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Legal — Transcript

by Sterling Anesthesia Education Solutions, Inc. · 9,106 words · 1,556 segments · language en · Watch on YouTube

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0:06the objectives for this lecture are as
0:08follows describe legal considerations
0:11encountered by the anesthetist and
0:13describe the anesthetist role in
0:15informed consent the American legal
0:19system is composed of federal and state
0:21court systems the latter of which is a
0:23usual forum for matters pertaining to
0:25anesthesia practice state courts are
0:27established to adjudicate civil and
0:29criminal actions many consider our legal
0:31system to be cumbersome overburdened and
0:33often ineffective and unfair
0:34despite this reputation it is our route
0:37to dispute resolution and protect the
0:39interests of the public when contracts
0:41are formed by private parties the legal
0:43system is called upon to interpret the
0:45language and hold parties to their
0:46contractual obligations when one party
0:49is injured by another the legal system
0:50is expected to resolve the matter and
0:52make whole the injured party to the
0:53extent possible when criminal actions
0:56are taken punitive action is imposed by
0:58the legal system statute law case law
1:01and regulations affect anesthesia
1:03providers statute law is a body of
1:06prescriptive law created by a
1:07legislature to achieve a specific
1:09purpose when statute laws need
1:11interpretation or when there is no
1:13definitive statute law disagreements may
1:15be adjudicated by the judicial system
1:17the aggregate of reported cases known as
1:20case law or common law is used as a
1:22basis for future court decisions the
1:25results of these cases are rarely
1:27prescriptive and may lead to a
1:28collection of confusing ambiguous and
1:30even contradictory cases that rests on
1:33diverse rulings in different
1:34jurisdictions regulations often come
1:37from administrative authorities such as
1:38executive branch agencies or state
1:40medical boards for example a US
1:43Department of Health and Human Services
1:44regulation requires hospitals wishing to
1:47participate in Medicare to have written
1:48policies that an organ procurement
1:50organization is notified of potential
1:52donors so let's get started we'll jump
1:56into a heavily debated and passionate
1:58topic supervision anesthesiologists who
2:01supervise certified registered nurse
2:03anesthetist
2:03and/or residents are held accountable
2:05for the actions of those under their
2:07supervision although there is really not
2:09an alternative to direct supervision of
2:11residents CRNA supervision is somewhat
2:13different a substantial portion of the
2:15total number of anesthetics administered
2:17in the United States are performed by
2:18CRNAs
2:19there with or without the supervision of
2:21an anesthesiologist this supervisory
2:24relationship when it exists is known as
2:26a anesthesia care team the distribution
2:28of anesthesia providers in this country
2:30is highly skewed toward metropolitan
2:32areas where supervision and the
2:33anesthesia care team is more prevalent
2:36CRNAs working in the anesthesia care
2:38team model are often more limited in
2:40their scope of practice when employed by
2:41the anesthesiology group rather than the
2:43hospital and many find their practice to
2:45be non collaborative the scope of
2:47practice of CRNAs in rural hospitals is
2:50often broader than in the metropolitan
2:51practice today no studies have shown a
2:54difference in the anesthesia quality of
2:56care or outcomes based solely on the
2:58distinction of the provider being a CRNA
2:59or an anesthesiologist in 2001 the
3:04Centers for Medicare and Medicaid
3:06Services or CMS published its ruling
3:08allowing state governments exemption
3:10from the requirement of CRNA supervision
3:12this required written notification of
3:15CMS by the state governor after
3:16consultations with the boards of
3:18medicine and nursing if determination
3:20that opting out was consistent with
3:21state law and that upon decision was in
3:23the best interest of the citizens of
3:25that state in addition to being seen as
3:28favorable to CRNAs this allowed an
3:30option to relieve supervising providers
3:31of liability which concerns some
3:33especially supervising providers who
3:35were not anesthesiologists although
3:39practitioners may become involved in the
3:41criminal law system in a professional
3:43capacity they more commonly become
3:44involved in the legal system of civil
3:46laws civil law is broadly defined into
3:49contract law and tort law a tort may be
3:52loosely defined as a civil wrongdoing
3:54negligence is one type of tort
3:57malpractice actually refers to any
3:59professional misconduct but it's use in
4:01legal terms typically refers to
4:02professional negligence to be successful
4:05in a malpractice suit the patient
4:07plaintiff must prove four things duty
4:09that the anesthetist owed the patient a
4:11duty breach of duty that the anesthetist
4:13failed to fulfill his or her duty
4:16causation that a reasonably close causal
4:19relation exists between the anesthetist
4:20acts and the resultant injury and
4:22finally damages that actual damage
4:25resulted because of a breach of the
4:27standard of care failure to prove any
4:29one of these four elements will result
4:31in a decision for the defendant or the
4:32anesthetist
4:33we will look at each of these four
4:35elements a little more closely as a
4:39provider the anesthetist establishes a
4:41duty to the patient when a provider
4:42patient relationship exists when the
4:45patient is seen preoperatively and the
4:46anesthetist agrees to provide anesthesia
4:48care for the patient but duty to the
4:50patient has been established in the most
4:52general terms the duty the anesthetist
4:54OS of the patient is to adhere to the
4:56standards of care for the treatment of
4:57that patient because it is virtually
5:00impossible to delineate specific
5:01standards for all aspects of medical
5:03practice and all eventualities the
5:05courts have created the concept of the
5:07reasonable and prudent provider for all
5:10specialties there is a national standard
5:12that has displaced the local standard
5:13there are certain general duties that
5:16all providers have to their patients and
5:17breaching these duties may also serve as
5:19a basis for a lawsuit one of the general
5:22duties is that of obtaining informed
5:23consent for a procedure consent may be
5:26written verbal or implied oral consent
5:29is just as valid although harder to
5:31prove years after the fact as written
5:33consent implied consent for anesthesia
5:35care may be present in circumstances in
5:37which the patient is unconscious or
5:39unable for any reason to give his or her
5:41consent but where it is presumed that
5:42any reasonable and prudent patient would
5:44give consent although there are
5:46exceptions to the requirement that
5:47consent be obtained an aesthetician
5:49should be sure to obtain consent
5:50whenever possible failure to do so in
5:53theory exposes the anesthetist to
5:55possible prosecution for battery the
5:57requirement that the consent be informed
5:59is somewhat more opaque the guideline is
6:02determining whether the patient received
6:03a fair and reasonable account of the
6:05proposed procedures and the risk
6:07inherent to these procedures
6:08most states have adopted a reasonable
6:11patient standard which requires that the
6:12provider disclose risks at a reasonable
6:14patient under similar circumstances
6:15would want to know to make an informed
6:17decision
6:18besides disclosure of common risk risks
6:21that would be important in deciding
6:22whether or not to undertake the proposed
6:24therapy should also be discussed for
6:26regional anesthesia these should include
6:28both the common risk like local pain and
6:30discomfort infection headache transient
6:33neuropathy as well as those that are
6:35rare but of major consequence like
6:37seizure cardiac arrest permanent
