), abnormal sweating or coldness, loss of hair, or atrophy. Frequently, however, other than the abnormal neurologic findings, the area of concern appears normal. The pain may mistakenly be dismissed as a psychological problem given the paucity of physical findings. Neuropathic pain presents a particular challenge to treat in that it tends to be less responsive to traditional analgesics, such as opioids, because the pain is not a result of activation of the pain receptors (nociceptors) but a dysfunction or lesion of the nerve itself. Treatment often involves polypharmacy with tricyclic antidepressants or anticonvulsants (or both) coupled with opioids. Topical local anesthetics may also be of benefit, in some cases combined with the anesthetic and N-methylaspartate receptor antagonist ketamine. Despite treatment, neuropathic pain may never fully resolve and can result in a chronic pain syndrome. There is a suggestion that the more rapidly the pain is controlled, the less likely it will persist. It is not uncommon that serious illness or new pain stimuli may worsen previous symptoms.
Answer
D
9 A 47-year-old woman is evaluated 2 years after the diagnosis of serous epithelial ovarian carcinoma because of a 3-month history of unpredictable bowel function, intermittent nausea and vomiting, abdominal pain, expanding abdominal girth, and weight loss. She is admitted 3 weeks after chemotherapy with protracted vomiting and no bowel movement for 7 days. Her physical examination is notable for temporal wasting, oral thrush, a protuberant tender abdomen with shifting dullness, and a palpable firm mass in the left lower quadrant. Imaging reveals multiple sites of partial small bowel obstruction, ascites, and enlarging pelvic tumors despite treatment. The initial approach most likely to alleviate this patient’s symptoms is:
A Endoscopic stenting of the obstructions.
B Placement of a venting percutaneous gastrostomy tube.
C Palliative surgery to relieve the obstruction.
D Medical management with corticosteroids, octreotide, and opioid analgesics.
E Palliative surgery to bypass the obstruction followed by pelvic radiation therapy.
Ref.: 45-48
Comments
Bowel obstruction is a common complication of ovarian cancer and may be part of the manifestation of the disease. Likewise, after debulking surgery, some patients are at risk for small bowel obstruction secondary to adhesions. These patients may benefit significantly from surgery to relieve the obstruction. However, a frequent complication of advanced ovarian cancer is malignant bowel obstruction that is not amenable to a surgical intervention, even one aimed purely at control of symptoms. This patient has several markers for a poor prognosis, including a palpable tumor, compromised nutritional status with weight loss, ascites, multiple sites of obstruction, and tumor progression while undergoing chemotherapy. In this scenario, the nonsurgical interventions must be considered carefully. Given the disease progression while undergoing chemotherapy, the patient is not likely to respond to further chemotherapy. Radiation therapy for the bulky pelvic disease is associates with a low response rate and significant morbidity. The administration of dexamethasone, 8 mg/day, to address bowel inflammation and edema and octreotide to diminish intestinal secretions, along with intravenous fluids and analgesics such as morphine, are very effective in relieving malignant bowel obstructions from ovarian, gastric, and colon cancers. These medications are available as a compounded suppository, which may facilitate outpatient therapy. Placement of a venting gastrostomy tube may alleviate vomiting but renders the patient unable to take oral alimentation; in the presence of palpable abdominal disease and ascites, this is controversial. Most recommend against the use of total parenteral nutrition (TPN) for patients with progressive malignant bowel obstruction unless their performance status is high. If TPN is considered, a clear and thorough discussion of the goals of the therapy, the desired outcomes, and the signs and symptoms of negative outcomes such as infection, worsening ascites, jaundice, or edema should take place before TPN is initiated.
Answer
D
10 An 82-year-old Taiwanese Chinese widow who speaks little English is evaluated for anemia, melena, and hematemesis. Endoscopy reveals a friable gastric carcinoma; biopsy confirms adenocarcinoma. You are asked to evaluate the patient for a surgical consultation. The family intercepts you in the hallway and asks that you not tell the patient her diagnosis. Her son, a 62-year-old businessman, states that he and his siblings will discuss the surgery with you and that he will sign all the necessary consents. The best course of action is:
A To insist on obtaining informed consent from the patient and ask the family to provide interpretation.
B To state that you must fully disclose the findings to the patient and will then ask her permission to have her son act on her behalf.
C Through a hospital interpreter, to explore with the patient how she prefers to make decisions about her medical care and how much information about diagnoses and test results that she prefers to know.
