Ethics consults called by surgical specialties differ somewhat from consults called by other hospital specialties.1
During the research period of her residency at Weill Cornell Medicine in New York City, Nicole Meredyth, MD, decided to pursue a clinical ethics fellowship. Surgeons called ethics consults less often than other hospital areas. “It seemed like surgeons tried to work through difficult decision-making on their own, instead of consulting our ethics consultation team,” Meredyth says.
Meredyth and colleagues set out to determine if this was the case. If so, why? “We believed this information would be relevant not only to surgeons, but also to ethics consultants,” says Inmaculada de Melo-Martin, PhD, MS, the study co-author and professor of medical ethics at Weill Cornell Medical College.
Knowing the unique factors involved could help ethicists identify where surgeons most need their help. Researchers analyzed 548 consults (135 in surgical areas, 413 in nonsurgical areas) called between 2013 and 2018 at NYP Weill Cornell Medical Center. Most surgical consults were called for ICUs, as opposed to the floor or step-down (lower-acuity) units.
Surgical patients were less likely to have a DNR order in place (22.2%) than nonsurgical patients (37.5%). “Surgical patients have to be full code, typically, to undergo an operation, which is likely why these patients were less likely to have a DNR in place on their charts,” Meredyth says.
Issues relating to withholding or withdrawing life-sustaining treatment came up more often in surgical consults than other hospital areas. “This is a common topic for ethics consultations in general,” Meredyth says. However, an analysis of the ethics notes revealed some interesting nuances. Many surgical consults were called when patients or surrogates requested to withdraw life-sustaining treatment in the postoperative period. “Surgeons thought that such a request was premature, because there was still significant prognostic uncertainty both in terms of survival and quality of life,” Meredyth reports.
For ethicists, these findings confirmed that different specialties face unique ethical issues. “It reminds ethics consultants that it is important to understand the context of the ethics consultation and the culture of the specialty from which the consult arises,” Meredyth says.
- Meredyth NA, Fins JJ, de Melo-Martin I. Ethics consultation in surgical specialties. HEC Forum. March 2021.