6:39neuropathy paralysis or even death in a
6:43malpractice action expert witnesses will
6:45review the medical records of the case
6:47and determine whether the anesthetist
6:48acted in a reasonable and prudent manner
6:50in the specific situation and fulfilled
6:52his or her duty to the patient if they
6:55find that the anesthetist either did
6:56something that should not have been done
6:57or failed to do something that should
6:59have been done then the duty to adhere
7:01to the standard of care has been
7:02breached and the requirement for a
7:03successful suit will have been met
7:07judges and juries are interested in
7:09determining whether the breach of duty
7:11was the proximate cause of the injury if
7:13the odds are better than even that the
7:15breach of duty lead however indirectly
7:17to the injury this requirement is met
7:19there are two common tests employed to
7:21establish causation the first is the
7:24but-for test and the second is a
7:26substantial factor test if the injury
7:29would not have occurred but for the
7:31action of the defendant or the
7:32anesthetist or if the act of the
7:34anesthetist was a substantial factor in
7:36the injury despite other causes
7:37then proximate cause is established
7:39although the burden of proof of
7:41causation ordinarily falls on the
7:43patient it may under special
7:45circumstances be shifted to the provider
7:46or defendant under the doctrine of res
7:48ipsa loquitur literally the thing speaks
7:52for itself
7:52applying this doctrine requires proving
7:55that the injury is of a kind that
7:57typically would not occur in the absence
7:58of negligence the injury must be caused
8:01by something under the exclusive control
8:02of the anesthetist the injury must not
8:04be attributable to any contribution on
8:06the part of the patient and that the
8:08evidence for the explanation of events
8:10must be more accessible to the
8:11anesthetist they into the patient
8:12because anesthetist render patience and
8:15sensible to their surroundings and
8:16unable to protect themselves from injury
8:18the doctrine of res ipsa loquitur may be
8:21invoked in anesthesia malpractice cases
8:23while this argument was commonly used in
8:26the past of lawsuits for nerve injuries
8:27it is less commonly used successfully
8:29today
8:32the law allows for three different types
8:34of damages general damages are those
8:37such as pain and suffering that directly
8:39result from the injury special damages
8:42are those actual damages that are a
8:44consequence of the injury such as
8:45medical expenses lost income and funeral
8:48expenses punitive damages are attended
8:51to punish the provider for negligence
8:52that was reckless wanton
8:54fraudulent were willful punitive damages
8:57are exceedingly rare in medical
8:59malpractice cases more likely in the
9:01case of gross negligence is a loss of
9:03the license to practice anesthesia in
9:05extreme cases criminal charges may be
9:07brought against the provider although
9:09this is rare determination of the dollar
9:11amount is usually based on some
9:13assessment of the plaintiffs condition
9:14versus a condition he or she would have
9:16been had there been no negligence
9:18plaintiffs attorneys generally charge a
9:20percentage of the damages and will
9:22therefore seek to maximize the award
9:24given because medical malpractice
9:28usually involves issues beyond the
9:30comprehension of the lay jurors and
9:31judges the court establishes a standard
9:33of care in a particular case by the
9:35testimony of expert witnesses these
9:38witnesses differ from factual witnesses
9:40mainly and that they may give opinions
9:41the trial court judge has sole
9:43discretion in determining whether a
9:45witness may be qualified as an expert
9:47although any licensed provider may be an
9:49expert information will be sought
9:51regarding the witnesses education and
9:53training the nature and scope of the
9:54person's practice memberships and
9:56affiliations and publications the
9:59purpose in gathering this information is
10:01not only to establish the qualifications
10:02of the witness to provide expert
10:04testimony but also to determine the
10:06weight to be given to that testimony by
10:07the jury in many cases the success of a
10:10lawsuit depends primarily on the stature
10:12and believability of the expert
10:14witnesses unfortunately there is a
10:16tendency for experts to link severe
10:18injury with inappropriate care in
10:20certain circumstances the standard of
10:22care may also be determined from
10:23published societal guidelines written
10:25policies of a hospital or department or
10:27textbooks some medical specialty
10:29societies have carefully avoided
10:31applying the term standards to their
10:33guidelines in the hope that no binding
10:35behavior or mandatory practices have
10:36been created the essential difference
10:39between standards and guidelines is that
10:40guidelines should be adhered to and
10:42standards must be adhere to
10:46relatively few adverse outcomes end up
10:49in a malpractice suit it has been
10:51estimated that less than one of 25
10:53patient injuries result in malpractice
10:54litigation the aasa' Committee on
10:57professional liability has conducted a
10:59nationwide analysis of malpractice
11:00claims against anaesthetist including
11:03dental damage since 1985 this is called
11:06the closed claims project the leading
11:08injuries and malpractice claims in the
11:101990s were death at 24 percent nerve
11:13damage at 22 percent permanent brain
11:15damage at 8 percent and airway injury at
11:187 percent the causes of death and
11:20permanent brain damage were
11:21predominantly problems in airway
11:23management and other complications such
11:25as pulmonary embolism inadequate fluid
11:27therapy stroke hemorrhage and myocardial
11:29infarction nerve damage especially to
11:32the ulnar nerve often occurs despite
11:34apparently adequate positioning spinal
11:37cord injury was the most common cause of
11:38nerve damage claims against anesthesia
11:40providers in the 1990s chronic pain
11:43management is an increasing source of
11:45malpractice claims against anesthesia
11:48the anesthetist is likely to be the
11:51target of a lawsuit if an untoward
11:52outcome occurs because the provider
11:54patient relationship is usually tenuous
11:56at best the patient rarely chooses the
11:59anesthetist the preoperative visit is
12:00brief and the anesthetist who sees a
12:02patient preoperatively may not actually
12:04anesthetize the patient communication
12:06between anesthetist
12:08and surgeons about complications is
12:09often lacking and the tendency is for
12:11the surgeon to blame anesthesia
12:13in addition anesthetist are often sued
12:16along with a surgeon in the case of an
12:17adverse outcome this may occur even if
12:20the outcome was in no way related to
12:21anesthetic care the most common cause of
12:26medical malpractice is medical
12:27negligence negligence is defined as a
12:30breach of a duty that is the immediate
12:32cause of a harm expanding on that
12:34definition medical negligence occurs
12:36when a provider's failure or the breach
12:38to meet the standard of care the duty
12:40directly leads proximate cause to
12:43patient injury or the harm proximate
12:46cause should be tightly coupled and
12:47requires proof of cause in fact and
12:49foreseeability cause in fact often known
12:52as the but-for test means that the harm
12:55would not have occurred but for the
12:56previous negligent act foreseeability
12:59just that injuries must be of the type
13:01that would be foreseen by a reasonable
13:02practitioner for example but for the
13:05absence of an entitled carbon dioxide
13:07monitor esophageal intubation would have
13:09been recognized because a reasonable
13:11practitioner would foresee that this
13:13breach of the standard of care may lead
13:15to unrecognized Safa geol intubation
13:17there must be a harm for which the
13:19individual needs to be compensated
13:23Awards may be conferred for non-economic
13:25losses for the economic loss of
13:27repairing the damage and for loss of