D After discussion with the family (without the patient), to allow the son to sign consents for the patient’s surgery while acknowledging and respecting their cultural preferences.
E To ask the patient’s primary care physician, who speaks Chinese, to talk to the son and obtain consent for surgery.
Ref.: 20, 21, 30, 33, 49-52
Comments
The approach to medical decision making will vary across cultures and ethnicities. In general, Asian cultures that are influenced by Confucianism ascribe to the family playing the central role in medical decision making. In many situations such as this, when the husband is deceased, the first-born male child or the oldest child will step forward as the decision maker. This scenario can cause significant moral distress for a physician who ascribes to the Western ethical construct of autonomy and self-determination. The United States is a culturally and religiously diverse nation. The current system of health care decision making based on patient autonomy does not appeal to all patients, and imposition of this approach may cause tremendous suffering. Family members of immigrants who were born in the United States may not be as observant of traditions, so ethnicity alone may not be helpful in understanding how patients make decisions. As physicians, we must be sensitive to the unique ways in which families make health care decisions and seek to clarify these issues before making any assumptions or moving ahead with any discussions. In this case, asking the patient through an interpreter how she prefers to make decisions and how much information she would like about her condition will allow her to direct decision making to her son and family should she so desire. Alternatively, she may make it clear that she would like to make her own decisions and that the family’s desire to “protect” her does not reflect her preferences. Ideally, conversations with patients are conducted via a nonbiased interpreter and not a family member. In this situation, a family member acting as interpreter may not convey to the patient what the physician is truly saying.
Answer
C
11 A resident making rounds with an eminent professor of surgery presents a case to him. In the patient’s room the professor calls the resident “stupid” and berates his decision making and evaluation of the patient, which is indeed incorrect. The patient is visibly upset. Which of the following is not true regarding disruptive physicians?
A The majority of cases of disruptive physician behavior are reported only when the offense is severe.
B Disruptive behavior may include inappropriate language, disrespectful behavior, refusal to complete tasks, and physical abuse, such as throwing objects.
C Disruptive physician behavior is most often directed at nurses and other allied health workers.
D Disruptive physician behavior is the most frequently reported type of complaint to disciplinary boards.
E Fear of reprisal is an uncommon reason for the underreporting of disruptive physician behavior.
Ref.: 49, 53, 54
Comments
The American Medical Association’s Code of Medical Ethics defines disruptive physician behavior as any “personal conduct, whether verbal or physical, that negatively affects or that potentially may affects patient care.” It is incumbent on surgeons to model their professional behavior toward other physicians, nurses, allied health care workers, and their students and residents in a circumspect manner. There is strong evidence that trainees learn abusive behavior from their mentors and emulate it in their own practices. When care by colleagues needs remediation, such discussion should be done promptly, but privately and away from patient care areas. It is always appropriate to maintain a sober decorum in patient care areas. Although disruptive physician behavior is not often reported, it is the most frequently reported issue to disciplinary boards, more than one half of the cases are directed against nonphysician health care workers, and the most frequently cited reason for hesitancy in reporting is fear of reprisal.
Answer
E
12 A 14-year-old Jehovah’s Witness who was in a motor vehicle accident undergoes emergency splenectomy and packing of a liver laceration. In the recovery room he is hypotensive and tachycardic and his hemoglobin is 6 g/dL. His parents refuse to give permission for transfusion of any blood products. The most appropriate next step in the care of this young patient is to:
A Repeat the hemoglobin test.
B Transfuse 2 units of packed red blood cells.
C Administer erythropoietin.
D Obtain a court order and then transfuse 2 units of packed red blood cells.
E Withhold transfusion.
Ref.: 55, 56
Comments
Since their 1945 ban on all blood products, Jehovah’s Witnesses are best known to health care workers for their refusal of transfusion for themselves and their minor family members, regardless of the possibility of significant morbidity or death in the absence of transfusion. However, the courts have recognized, and the Supreme Court has upheld, that parents are expected to act in their child’s best interests at all times and that although parents have the right to freely practice and exercise their own religious beliefs, this does not include the right to expose their children to illness or death. This principle applies regardless of whether the life of the child is in imminent danger. Repeating the hemoglobin determination in the clinical scenario just described is unlikely to alter the need for transfusion. Erythropoietin first acts by increasing the reticulocyte count with a noticeable increase in hemoglobin and hematocrit at 2 to 6 weeks after administration, too slow to be of benefit in this acutely ill child.
