Ethics Curriculum

APSA Symposium: Ethics, Professionalism and the Pediatric Surgeon

Presented during the APSA 39th Annual Meeting, Thursday, May 29, 2008

The following three vignettes were presented as part of a symposium entitled, Professionalism and the Pediatric Surgeon. Each vignette includes a series of questions in order to explore the topics of Medical Error, The Disruptive Surgeon and End of Life Care in Neonates, along with a bibliography with salient articles.

At the end of your reflection exercise you should:

  • Have a basic understanding of professionalism in the practice of pediatric surgery: ethical duties and obligations to patients, peers and society.

  • Understand how strong professionalism values can be transmitted to trainees and understand the hidden curriculum.

  • Have reviewed the pediatric surgeon’s response to medical error: ethical obligations for truth telling and disclosure.

  • Understand the definition of a Disruptive Surgeon and learn way to deal with this professional challenge.

  • Have reviewed the best interest ethical standard in end of life care for infants with catastrophic illness.

  • Have learned how to access/utilize resources such as hospital legal counsel and ethics committee with this professional challenge.


Medical Error

You are asked to see a 10-year-old child in the emergency room for abdominal pain. The pain has been present for 24 hours and has now localized itself in the right lower quadrant. The child’s white count is 15 with a left shift. On exam, he has right lower quadrant tenderness but no evidence of peritonitis. The child has a significant past medical history. As a neonate he suffered from idiopathic small bowel perforation and had a laparatomy. He also had a pyloromyotomy. These were done at another hospital. The child has been diagnosed with type 1 diabetes and is well controlled on insulin.

An abdominal ultrasound was done and you review it with the staff radiologist. The radiologist tells you that the ultrasound is consistent with acute non-perforated appendicitis. You discuss the diagnosis with the parents. You explain to them that you will try doing a laparascopic appendectomy but in view of the previous peritonitis it might be impossible and you may need to convert to an open appendectomy. You consult endocrine medicine to help with the glucose control peri-operatively.

You start the surgery and the abdomen is full of adhesions but they are flimsy. After an hour of lysis of adhesion you have finally located the cecum. There is some edema around it but after the complete dissection there is no appendix. You come to the conclusion that the child had his appendix removed as a neonate.

After the surgery you prepare yourself to go talk to the parents.

What should you disclose to the parents?

Should you apologize for the error?

What are the legal implications if you do so?


The Disruptive Surgeon

Richard is a 43-year-old general pediatric surgeon. He has been in practice for 8 years at a children’s hospital. His practice is essentially a full-time clinical practice, with little in the way of academic demands. Richard practices in a competitive urban market, with 2 other active, well established pediatric surgery practices serving the same region. Because of this pressure, over the years Richard and his partners have extended themselves to provide coverage to 5 different hospitals to maintain an adequate patient base. These include both a small children’s facility with junior level surgical residents, a university hospital, and 3 community hospitals. The hospitals are spread across 50 miles of both urban and suburban communities, and all expect 24/7 coverage. With the recent retirement of the most senior partner, and inability to recruit over the past 18 months, Richard and his remaining two partners have been facing an increased call responsibility, and later nights when not on call. They have been reluctant to cut back on any of their clinical responsibilities due to the fear of losing “market share.” As they all have a “surgical personality,” they have not been able to admit that the increased workload and chronic sleep deprivation is beginning to take its toll.

Richard had been known for his kindness and interest in his patients and their families. He would take a true personal interest and responsibility in their care. Recently, nurses, residents, and referring physicians had noted that he had become curt in his response to pages, and seemed impatient during his interactions with families. He seemed available, but disinterested and angry, when needing to come in while on call. The nursing staff was especially concerned that the children and their families were not getting the attention they needed or deserved from Richard, and they were becoming increasingly concerned that important clinical changes might be missed and not acted on appropriately as Richard often seemed rushed and tired. Limited attempts by the more senior nursing staff to raise these concerns with Richard were met with denial. This left the nursing staff unsure of how to proceed, especially as Richard had been very well liked and there was a strong motivation to provide help. The residents were confused. While they enjoyed the autonomy that Richard’s limited availability with clinical problems provided; they had become scared to call with clinical problems as they knew that he could be angry and curt when disturbed. The problem of how to proceed was extremely difficult for two of the residents who were interested in careers in pediatric surgery, and were anxious to be well liked by the faculty.