13:29income the amount of time in which a
13:32plaintiff can bring an action is
13:33governed by state statutes and typically
13:35begins on occurrence or discovery of the
13:37allegedly negligent act or the harm
13:39medical negligence may be a judge as
13:41criminal medical negligence if it
13:43deviates greatly from the standard of
13:44care whether unknowingly or knowingly
13:47criminal medical negligence is rarely
13:49prosecuted but characteristics of such
13:51cases include failure to modify care
13:53based on past similar experiences hiding
13:56errors and practicing in a way that
13:58appears to favor financial and personal
13:59gains over patient care for example an
14:02anesthetist was prosecuted but
14:05eventually acquitted for reckless
14:07manslaughter when after more than five
14:08documented episodes of falling asleep
14:10while providing anesthesia he fell
14:12asleep during a case in which the child
14:14died the anesthetist was convicted for
14:16criminal medical negligence although
14:18that conviction was eventually
14:19overturned because the prosecutors had
14:21not brought the criminal medical
14:22negligence charge within the legal time
14:24limits there are several elements of
14:28negligence when very important element
14:31is record keeping good records can form
14:34a strong defense if they are adequate
14:35however records can be disastrous if
14:37inadequate the anesthesia record itself
14:40should be as accurate complete and as
14:41neat as possible the use of automated
14:44anesthesia records may be helpful in the
14:46defense of malpractice cases but they
14:48may also serve as damaging evidence for
14:50the lack of vigilance prior to an
14:51adverse event in addition to documenting
14:54vital signs at least every five minutes
14:55special attention should be paid to
14:57ensure that the patient's aasa
14:58classification the monitors used fluids
15:01administered and doses and times of all
15:04administer drugs are accurately charted
15:06because the principal causes of hypoxic
15:08brain damage and death during anesthesia
15:10are related to ventilation and/or ox
15:12all respiratory variables that are
15:14monitored should be documented
15:15accurately it is important to note when
15:18there is a change of anesthesia
15:19personnel during the conduct of a case
15:21sloppy
15:22inaccurate anesthesia records with gaps
15:24during critical events can be extremely
15:26damaging to the defense when enlarged
15:28and placed before a jury a lawsuit
15:32begins when the patient plaintiff's
15:34attorney files a complaint and demand
15:36for jury trial with the court the
15:38anesthetist is in served with a
15:39complaint and a summons requiring an
15:41answer to the complaint until this
15:43happens no lawsuit has been filed
15:46insurance carriers must be notified
15:48immediately after the receipt of the
15:49complaint the anesthetist will need
15:52assistance in answering the complaint
15:53and there is a time limit placed on the
15:55response these are some specific actions
15:58at this point do not discuss the case
16:00with anyone including colleagues who may
16:02have been involved operating room
16:03personnel or friends never alter any
16:06records gather together all pertinent
16:09records including a copy of the
16:10anesthetic record billing statements and
16:12correspondence concerning the case make
16:15notes recording all events recalled
16:17about the case and cooperate fully with
16:20the attorney provided by the insurer the
16:23first task the anesthetist must perform
16:26with an attorney is to prepare an answer
16:28to the complaint the complaint contains
16:30certain facts and allegations with which
16:32the defense may either agree or disagree
16:34defense attorneys rely on the Frank and
16:37totally candid observations of the
16:38provider and preparing an answer to the
16:40complaint providers should be willing to
16:42educate their attorneys about the
16:43medical facts of the case although most
16:46medical malpractice attorneys will be
16:47knowledgeable and medically
16:48sophisticated the next phase of the
16:51malpractice suit is called discovery the
16:53purpose of discovery is the gathering of
16:55facts and clarification of issues in
16:57advance of the trial in all likelihood
16:59the anesthetist will initially receive a
17:01written interrogatory which will request
17:03factual information in consultation with
17:06the defense attorney the interrogatories
17:08should be answered in writing because
17:09carelessly or inadvertently misstated
17:12facts can become troublesome later
17:14depositions are the second mechanism of
17:16discovery the defendant or necess will
17:19be deposed as a fact witness and
17:20depositions will be obtained from other
17:22necess who will act as expert witnesses
17:25a nationally recognized expert in the
17:27area in question recommended by the
17:29defendant but who is not a personal
17:31friend and who agrees with the defense
17:32position may be very valuable the
17:35plaintiff's attorney not the defense
17:37attorney will depose the anesthetist
17:39despite the apparent informality of the
17:41deposition the anesthetist must be
17:43constantly aware that what is said
17:45during the deposition carries as much
17:46weight as what would be said in court it
17:48is important to be factually prepared
17:50for the deposition by review of personal
17:52notes the anesthetic record and the
17:54medical record the providers should
17:56dress conservatively and professionally
17:58because appearance and image are very
18:00important the opposition is assessing
18:02the provider to see how he or she will
18:04appear to a jury answer only the
18:09question asked and do not volunteer any
18:11information rely on one's attorney for
18:14assistance when preparing for a
18:15deposition
18:16there will be depositions from expert
18:18witnesses both for the plaintiff and for
18:20the defense
18:20the anesthetist should work with his or
18:23her attorney to suggest questions and
18:24rebuttals the better educated the
18:27attorney is about the medical facts the
18:28reasons the anesthetist did what was
18:30done and the alternative approaches the
18:32better able the attorney will be to
18:33conduct these expert depositions if
18:35there is some merit in the case but the
18:38damages are minimal or a proof of
18:40innocence will be difficult there will
18:41probably be a settlement offer there is
18:44a high cost incurred by both plaintiffs
18:45and defendants in pursuing a malpractice
18:47claim up through a jury trial unless
18:50there is a strong probability of a large
18:52dollar award reputable plaintiff
18:54attorneys are not likely to pursue the
18:55claim thus even if providers believe
18:58that they are totally innocent of any
18:59wrongdoing
19:00they should not be offended or angered
19:02about settling of a case this is solely
19:04a matter of money not medicine
19:06if a settlement is not reached during
19:08the discovery phase a trial will occur
19:10only about one in twenty mile practice
19:12cases ever reach the point of a jury
19:14trial only those cases in which both
19:16sides think they can win or in which
19:18there is likely to have significant
19:19financial impact will proceed to trial
19:23the discussion of deposition testimony
19:26also applies to testimony in court but
19:28there are a few additional points to
19:29consider during a trial the members of a
19:32jury will not be as sophisticated
19:33medically as the attorneys who deposed
19:35the anesthetist during discovery however
19:37do not underestimate
19:39the intelligence of the jury talking
19:41down to them will create an unfavorable
19:42impression if the answer to a question
19:44is not known avoid guessing if specific
19:48facts cannot be remembered say so nobody
19:51expects total recall of events that may
19:53have occurred years before the defendant
19:55provider should be present during the
19:57entire trial even when not testifying
19:59and should dress professionally displays
20:02of anger remorse relief or hostility