Answer
D
13 A surgeon wishes to perform a new procedure on a patient. Which of the following does the surgeon need to do beforehand?
A Obtain informed consent from the patient, including disclosure that the procedure in question is new; the physician’s experience, training, and qualifications for performing the procedure; the rationale for recommending this procedure; and its attendant risks, benefits, and possible outcomes.
B Obtain an institutional review board (IRB) waiver to treat the patient in this manner, followed by a standard preoperative informed consent.
C Obtain IRB approval for the proposed treatment after submitting a formal IRB application describing the experimental surgery and then obtain a special informed consent for experimental procedures.
D Obtain approval from hospital administration and the department chair and then obtain a special informed consent for experimental procedures.
E Obtain approval from hospital administration and the department chair and then obtain a standard preoperative informed consent.
Ref.: 57, 58
Comments
Surgical innovation is a constant feature of the practice of surgery, and the introduction of a new procedure may be necessary to provide optimum care for an individual patient, as well as to improve surgical patient care in general. Rare disorders and unusual clinical scenarios demand that surgeons “think outside the box.” The basis of informed consent is that the patient is provided with sufficient relevant information in a noncoercive setting to arrive at a prudent decision. In the setting of new surgical procedures, it is especially important to stress the completeness of this consent as outlined in choice A. Informed consent requires discussion of the nature of the intervention and the expected benefits, risks, and consequences. Patients also need to know, especially in this case, alternatives to the proposed treatment and their risks, benefits, and consequences. Physicians are not required to inform a patient of alternatives for care that they do not believe are medically indicated but rather alternatives that other reasonable physicians would recommend.
The institutional review board does not have any role in the care of individual patients outside the research setting. The National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research serves to identify the basic ethical principles that underlie biomedical and behavioral research involving human subjects. In this scenario, there is no plan to conduct any formal research study. Hospital administration has no role in policing surgical conduct; individual institutional policies regarding departmental approval for novel procedures vary, as does the specificity of the surgical privileges that surgeons are granted. As surgeons wish to perform newly developed procedures after the completion of their formal training, departments may require evidence of additional training such as via a seminar with a hands-on laboratory component, proctoring by colleagues or national experts, and outcomes reporting for a defined number of cases.
Answer
A
14 A 65-year-old man with a very recent diagnosis of cholangiocarcinoma is brought to the emergency room by his exhausted wife. She reports that he is “in severe pain” and that neither of them have slept in days because of his symptoms. She says that he has been seeing people who are not present, such as the patient’s father, who is deceased. On examination, he is disoriented, grimacing and groaning, and persistently trying to pull off his clothing and the bedsheet to get out of the gurney. He is repetitively saying “let’s go” and becomes combative when examined. He has been taking a long-acting morphine, 60 mg every 12 hours by mouth, and his wife has been giving him several doses of a short-acting morphine concentrate through the night without any improvement. He has taken another 10 mg six times over the past 8 hours. He is not hypoxemic. After correcting the metabolic derangements, he remains confused and agitated. You decide:
A To admit the patient and start intravenous morphine, as well as a benzodiazepine, for his anxiety. You recommend wrist restraints to keep him from pulling out his intravenous line.
B The problem is related to too much medication, so you stop the long-acting morphine and change the analgesic to a hydrocodone-acetaminophen combination.
C To double the long-acting morphine given how much short-acting medication that he has required and initiate treatment with a benzodiazepine for anxiety.
D The clinical scenario is most consistent with delirium, which is probably multifactorial in etiology. You admit the patient and initiate intravenous morphine, haloperidol, and lactulose.
E To obtain psychiatric consultation regarding this acute psychotic episode.
Ref.: 26, 59-63
Comments
Delirium is one of the most common neuropsychiatric symptoms of advanced cancer; it occurs in up to 83% of patients near the end of life. The diagnosis is based on the clinical picture and connotes an elevated risk for mortality. The findings may be subtle—an acute onset of global confusion or changing cognition, a waxing and waning of attention and organized thinking, altered levels of consciousness, and psychomotor symptoms of agitation (hyperactive or agitated delirium) or lethargy (hypoactive delirium). Delirium may be the sole manifestation of a serious illness, but there are often many contributing causes. Such causes include medications such as opioids (the worst being meperidine), dopaminergic and anticholinergic drugs, sedatives such as benzodiazepines, and corticosteroids; electrolyte disturbances from volume depletion, renal failure, or hepatic encephalopathy; sepsis; and accumulated physiologic stress from uncontrolled pain, disrupted sleep patterns, or chronic activation of the sympathetic nervous system. Delirium can be reversed in more than 50% of cases; however, in a patient at the end of life, its onset may reflect a transition toward death.