What resources are available to the nursing and resident staff to address their concerns?

What are the responsibilities of Richard’s partners in this scenario? What is the responsibility of the Chief of Staff/Department Chair?

What are the issues that may be impairing Richard’s abilities to perform well and provide safe care?

How do these issues relate to physician impairment?


Neonatal End-Of-Life Care: Withdrawal and Withholding of Treatment

Caroline was born at twenty-eight weeks of gestational age to a 35-year-old woman. Caroline is the result of an IVF treatment after 3 unsuccessful attempts. Her birth weight was 1200 grams. The initial physical examination revealed a tiny female infant with marked bruising. She appeared blue and limp and was gasping for air. Initial resuscitation included endotracheal intubation, mechanical ventilation, volume transfusion and inotropic support to maintain adequate cardiorespiratory function.

Caroline was immediately admitted to the NICU. Her primary diagnosis was respiratory distress syndrome. She required fairly high ventilator rates and pressures to maintain adequate oxygenation and ventilation. She required surgical ligation of the patent ductus arteriosis within the first week of life. Cranial ultrasounds performed at days 3 and 14 of life revealed the presence of Grade III bilateral intraventricular hemophages.

The parents were kept informed of their daughter’s progress throughout these first weeks of life. They were assured that important decisions would be made only when consensus was reached between them and the health care team. Both parents asked many questions about how medical staff would know if their daughter was getting worse or perhaps even dying.

On day 17 of life, Caroline started to have increasing residual of her nasogastric feeds, which had been introduced slowly. Her abdomen was distended and feeds were stopped. Abdominal x-rays were taken and showed diffuse pneumatosis and a small amount of intraportal air.

You are called to assess the baby. On physical exam, the baby is not active, the abdomen is red and tender diffusely. She is started back on pressors but her respiratory status is unchanged.

You discuss the situation with the parents. You explain to them that you think Caroline needs an operation. She has necrotizing enterocolitis likely perforated. You are concerned it involves a long segment of her gut. You are planning a bowel resection +/- stoma. You discuss with them that if too much gut involved is removed, Caroline might suffer from short gut syndrome. You explain to them the TPN and its liver injury and the eventuality of small bowel transplant, but that most babies this size do not survive long enough to get an organ.

Both parents are upset, but understand the gravity of the situation. The mother says that she cannot think of her daughter dying. The father says that he wants his daughter to survive at all costs and wants you to promise that you will do everything to save the daughter’s life.

In the OR, you find that most of Caroline’s small bowel is necrotized, except for 10 proximal cm.  Her colon is also necrotic to the mid-transverse colon.

What should you do in this situation?

Are there morally defensible limits to parental decision-making?


FINAL QUESTIONS

Medical Error

As the operating surgeon, I am legally responsible to:

  1. Obtain all information about the patient before starting the operation.

  2. Evaluate and interpret all radiology tests personally.

  3. Discuss all risks and complications that might occur, such as absence of the appendix.

  4. Discuss common and rarer serious complications with the family to their level of understanding.

The physician's disclosure of medical error

  1. Is determined and limited by the hospital legal/risk management team who should be consulted prior to any disclosure.

  2. Will increase the risk of a medical malpractice action being initiated.

  3. Will increase the physician's feeling of guilt regarding the error.

  4. Is an ethical obligation described in the AMA Code of Medical Ethics, independent of any risk of legal liability.

Would an apology be appropriate or useful in this case?

  1. No apology necessary. The patient had signs and symptoms of appendicitis. Laparoscopic examination was justified to rule this out.

  2. Yes. I would apologize for being misled by ultrasound, which has poor specificity for this diagnosis. Nevertheless, I would explain the operation had some usefulness for making certain the child was not at risk from appendiceal rupture.