20:04will hurt the provider in court the
20:07provider should be able to give his or
20:08her testimony without notes or documents
20:10when it is necessary to refer to the
20:12medical record it will be admitted into
20:14evidence the anesthetist goal is to
20:17convince a jury that he or she behaved
20:18in this case as any other competent and
20:21prudent and necess would have behaved it
20:23is important to keep in mind that proof
20:25in a malpractice case means only more
20:27likely than not the patient plaintiff
20:29must prove the four elements of
20:31negligence not to absolute certainty but
20:33only to a probability greater than 50%
20:35on the positive side this means that the
20:39defendant or anesthetist must only show
20:40that his or her actions were more than
20:42likely not within an acceptable standard
20:44of care
20:47if a critical incident occurs during the
20:50conduct of an anaesthetic the
20:52anesthetist should document in narrative
20:54form what happened
20:55which drugs were used the time sequence
20:57and who was present this should be
20:59documented in the patient's progress
21:01notes as a catastrophic inter anesthetic
21:03event cannot be summarized adequately in
21:05the small box provided on a usual
21:07anaesthetic record the critical incident
21:10note should be written as soon as
21:11possible the report should be as
21:13consistent as possible with concurrent
21:15records such as the anesthesia operating
21:17room recovery room and cardiac arrest
21:20records if significant inconsistencies
21:22exist they should be explained records
21:26should never be altered after the fact
21:27if an error is made in record-keeping a
21:30line should be drawn through the error
21:31leaving it legible and the correction
21:33should be initialed in time litigation
21:36is a lengthy process and a court
21:37appearance to explain the incidence to a
21:39jury may be years away when memories
21:41have faded
21:41if anesthetic complications occur the
21:46anesthetist should be honest with both
21:47the patient and the family about the
21:49cause the providers should provide the
21:51facts about the event express regret to
21:53the patient and the family about the
21:54outcome and give a formal apology if the
21:57unanticipated outcome is a result of an
21:59error or system failure some states have
22:02laws mandating disclosure of serious
22:03adverse events to patients and
22:05disclosure has been incorporated into
22:07quality reporting other states prohibit
22:09use of disclosure discussions as
22:11evidence in malpractice litigation
22:13whenever an anaesthetic complication
22:15becomes apparent appropriate
22:17consultation should be obtained quickly
22:19and the departmental or institutional
22:21risk management group should be notified
22:22if the complication is apt to lead the
22:25prolonged hospitalization or permanent
22:27injury the liability insurance carrier
22:29should also be notified the patient
22:31should be followed closely while in the
22:32hospital with telephone follow-up if
22:34indicated after discharge the
22:37anesthetist surgeons and consulting
22:39providers and the institution should
22:41coordinate and be consistent in their
22:43explanations to the patient or the
22:44patient's family as to the cause of any
22:46complication the informed consent
22:51process requests honest disclosure of
22:53medical information to the patient u.s.
22:55courts currently rely on two standards
22:57of disclosure the reasonable person
22:59standard and the subject
23:00standard 1/3 professional standard in
23:04which the provider is obliged to
23:05disclose only what other providers of
23:07the same specialty would disclose was
23:08subject to abuse and manipulation and is
23:10essentially no longer recognized in the
23:13reasonable person standard the provider
23:15must disclose any information that a
23:17theoretical reasonable person would want
23:19to know this standard does not require
23:21an exhaustive recitation of facts and
23:23acknowledges that not all information
23:25related to the procedure is integral in
23:27making a decision about whether to
23:28undergo the procedure the subjective
23:31standard recognizes that some patients
23:33may have special needs for specific
23:34information and that when that need is
23:36obvious or has been brought to the
23:38attention of the provider the
23:39information must be disclosed for
23:42example a concert violinist may have a
23:44specific need to know about the
23:46potential for nerve damage from an
23:47axillary block in general legal and
23:52ethical standards now require that
23:54number 1 the provider accurately
23:56discussed the therapy and its potential
23:58alternatives including no therapy and
23:59number 2 disclosed the common risk
24:02because they are more likely to happen
24:03and the serious risk because the
24:05consequences are severe the doctrine of
24:08therapeutic privilege is sometimes cited
24:10to avoid discussing risk under the
24:11reasoning that the stress of discussing
24:13these risks can harm the patient
24:15psychologically or physically studies a
24:17patient's stress during the informed
24:19consent process do not support this
24:21concept therapeutic privilege is
24:23probably invoked in many cases because
24:25the provider is uncomfortable with
24:26disclosure or wants to curtail
24:28discussion although it is ethical to
24:30forego or curtail risk discussions at
24:32the patient's request it is not
24:34generally ethical for the provider to
24:36unilaterally decide to do so the
24:38provider patient relationship is an
24:40inherently unequal one because of the
24:42providers knowledge and authority and
24:43the patient's dependence on them for
24:45care providers have ethical obligations
24:48to avoid exploiting their influence for
24:49the purpose of accomplishing their own
24:51ends although it is acceptable to offer
24:54a rational basis for a medical choice it
24:56is generally unethical to coerce or
24:58manipulate patients into decisions by
25:00presenting real or implied threats or by
25:02omitting or misrepresenting key
25:04information although often
25:06inappropriately conflated an apology an
25:09expression of regret or sorrow is
25:10distinct from disclosure which is a
25:12revelation about what happened
25:14apologies and disclosures may occur at
25:16the same time as we mentioned before
25:19more than half the states have laws
25:20prohibiting an admission of apology or
25:22sympathy as evidence of wrongdoing some
25:25recommendations suggest apologizing for
25:27the effect on the patient without
25:28admitting fault
25:29sometimes this may make sense for
25:31example if a previously acceptable
25:33antibiotic caused a rash however not to
25:37take responsibility may seem unnatural
25:38such as when an anesthetist errantly
25:40administers an antibiotic to a patient
25:42for whom there is a clear documentation
25:44of an allergy in the name of good
25:47relationships with patients apology
25:49should not be limited solely to events
25:50that may result in a suit for example
25:53consider a six-year-old who on the
25:55initiation of mass conduction starts to
25:57scream and cry uncontrollably after a
26:00discussion with the father who is
26:01present a decision is made to in essence
26:03hold her down and apply the mask a
26:05follow-up discussion with the family may
26:07include an apology not only for the
26:09induction like I am sorry that was so
26:11unpleasant for Becky Nia but also to
26:13acknowledge that this was not the
26:15desired reaction that is not our goal
26:17for induction we would like for it to be
26:19smoother and going without sedation
26:21turned out to be a mistake as well as a
26:23recommendation for the future in the
26:25future I would recommend giving oral
26:27sedation before going to the operating
26:28room although this technically seems
26:30submit wrongdoing it is simply
26:32acknowledging what happened and
26:33educating the family for the future now
26:38we'll talk about competence autonomy to
26:41make medical decisions cannot exist in