In this case, the causes of delirium may be poorly controlled pain, medication side effects from morphine and its metabolites, volume depletion secondary to insufficient oral intake, hepatic changes related to obstruction and advanced disease, and sleep deprivation. Treatment of delirium is multifactorial and starts with controlling the environment to limit overstimulation. Treatment of the agitation or the abnormal lethargy of apathetic delirium with antipsychotic medications such as haloperidol is indicated. Antipsychotics, including the newer alternative medications such as olanzapine and risperidone, are preferred over benzodiazepines, although the latter may be added for improved efficacy. Long-acting opioids require a functional gastrointestinal tract to be effective, so in this case, changing the morphine to a continuous infusion may be beneficial. Combination medications that includes acetaminophen are not recommended in patients with hepatic dysfunction because they are at greater risk for hepatotoxicity and overdosing. The ceiling dose of an opioid is not related to its analgesic potential but is determined by dose-related side effects such as intractable nausea, sedation, or myoclonus. In this case it may be beneficial to rotate to another opioid such as hydromorphone with the use of equianalgesic conversion tables while keeping in mind that if the side effects are related to the accumulation of morphine-6-glucoronide, they may take several days to clear even after the change. Lactulose diminishes the absorption of ammonia, which contributes to hepatic encephalopathy. Severe or refractory deliriumsometimes requires therapeutic sedation to control the symptoms. Sedation is often considered a last option to relieve the distress of intractable symptoms or refractory suffering. Medications prescribed for the controlled sedation of intractable symptoms and suffering are usually provided via an intravenous infusion. The intended outcome is to control the symptoms and relieve the suffering through an altered level of consciousness. In fact, it is sometimes observed that an individual may awaken and be free of symptoms and suffering for intervals even while sedating infusions are being administered.
The ethical principle of double effect does apply in this setting of therapeutic sedation—the good intent (relief of suffering) is pursued while an unintended bad effect (such as death) will also foreseeably occur. However, the sole intent of the intervention of therapeutic sedation is to relieve refractory symptoms and uncontrolled suffering, not to hasten death. If death occurs during this intervention, it reflects the terminal state of the patients receiving the intervention, and the intervention is not a form of euthanasia, nor does it constitute physician-assisted suicide. Therapeutic sedation differs from palliative or terminal sedation in that the sedation is routinely decreased at predetermined intervals to continually reassess its necessity.
Answer
D
15 An 84-year-old woman is admitted for the third time to the ICU from a local nursing home with aspiration pneumonia. She has a 10-year history of Alzheimer dementia, is now fully bedbound and incontinent, can speak no more than six words, and can no longer smile. During her last admission a feeding tube was placed. Now her kidneys are failing and her son requests that she receive dialysis. You are asked to see her for placement of a dialysis catheter and for further assessment regarding the placement of an arteriovenous shunt. You assess that the son’s understanding of his mother’s condition is very limited; he is focused on correcting medical problems when they arise and indicates to you that resolution of the problems will lead to improvement in his mother’s cognition. You decide that the son’s requests are based on denial and:
A You refuse to place the catheter and the shunt according to the ethic of nonmaleficence.
B You refuse to place the catheter according to the ethical imperative of justice.
C You go ahead with the surgery according to the ethic of patient autonomy as expressed through her DPAHC (her son) and her living will.
D You request an ethics consultation.
E You request and attend a family meeting with the son, the social worker, the patient’s primary care physician, and the intensive care physician to better elucidate the goals of care.
Ref.: 24, 49, 64, 65
Comments
The moral duty or principled approach is often cited in the discussion of medical ethics. Table 37-1 lists the principles and definitions and how they specifically apply to physicians.
TABLE 37-1 Principles and Definitions of Medical Ethics
|
Autonomy |
Self-rule, self-determination |
Physicians must respect patients’ rights to make decisions regarding their medical care |
|
Beneficence |
An action done for the benefit of others |
Physicians seek to promote the welfare of their patients |
|
Nonmaleficence |
To do no harm |
Physicians refrain from providing ineffective treatments or harming patients |
|
Confidentiality |
The information shared is private and will not be disclosed |
Physicians respect the confidentiality of their patients and will not disclose this information except under certain mandates |
|
Justice |
Fairness and equality |
The process for making medical decisions is fair and just and like-situated patients will be treated in a similar manner. Resources will be allocated justly |
The process of applying the principles is not intended to be rigid or programmatic but rather to give guidance to those making complex decisions. In every decision, weighing the principles is often the discussed intellectual process, and no individual principle is intended to be supreme over the others. Overreliance on any one principle can lead to a dogmatic approach to decision making, which then risks truncating candid discussion, understanding, and joint decision making. As discussed in the article by Pawlik and Curley, our character gives us orientation and direction and provides the foundation on which we approach our ethical struggles. When we approach patients and families as human beings, are professionally trained with expertise in our medical discipline, and are overarchingly committed to doing what is best for the patient, we are more likely to effectively communicate with patients and their families and reach a plan of care that is based on aligned values. Requesting an ethics consultation can always be of value to review the principles that are active, but it does not serve as a substitute for an effective family meeting. Such meetings allow medical professionals to hear what the patient, family, or both understand regarding the medical issues (as opposed to what they have been told) and to thoughtfully discuss the patient’s condition and prognosis and what value or impact that treatments and procedures may have on the underlying condition (treating the pneumonia or correcting the renal failure does not reverse the Alzheimer dementia). Time-limited trials of interventions may be beneficial for patients and families confronting end-stage diagnoses and further strengthen the sense of collaboration and commitment between the surgeon, patient, and family.
Answer
E
References
1 Alvarado M, Ewing CA, Elyassnia D, et al. Surgery for palliation and treatment of advanced breast cancer. Surg Oncol. 2007;16:249-257.
2 Emanuel EJ, Emanuel LL. Proxy decision making for incompetent patients: an ethical and empirical analysis. JAMA. 1992;267:2067-2071.
3 Ganzini L, Volicer L, Nelson W, et al. Ten myths about decision making capacity. J Am Med Dir Assoc. 2005;6:S100-S104.
4 Karnofsky DA, Burchenal JH. The clinical evaluation of chemotherapeutic agents in cancer. In: MacLeod CM, editor. Evaluation of chemotherapeutic agents. Columbia: Univ Press; 1949:196.
5 Lau F, Downing M, Lesperance M, et al. Using the palliative performance scale to provide meaningful survival estimates. J Pain Symptom Manage. 2009;38:134-144.
6 Lau F, Maida V, Downing M, et al. Use of palliative performance scale in end-of-life prognostication in a palliative medicine consultation service. J Pain Symptom Manage. 2009;37:965-972.
7 Lee KF, Ennis WJ, Dunn GP. Surgical palliative care of advanced wounds. Am J Hosp Palliat Med. 2007;24:154-160.
8 Nakura EK, Warren RS. Palliative care for patients with advanced pancreatic and biliary cancers. Surg Oncol. 2007;16:293-297.
9 Ross EL, Abrahm J. Preparation of the patient for palliative procedures. Surg Clin North Am. 2005;85:191-207.
10 Kaufman M, Singh G, Das S, et al. Efficacy of endoscopic ultrasound-guided celiac plexus block and celiac plexus neurolysis for managing abdominal pain associated with chronic pancreatitis and pancreatic cancer. J Clin Gastroenterol. 2010;44:127-134.
11 Khorana AA, Fine RL. Pancreatic cancer and thromboembolic disease. Lancet Oncol. 2004;5:655-663.
12 Lee AY, Levine MN, Baker RI, et al. Low-molecular-weight heparin versus a coumarin for the prevention of recurrent venous thromboembolism in patient with cancer. N Engl J Med. 2003;349:146-153.
13 Universal protocol for preventing wrong site, wrong procedure, and wrong person surgery. The Joint Commission on Accreditation of Healthcare Organizations. National Patient Safety Goals 2009 http://www.jointcommission.org/NR/rdonlyres/868C9E07-037F-433D-8858-0D5FAA4322F2/0/RevisedChapter_HAP_NPSG_20090924.pdf (accessed November 22, 2009)
14 Fein SP, Hilborne LH, Spiritus BM, et al. The many faces of error disclosure: a common set of elements and a definition. J Gen Intern Med. 2007;22:755-761.