26:42the absence of competence because
26:45competence is a legal term most medical
26:47experts prefer the term capacity to
26:49describe the necessary skills to
26:50participate in medical decisions
26:52impairment of capacity can be temporary
26:55or permanent
26:56examples include some mental illnesses
26:58dementia immaturity anxiety pain and
27:02effects of medications the elderly those
27:05suffering from mental impairment and
27:06children are particularly vulnerable to
27:08having their participation and medical
27:10decisions inappropriately curtailed or
27:12even denied because their capacity to
27:14participate is frequently underestimated
27:17hearing loss dysarthria and expressive
27:20aphasia can create the false impression
27:22that capacity is impaired many children
27:24make medical decisions in ways similar
27:26to adults but may be
27:27secondly excluded from the
27:28decision-making process solely because
27:30of their age language barriers can
27:33present significant challenges to
27:34communication capacity is both relative
27:38and task specific patients may be able
27:41to understand and make decisions about
27:42medical issues while being unable to
27:44care for themselves in other ways
27:46surveys indicate that providers and
27:48other healthcare workers are likely to
27:50act on personal prejudices regarding
27:52handicapped or impaired patients
27:54functional capacity for decision-making
27:56must be judged separately from the
27:57perceived quality of the decision itself
28:00patients have the right to make bad
28:02decisions if they are competent and have
28:04the appropriate information otherwise
28:07providers could merely substitute their
28:09own judgment for that of the patient an
28:10autonomy and medical decision making
28:12would be non-existent it is usually the
28:17obligation of the hospital risk
28:18management department to make reports
28:20and enquiries to the national
28:22practitioner data bank or npdb a
28:24nationwide information system that
28:26theoretically allows licensing boards
28:28and hospitals a means of detecting
28:29adverse information about providers
28:31simply moving into another state would
28:34no longer provide safe haven for
28:35incompetent providers the NPDB requires
28:38input from five sources medical
28:41malpractice payments license actions by
28:43medical boards professional review or
28:46clinical privilege actions taken by
28:47hospitals and other healthcare entities
28:49actions taken by the Drug Enforcement
28:51Agency and Medicare Medicaid exclusions
28:56there has been a great deal of effort to
28:58establish a minimum malpractice payment
29:00below which no report is necessary but
29:02to date any payment made on behalf of a
29:04provider in response to a written
29:06complaint or claim must be reported
29:08settlements made by cancellation of
29:10bills or settlements made on verbal
29:12complaints are not considered a
29:13reportable payment once a report has
29:15been submitted the provider is notified
29:17and may dispute the accuracy of the
29:19report at this time the reporting entity
29:21may correct the form or void it failing
29:24that the provider has the option of
29:26putting a brief statement in the file or
29:28appealing to the US Secretary of Health
29:30and Human Services who may also either
29:32correct or void the form a practitioner
29:35may make a query about his or her file
29:36at any time a provider may also add a
29:39statement to a report at any time
29:41such statements will be included in any
29:43reports that are sent in response to
29:45inquiries the existence of the NPDB
29:48reporting requirements has made
29:49providers reluctant to allow settlement
29:51of nuisance suits because it will cause
29:53their names to be added to the databank
29:57informed consent regarding anesthesia
29:59should be documented with a general
30:01surgical consent which should include a
30:02statement to the effect that I
30:04understand that all anesthetics involve
30:06risk of complications serious injury or
30:08rarely deaths from both known and
30:10unknown causes in addition there should
30:13be a note in the patient's record that
30:14the risk of anesthesia and alternatives
30:16were discussed and that the patient
30:17accepted the proposed anesthetic plan a
30:19brief documentation in the record that
30:21the common complications of the proposed
30:23technique were discussed is helpful in
30:25some institutions a separate written
30:27anesthesia consent form may be used
30:29which may include more detail about risk
30:31if it is necessary to change the agreed
30:34on anesthesia plan significantly after
30:35the patient is pre medicated or
30:37anesthetized the reasons for the change
30:39should be documented in the record the
30:41informed consent process does not
30:43prevent legal liability when adverse
30:45events occur flawed informed consent
30:48processes have been cited however as
30:49evidence of a lack of quality of care by
30:51the provider the AAS a closed claims
30:54database reveals that the absence of
30:56informed consent is cited in
30:57approximately 1% of claims and that
30:59cases with inadequate documentation of
31:01informed consent are associated with
31:03large monetary awards studies have
31:06repeatedly shown that the risk of filing
31:07a malpractice claim is directly related
31:09to patient's perception of the
31:11relationship with the provider the
31:13informed consent process provides one of
31:15the few opportunities that anesthesia
31:17providers have to establish that
31:18relationship however brief and that
31:20should not be underestimated in its
31:22medical legal importance informed
31:26consent is meaningless if the patient
31:28cannot also refuse medical therapy
31:30examples of informed refusal in
31:32anesthesiology include requests to
31:34withdraw or withhold life supporting
31:35care in the ICU do not attempt
31:37resuscitation orders in the operating
31:39room cases in which the patient has
31:41objections to certain forms of therapy
31:43such as a Jehovah Witness who refuses
31:44blood transfusions and cases in which a
31:46patient refuses preoperative testing
31:48such as for HIV or pregnancy testing
31:51inform refusal has similar concerns and
31:53requirements as informed consent
31:55when patients refuse medical care or
31:57insist on what the provider believes is
31:58sub optimal care disclosure of the risk
32:01and benefits become even more important
32:02because these decisions may veer from
32:04options that are already widely accepted
32:07and for which the risk are believed to
32:08be the lowest it is easier to justify
32:11agreeing to the unusual preferences of a
32:13well-informed patient than to subject a
32:15poorly informed patient to an Orthodox
32:16care despite full information patients
32:19may sometimes request or demand care
32:21that is unreasonable either because it
32:23will adversely affect the performance of
32:24surgery or because it would be
32:26associated with unreasonably high risk
32:28when a patient demands a technique that
32:30is inappropriate or outside the realm of
32:32reasonable practice the anesthetist is
32:34under no ethical obligation to provide
32:36that care
32:37no provider can be compelled by a
32:39patient to practice negligently in the
32:43case of Jehovah Witnesses the treatment
32:45that may be refused as the
32:46administration of blood or blood
32:48products a central religious belief of
32:50many Jehovah Witnesses is that the
32:52faithful will be forbidden the pleasures
32:54of the afterlife if they receive blood
32:55or blood products thus for them to
32:58receive a transfusion is a mortal sin
32:59and many Jehovah Witnesses would
33:01actually rather die in grace than live
33:03with no possibility of salvation
33:05anesthetist must recognize and respect
33:07these beliefs that may also be cognizant
33:09that these convictions may conflict with
33:10their own personal religious or ethical
33:12codes as a general rule providers are
33:15not obligated to treat all patients who
33:17apply for treatment in elective
33:18situations it is well within the rights
33:21of a provider to decline to care for any
33:23patient who wishes to place burdensome
33:25constraints on the provider or to
33:27unacceptably limit the providers ability
33:29to provide optimal care when presented
33:31with the opportunity to provide elective
33:33care for a Jehovah Witness the provider
33:35may decline to provide any care or may
33:37limit by mutual consent with the patient
33:39his or her obligation to adhere to the
33:41patient's religious beliefs if such an
33:43agreement is reached it must be
33:45documented clearly in the medical record
33:46and it is desirable to have the patient
33:48co-sign the note not all Jehovah
33:50Witnesses have identical beliefs
33:52regarding blood transfusions or which
33:54methods of blood preservation or
33:55sequesteration will be allowed some
33:58patients will not allow any blood that
33:59has left the body to be re-infused
34:01yet others will accept auto transfusion
34:03if their blood remains in constant
34:04contact with the body via tubing
34:07therefore it is important
34:08reach a clear understanding of which
34:10techniques for blood preservation are to
34:12be used and to document this plan in the
34:13record parents of a minor child may not
34:16legally prevent that child from
34:18receiving blood it may be necessary to
34:20obtain a court order in this
34:22circumstance transfusion of pediatric
34:25Jehovah Witnesses patients by court
34:26order is common at this time that may
34:28become ethically and legally less
34:30acceptable as therapy other than blood
34:32transfusion to maintained oxygen
34:34carrying capacity evolves as a Jehovah
34:36Witness church further defines its
34:37doctrines with regard to children and as
34:39the capacity of children to consent to
34:41or refuse therapy is better understood
34:45the ethical practice of medicine weighs
34:48heavily toward adherence to respect for
34:49autonomy and patients who are competent
34:51to make medical decisions or who have
34:53executed it beens directives when they
34:55were competent to do so medical care of
34:57individuals who have never been
34:58autonomous relies on principles such as
35:00respect for human dignity beneficence
35:03avoidance of harm and adherence to the
35:05principle of justice children are an
35:07example of persons who may or may not
35:09yet be autonomous laws in each state
35:12defined the age at which children become
35:13legally competent to make medical
35:15decisions usually 18 but many younger
35:17children have the mental and emotional
35:19capacity to make medical decisions
35:21forcing such individuals to undergo
35:23treatments that they do not want is
35:25unethical and could be illegal as well
35:27decision-making capacity and children is
35:29variable most two-year-olds are clearly
35:32not able to make medical decisions but
35:34there is a wide range of capability
35:36present in children as young as seven or
35:38eight and studies suggest that the
35:39average fourteen-year-old makes medical
35:41decisions similar to adults in one study
35:44children from 6 through 9 years of age
35:46invited to participate in influenza
35:48vaccine research asked pertinent
35:49questions about individual risk and
35:51benefits and whether their community and
35:53other children would benefit most states
35:55recognize emancipated minor status
35:57whereby a court determines that minors
35:59can legally make medical decisions for
36:01themselves legal exceptions to the age
36:03of consent are recognized in most states
36:05when treatment is believed to be in the
36:06minors best interest and a requirement
36:08for parental consent would interfere
36:10with the child's ability to receive
36:11medical help the law recognizes that
36:14tragically some conditions for which a
36:16minor six therapy may even be the result
36:18of parental abuse and that seeking
36:20parental permission for treatment may
36:21further endanger the minor thus minors
36:24are allowed in many states to consent to
36:26treatment for substance abuse sexually
36:28transmitted diseases mental illness and
36:30medical care affecting pregnancy
36:32including abortion in situations in
36:34which a minor has decision-making
36:36capacity but is not emancipated a judge
36:38may declare the child to be a mature
36:40minor with decision-making rights
36:42ideally individuals of any age should be
36:45involved in medical decisions to the
36:46degree that their capacity allows a
36:48minor who possesses the capacity to make
36:51decisions should not be coerced or
36:52restrained under most circumstances
36:55determining whether a minor has such
36:56capacity may require a formal
36:58consultation and assessment the term
37:01ascends rather than consent is used to
37:03refer to agreement for treatment by
37:05children who did not fall into legal
37:06categories awarding them adult rights
37:08the American Academy of Pediatrics has
37:11stated that providers who care for
37:12children should give serious
37:13consideration to each patients
37:15developing capacities for participating
37:17and decision-making including
37:18rationality and autonomy when children
37:21die sent to undergo medical care
37:23persistent refusal may be ethically
37:25binding particularly in the case of
37:27participation in research medical
37:30personnel should respect the wishes of
37:31patients who withhold assent and try to
37:33gain a better understanding of their
37:35situation or deal with their fears a
37:37patient's reluctance or refusal to
37:39assent should also carry considerable
37:41weight when the proposed intervention is
37:43not essential to his or her welfare
37:44and/or can be deferred without
37:46substantial risk child protective
37:50services are established by state
37:52governments to all of the states to take
37:54custody of children her being denied the
37:55necessities of life such as housing
37:57clothing food education and medical care
38:00there is some variation among the states
38:02but most allow the state to take custody
38:04of the child upon little or nothing more
38:06than a verified petition alleging
38:07neglect or abuse temporary custody may
38:10be sufficient to allow provision of
38:12medical care but ultimately unless the
38:13state shows by clear and convincing
38:15evidence that all statutory requirements
38:17are met there is little chance of
38:18terminating parental rights and
38:20maintaining custody children are
38:22commonly the victims of injury with
38:24trauma in accidents being the leading
38:25causes of death between the ages of 1
38:27and 14 years at times patterns of injury
38:30may be of concern especially with acute
38:33injury seen in the conjunction with
38:34signs of prior trauma
38:36such as bruises contusions and healing
38:38fractures which may be suggestive of the
38:40battered child syndrome in general the
38:44rights of pregnant women to refuse
38:46therapy
38:46even if refusal would be detrimental to
38:48their fetuses are protected under right
38:50to privacy provisions in the US
38:51Constitution these rights are weighed
38:54against potential harm to the fetus in a
38:56decremental fashion as the fetus
38:57approaches and surpasses viable age when
39:00the fetus is of non-viable age mother's
39:02rights prevail Court decisions have
39:05consistently upheld the rights of
39:06pregnant women to have abortions to not
39:08be subjected to drug testing and to
39:10forego transfusions early in pregnancy
39:12attempts to charge women with child
39:14abuse child endangerment
39:16drug trafficking murder and attempted
39:18murder for activities deemed dangerous
39:19to their fetuses have almost uniformly
39:21failed in general women do not lose
39:24their rights to bodily integrity and
39:26informed consent when they become
39:27pregnant and neither fetal rights nor
39:29state interest supersede a pregnant
39:31woman's right as medical decision maker
39:33the American Academy of Pediatrics
39:35Committee on ethics has outlined
39:37conditions that in their view are
39:38necessary to override a mother's refusal