15 Institute of Medicine Committee on Quality of Health Care in America. To err is human: building a safer health system. Washington, D.C.: National Academies Press; 2000.
16 Kwaan MR, Studdert DM, Zinner MJ, et al. Incidence, patterns, and prevention of wrong-site surgery. Arch Surg. 2006;141:353-357. discussion 357-358
17 Gallagher TH. A 62 yo woman with cancer who experienced wrong site surgery. JAMA. 2009;302:669-677.
18 Gallagher TH, Studdert D, Levinson W. Disclosing harmful medical errors to patients. N Engl J Med. 2007;356:2713-2719.
19 Azoulay E, Pochard F, Kentish-Barnes N, et al. Risk of post-traumatic stress symptoms in family members of intensive care unit patients. Am J Respir Crit Care Med. 2005;171:987-994.
20 Bradley CT, Brasel KJ. Core competencies in palliative care for surgeons: interpersonal and communication skills. Am J Hosp Palliat Med. 2008;24:499-507.
21 Buckman RA. Breaking bad news: the S-P-I-K-E-S strategy. Commun Oncol. 2005;2:138-142.
22 Emanuel EJ, Emanuel LL. Proxy decision making for incompetent patients. An ethical and empirical analysis. JAMA. 1992;267:2067-2071.
23 Kirchhoff KT, Song MK, Kehl K. Caring for the family of the critically ill patient. Crit Care Clin. 2004;20:453-466.
24 Pawlik TM, Curley SA. Ethical issues in surgical palliative care: am I killing the patient by “letting him go”? Surg Clin North Amer. 2005;85:273-286.
25 Caruso LJ, Gabrielli A, Layon AJ. Perioperative do not resuscitate orders: caring for the dying in the operating room and intensive care unit. J Clin Anesth. 2002;14:401-404.
26 Casarett DJ, Inouye SK. Diagnosis and management of delirium near the end of life. Ann Intern Med. 2001;135:32-40.
27 Dean M. Opioids in renal failure and dialysis patients. J Pain Symptom Manag. 2004;28:497-504.
28 Dunn GP. Surgical critical care: surgical palliative care. In: Cameron JL, editor. Current surgical therapy. ed 9. Philadelphia CV: Mosby; 2008:1179.
29 Sjogren P. Clinical implications of morphine metabolites. In: Portenoy RK, Bruera EB, editors. Topics in palliative care, Vol 1. New York: Oxford University Press; 1997:163.
30 Crawley LM, Marshall PA, Lo B, et al. Strategies for culturally effective end-of-life care. Ann Intern Med. 2002;136:673-679.
31 Crawley L, Payne R, Bolden J, et al. Palliative and end-of-life care in the African American community. JAMA. 2000;284:2518-2520.
32 Olick RS, Braun EA, Potash J. Accommodating religious and moral objections to neurological death. J Clin Ethics. 2009;2:183-191.
33 Weiner JS, Roth J. Avoiding iatrogenic harm to patient and family while discussing goals of care near the end of life. J Palliat Med. 2006;9:451-463.
34 Gan TJ, Meyer T, Apfel CC, et al. Consensus guidelines for managing postoperative nausea and vomiting. Anesth Analg. 2003;97:62-71.
35 Herndon CM, Jackson KC, Hallin PA. Management of opioid-induced gastrointestinal effects on patients receiving palliative care. Pharmacotherapy. 2002;22:240-250.
36 Mannix KA. Gastrointestinal symptoms: palliation of nausea and vomiting. In: Doyle D, Hanks G, Cherny NI, et al, editors. Oxford textbook of palliative medicine. ed 3. Oxford: Oxford University Press; 2004:459-468.
37 Philip BK. Etiologies of postoperative nausea and vomiting. Pharm Ther Supp July. 1997:18s-24s.
38 Faranak KK, Henzi I, Tramèr MR. Treatment of established postoperative nausea and vomiting: a quantitative systematic review. BMC Anesthesiol. 2001;1:2.
39 Chong MS, Bajwa ZH. Diagnosis and treatment of neuropathic pain. J Pain Symptom Manage. 2003;25:S4-S11.
40 Gilron I, Watson PN, Cahill CM, et al. Neuropathic pain: a practical guide for the clinician. Can Med Assoc J. 2006;175:265-275.
41 Kingery WA. A critical review of controlled clinical trials for peripheral neuropathic pain and complex regional pain syndromes. Pain. 1997;73:123-139.
42 Lynch M, Clark A, Sawynok J, et al. Topical amitriptyline and ketamine in neuropathic pain syndromes: an open-label study. J Pain. 2005;6:644-649.
43 Milch RA. Neuropathic pain: implications for the surgeon. Surg Clin North Am. 2005;85:225-236.
44 Pappagallo M. Optimizing pharmacologic treatments for patients with neuropathic pain. Am J Cont Med Educ. 2007:8-11.
45 Bozzetti F, Cozzaglio L, Iganzoli EB, et al. Quality of life and length of survival in advanced cancer patients on home parenteral nutrition. J Clin Nutr. 2002;21:281-288.
46 Jatoi A, Podratz KC, Gill P, et al. Pathophysiology and palliation of inoperable bowel obstruction in patients with ovarian cancer. Supportive Oncol. 2004;2:323-327.
47 Philip J, Depczynski B. The role of total parenteral nutrition for patients with irreversible bowel obstruction secondary to gynecological malignancy. J Pain Symptom Manage. 1997;13:104-111.
48 Ripamonti C, Twycross R, Baines M, et al. Clinical-practice recommendations for the management of bowel obstruction in patients with end-stage cancer. Working Group of the European Association for Palliative Care. Support Care Cancer. 2001;9:223-233.
49 Carson RA. Ethics in surgery. In Townsend CM, Beauchamp RD, Evers BM, et al, editors: Sabiston textbook of surgery: the biological basis of modern surgical practice, ed 18, Philadelphia: WB Saunders, 2008.
50 Haffner L. Translation is not enough: Interpreting in a medical setting. 2. West J Med. 1992;157:255-259.
51 McLaughlin LA, Braun KL. Asian and Pacific Islander cultural values: considerations for health care decision making. Health Social Work. 1998;23:116-126.
52 Parker SM, Clayton JM, Hancock K, et al. A systematic review of prognostic/end-of-life communication with adults in the advanced stages of a life-limiting illness: patient/caregiver preferences for the content, style, and timing of information. J Pain Symptom Manage. 2007;34:81-93.
53 American Medical Association. E.9.045 Code of Medical Ethics: Current opinions with Annotations: 2006-2007. Chicago: American Medical Association; 2006.
54 Mueller PS, Snyder L. Dealing with the “disruptive” physician colleague. In Medscape CME Activities http://cme.medscape.com/viewarticle/590319 accessed 4/20/09
55 Rutherford EJ, Brecher ME, Fakhry SM. Hematologic principles in surgery. In Townsend CM, Beauchamp RD, Evers M, et al, editors: Sabiston textbook of surgery: the biological basis of modern surgical practice, ed 18, Philadelphia: WB Saunders, 2008.
56 Woolley S. Children of Jehovah’s Witnesses and adolescent Jehovah’s Witnesses: what are their rights? Arch Dis Child. 2005;90:715-719.
57 Lieberman I, Herndon J, Hahn J, et al. Surgical innovation and ethical dilemmas: a panel discussion. Cleve Clin J Med. 2008;75:S13-S21. S6
58 The Belmont Report: Ethical Principles and Guidelines for the protection of human subjects of research. The National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research April 18, http://ohsr.od.nih.gov/guidelines/belmont.html, 1979. accessed 11/28/09
59 Brietbart W, Rosenfeld B, Roth A. The memorial delirium assessment scale. J Pain Symptom Manage. 1997;13:128-137.
60 Lawlor PG, Gagnon B, Mancini IL, et al. Occurrence, causes, and outcome of delirium in patients with advanced cancer. Arch Intern Med. 2000;160:786-794.
61 Inouye SK. Delirium in older persons. N Engl J Med. 2006;354:1157-1165.
62 Roth-Roemer S, Fann J, Syrjala K. The importance of recognizing and measuring delirium. J Pain Symptom Manage. 1997;13:125-127.
63 Twaddle ML. Therapeutic sedation protocol. Midwest Palliative & Hospice Care Center. 2001.
64 Lo G. Patient or surrogate insistence on life-sustaining interventions. In Resolving ethical dilemmas: a guide for clinicians, ed 2, Philadelphia: Lippincott Williams & Wilkins; 2000:128.
65 Roy DJ. Euthanasia and withholding treatment. In: Doyle D, Hanks G, Cherny N, Calman K, editors. Oxford textbook of palliative medicine. ed 3. Oxford: Oxford University Press; 2004:84-97.