39:40of care number one the fetus will suffer
39:43irrevocable harm without the treatment
39:45number two the treatment is clearly
39:47indicated and likely to be effective
39:49number three the risk to the woman is
39:52low however the American College of
39:54obstetrics and Gynecologists condemns
39:56the use of coercion on pregnant women
39:58and advocates counseling the patient
39:59carefully about the risk in addition to
40:01recommending consultation with an ethics
40:03committee the use of physical restraint
40:07to control medical research subjects was
40:09first addressed directly in the
40:10Nuremberg code after the doctor's trial
40:12in 1947 through 1949 and is a continuing
40:15subject of intense scrutiny for
40:18anesthetist chemical restraints often
40:20replace physical ones
40:21but the ethical issues are the same
40:23Inessa tests are often asked by medical
40:25colleagues to chemically restrain
40:26uncooperative patients the use of
40:29restraint is anti ethical to promotion
40:31of autonomy and anesthetist have both
40:33ethical and legal obligations to
40:34determine whether such extreme
40:36intervention is warranted coercing are
40:39using physical or chemical means to
40:40force competent patients to undergo
40:42treatment that they are refusing is both
40:43unethical and illegal refusal of medical
40:46care and angry behavior are not proof of
40:48income
40:49intoxication or the inability to make
40:51medical decisions when faced with an
40:54uncooperative adult patient questions to
40:56ask include is the patient clearly
40:58incompetent or merely angry and
41:00uncooperative is there evidence of
41:02neurological impairment acute
41:04intoxication or severe mental disability
41:06is the patient in immediate danger does
41:10the patient pose a direct threat to
41:11staff or other patients and is there a
41:14compelling need to treat
41:15life-threatening injuries in the absence
41:17of these considerations the use of
41:19coercion or physical or chemical
41:20restraints is neither ethical or legal
41:23providers may be forced in some
41:25situations to act within a time frame
41:26that does not permit lengthy evaluation
41:28of a patient's competence or a
41:30protracted search for a surrogate
41:31decision-maker in such cases the
41:34provider must rely on their professional
41:35judgment in deciding how to care for
41:37uncooperative patients who either cannot
41:39speak for themselves or appear
41:40incompetent to refuse care at a time
41:42when a decision must be made the
41:44standard applied here would be to do
41:46what a reasonable person would wish
41:48coercion or restraint or both in such
41:51situations is not ideal but may be
41:53necessary and ethically permissible
41:57critical decisions regarding medical
41:59care often arise when patients are too
42:01ill to formulate or express decisions
42:03regarding medical interventions advanced
42:05directives were developed after several
42:07legal decisions affirm the patient's can
42:09refuse even life-saving medical care and
42:11that clear and convincing evidence of
42:12the patients wishes is needed to allow
42:14surrogate decision-makers to request
42:16withdrawal of life-sustaining therapies
42:18and it be instructive is a document
42:20executed by patients before in capacity
42:22to provide providers with guidance and
42:24medical decision-making when the
42:25patients cannot communicate for
42:27themselves an advance directive is a
42:29document executed by patients before in
42:32capacity to provide providers with
42:33guidance and medical decision making
42:35when the patients cannot communicate for
42:36themselves such directives include
42:39living wills which detail which
42:41therapies a patient would accept or
42:42refuse in the case of terminal
42:44incapacity DNA are orders and any other
42:47information regarding medical care
42:48decisions a surrogate decision maker may
42:51be someone whom the patient has
42:52appointed to make healthcare decisions
42:54for them a durable power of attorney or
42:56an individual with other legally
42:57recognized Authority by virtue of their
42:59relationship with the patient a durable
43:02power of attorney for health care
43:03maybe given by patience to a specific
43:05person whom they designate to make
43:07healthcare decisions for them if they
43:08become incapacitated the authority
43:11vested in a POA supersedes most other
43:13decision makers including family members
43:15except court-appointed Guardians when
43:18the patient has not designated a durable
43:20power of attorney doctors rely on family
43:21members to make decisions for the
43:23patient in many states there is no
43:25legally defined hierarchy of decision
43:27makers usually the spouse or legally
43:30recognized domestic partner is
43:32considered the first-line surrogate
43:34commonly the surrogate hierarchy after
43:36the spouse is the children if all are in
43:38agreement and then the parents if both
43:40are in agreement and then the siblings
43:42if all are in agreement in cases in
43:45which there are no advance directives
43:46and either a surrogate decision maker is
43:48not available or family members cannot
43:50agree the courts may appoint a guardian
43:51ad litem to represent the patient in
43:53medical decision-making surrogates
43:56explicitly act and substituted judgment
43:58to provide what the patient would have
43:59wanted and theoretically are not being
44:01asked merely for their own preferences
44:03however surrogate decision makers at
44:06best only approximate the patient's
44:08decisions because their interpretation
44:09is subject to their own biases values
44:11and psychological agendas incompetent
44:14patients can be emotionally and
44:16financially burdensome and decision
44:18makers may have conflicts of interests
44:19that distort their beliefs and testimony
44:21about what the patient would have wanted
44:23neither providers nor proxies can always
44:26accurately predict the patient's
44:27preferences for life-sustaining therapy
44:29but despite all of its imperfections
44:31proxy decision-making may be the only
44:32option if a patient has not left
44:34specific directives up to 60% of
44:39anaesthetist and correctly believe that
44:40DNR orders are automatically suspended
44:42during anesthesia and surgery how many
44:45times have we heard no one's a DNR in
44:47the operating room the a si the American
44:50College of Surgeons the association of
44:52operating room nurses and the Joint
44:53Commission on Accreditation of health
44:55care organizations all have published
44:57practice guidelines requiring
44:58reconsideration not abandonment of DNR
45:01orders in the perioperative period the
45:03DNR order is in essence a documentation
45:06of the patient's wishes to avoid the
45:07medical interventions associated with
45:09resuscitation because the causes and
45:12outcomes expected with cardiac arrest in
45:14the operating room are different from
45:15what may happen elsewhere and the park
45:17is much more favorable it is very
45:19important to reassess the patient's
45:20desires when surgery is anticipated the
45:23a si has issued guidelines for the
45:25management of a patient with DNR orders
45:26and other directives limiting medical
45:28care although the patient's primary care
45:30provider may have introduced the idea of
45:32DNR orders to the patient or surrogate
45:34it is specifically the anesthetist duty
45:36to discuss the risk and benefits of
45:37resuscitation in the setting of
45:39anesthesia and surgery before
45:40undertaking the patient's care the
45:42anesthetist should include in the
45:44discussion the following steps determine
45:45what the patient's goals are regarding
45:47surgery and resuscitation establish
45:50exactly what is meant by resuscitation
45:51in contrast to routine anesthetic care
45:54educate the patient about the risk and
45:56benefits of resuscitation in the
45:57operating room setting and document the
46:00agreements reached with the patient
46:01about which interventions commonly
46:03associated with resuscitation are
46:04acceptable to the patient such
46:07interventions might include but are not
46:08limited to intubation the administration
46:11of vasoactive drugs the administration
46:13of the fibrillation and the institution
46:15of chest compressions many patients who
46:18express reluctance about resuscitation
46:20during surgery are fearful of burdensome
46:22outcomes such as permanent neurologic
46:24impairment education and discussion may
46:26reassure them about the favorable
46:28outcomes of resuscitation in the
46:29operating room and can establish ground
46:31rules for discontinuing interventions
46:33postoperatively if they do not lead to a
46:35chance of meaningful recovery surgery is
46:38dependent on the cooperation of many
46:39caregivers with differing expertise each
46:41of whom has independent ethical
46:43obligations to the patient it is
46:45therefore imperative that resuscitation
46:47agreements be discussed with other
46:48members of the operating room team such
46:51a policy prevents crucial disagreements
46:53from occurring during a critical event
46:54when treatment decisions must be made
46:56quickly it also allows for conscientious
46:58objectors to withdraw from the
47:00healthcare team advance directives are
47:02legally and ethically binding despite
47:05clear consistent and forceful legal
47:07decisions many providers still resist
47:09imperative to respect patient's wishes
47:11regarding resuscitative care
47:12life-sustaining therapies or both
47:15anesthetist have ignored DNR directives
47:17under the false assumptions that the
47:18legal authority of advanced directives
47:20and living wills is not binding in the
47:22operating room or that the provider has
47:23discretion in deciding when to follow or
47:26ignore such directives in response
47:28courts have awarded significant monetary
47:30damage
47:30for the cost of continued healthcare and
47:32punitive damage for the pain suffering
47:34and mental anguish of the patient
47:36survivors when DNR instructions are
47:38ignored
47:38finally DNR orders must never be
47:41construed as an excuse not to care for
47:43the patient a patient's decision to
47:45forego resuscitation does not imply a
47:47wish to avoid other beneficial
47:48interventions placement of a pulmonary
47:51artery catheter for example may help
47:53ensure optimal management of a frail
47:55patient who has DNR order by enabling
47:57the anesthetist to avoid situations in
47:59which the patient's DNR status becomes
48:01pivotal
48:04Inessa this may refuse to provide care
48:06when they ethically or morally disagree
48:08with the procedure or situation such as
48:10elective termination of pregnancy
48:12although providers have an obligation to
48:14altruistically provide care
48:15this requisite does not always oblige
48:17providers to subjugate their morals
48:20furthermore society and medicine have a
48:22fundamental interest in preserving the
48:24moral fabric of individual providers
48:26anaesthetist should provide care that
48:28violates their conscious and possibly
48:30weakens their moral Constitution only in
48:32critical presumably life-or-death
48:34circumstances more practically an
48:36anesthetist who ethically or morally
48:38disagrees with a patient's choice will
48:40have difficulty providing the care
48:41requested in a non-emergency situation
48:44such an anesthetist should withdraw from
48:46or refuse patient care the anesthetist
48:48may be obligated to make a reasonable
48:50effort to find a competent and willing
48:52replacement providers may also ethically
48:55refuse to provide care if they believe
48:56that the patient's choice is too
48:58inappropriate or likely to result in
49:00harm determining that a choice of
49:02anesthesia is inappropriate is difficult
49:04and should not be invoked lightly or out
49:06of convenience the patient's choice and
49:09the result in risk must be sufficiently
49:10extreme that they say elicit a similar
49:12response from at least several other
49:14anesthetist
49:15in addition anaesthetist may refuse to
49:18provide care if they do not feel
49:19qualified to provide the needed service
49:23to issues critical divide elorg and
49:25transplantation that confront
49:27anesthetist are the concept of brain
49:28death and linkage of withdrawal of
49:30life-sustaining therapies with organ
49:31retrieval and transplantation after
49:33cardiac death before the 1960s death was
49:36defined as a moment when the heartbeat
49:38stopped and respiration ceased advances
49:41in cardiopulmonary resuscitation and
49:42mechanical ventilation then made it
49:44possible to postpone death seemingly
49:46indefinitely in 1968 the ad hoc
49:49committee of the Harvard Medical School
49:51proposed redefining death as a point at
49:53which all cardio respiratory function
49:54has irreversibly ceased or all function
49:57of the whole brain has irreversibly
49:58stopped the committee gave two explicit
50:01reasons for redefining death the first
50:03was to allow patients to be declared
50:05dead and not maintained on machines
50:07thereby limiting expense reallocating
50:09medical resources to other salvageable
50:11patients and allowing the social ritual
50:13surrounding the death to occur the
50:15second was
50:16donation of vital organs before the
50:18circulation stopped the public has been
50:20slow to accept brain death in part
50:22because it requires the complete trust
50:23and providers and ignores indications of
50:25death that the public already
50:27understands for non providers brain-dead
50:29donors are superficially
50:31indistinguishable in many ways from
50:32living persons and they must therefore
50:34rely completely on the provider for both
50:36accurate and honest information of a
50:38loved ones death diagnosing brain death
50:40is relatively straightforward in the
50:43United States it requires demonstration
50:45that in the absence of drugs paralytic
50:47agents hypothermia and other reversible
50:49conditions that mimic loss of brain
50:50function cortical and brain stem
50:52function is absent the diagnosis is
50:55usually made either clinically by
50:56demonstrating that cortical activity and
50:58brain stem reflexes are absent or by
51:00radiographic studies demonstrating
51:02complete absence of cerebral blood flow
51:04nevertheless medical ethical theologic
51:07and legal experts generally agree that
51:09brain death adequately defines a
51:11condition in which a person with ethical
51:13and legal rights and moral standing
51:14ceases to exist and should no longer be
51:16treated as an alive being expensive
51:19medical interventions could be
51:20discontinued without legal ramifications
51:22and vital organs can be donated for
51:24transplantation if the patient or
51:26surrogate agrees before assuming care of
51:29a brain-dead organ donor the anesthetist
51:31is obliged to review the chart for
51:33documentation of the declaring of brain
51:34death as well as the criteria on which
51:36it was based if there are any questions
51:39about the diagnosis organ donation
51:41should be postponed until the
51:42anesthetist is satisfied that these
51:44concerns are addressed in conclusion
51:48anesthetist faced many ethical
51:50challenges including promotion of
51:52patient autonomy resolution of patient
51:54provider conflicts and medical decision
51:56making ethical obligations in human
51:58subjects and animal research and ethical
52:00conflicts during end-of-life care in the
52:02ICU and during organ donation knowledge
52:05about ethical and professional standards
52:07and patient care and research is
52:08essential in the specialty of
52:09anesthesiology which is more than just a
52:11mere provision of technical service on
52:13demand anaesthetist may find that at
52:16times accepted values and ethical
52:17practice conflict with personal values
52:19and goals this is a common challenge to
52:22all providers but ethical decisions
52:24cannot be left to the individual
52:25providers values and adherence to
52:27ethical principles of the medical
52:28profession should prevail

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