  3. No apology necessary. Medical diagnosis is not an exact science. We did an appropriate workup, with history, exam, blood tests and imaging studies. The parents offered no knowledge of appendectomy in infancy, and the record was not available for our review. The laparoscopic exploration was appropriate, given the circumstances.

  4. Yes. I would express regret that surgical exploration was made necessary by unavailability of the operative note from 10 years previously. Given the circumstance of incomplete historical information, however, I would add that laparoscopic exploration was useful, in my opinion, to interpret the other signs suggesting appendicitis.

The Disruptive Surgeon

Identify the Disruptive Surgeons listed below.

  1. Dr. Smith loses his temper and ‘throws a fit’ at the OR front desk scaring the OR staff.

  2. Dr. Jones is frequently seen drunk publically and has had several DUIs. There is also concern that his quality of care is sliping.

  3. Dr. Murray often strongly disagrees with the Department Head especially at monthly Department meetings.

  4. Dr. Early is very confrontational with Dr. Beam and they are often seen arguing loudly in the OR.

  5. Dr. Jay frequently criticizes the administration for inadequate resources and the nursing staff for poor quality of care.

The “hidden curriculum” in medical education refers to:

  1. Formal training in ethics.

  2. Informal training in ethics.

  3. Formal training in professionalism.

  4. Informal training in professionalism.

  5. What is taught by observing the daily behavior of health care professionals.

Richard’s behavioral changes are best addressed:

  1. By "collegial intervention" by a staff member Richard respects and considers a friend.

  2. By reporting Richard to a Standards of Behavior committee or Board.

  3. By demanding Richard undergo medical and psychological evaluation - including assessment for substance abuse - because of the dramatic behavior changes.

  4. Through the Surgery Peer Review process.

End of Life Care

The operative findings include necrosis of all but 10cm of proximal jejunum and necrosis of the cecum and ascending colon with viability of the remainder of the colon.

What should you do in this situation?

  1. Close the abdomen and inform the parents that comfort care should be done.

  2. Close the abdomen, institute aggressive medical treatment, and plan a second-look laparotomy in 24 hours.

  3. Resect all necrotic bowel and construct stomas.

  4. Leave the OR and speak with the parents about the poor prognosis, advising that no further aggressive treatment should occur.

Caroline’s parents insist that all aggressive treatment be given to their infant. On the third postoperative day, the infant has massive edema and she remains on oscillatory ventilation, high dose pressors, and there is minimal urine output. The stomas are purple in color and their viability is doubtful. You and the neonatologist meet with the parents and explain that Caroline is in very critical condition. The parents request that you reoperate and remove any nonviable bowel. They believe that a bowel transplant in the future will “save” their infant.

  1. Inform the parents that Caroline is dying and that comfort care should be instituted.

  2. Refuse to perform any more surgery for Caroline and tell the parents that, if they insist on another operation, you will transfer the care to a different pediatric surgeon.

  3. Agree to continue all aggressive medical measures to sustain Caroline, but not to perform another operation.

  4. Ask your partner to meet with the parents and emphasize that their infant is dying and that they should stop aggressive treatment.

  5. Request a consultation from your hospital’s ethics committee.

Parents of infants with extensive necrotizing enterocolitis and extreme short bowel syndrome should:

  1. Have the authority to make all treatment decisions for their infant, even if these decisions are counter to their physicians’ recommendations.

  2. Have limits placed on their decision making authority when the infant is clearly in a terminal situation and has a “dismal” prognosis.

  3. Request an ethics consultation when there is disagreement/conflict with the treating physicians about the recommended plan of care.

  4. Request that their infant be evaluated by another pediatric surgeon when there is disagreement/conflict about the recommended plan of care.

Bibliography

Professionalism

  1. Inui TS. A Flag in the Wind: Educating for Professionalism in Medicine. Washington, DC: Association of American Medical Colleges; 2003

  2. AAP Policy Statement, Professionalism in Pediatrics: Statement of Principles

  3. Lawrence W. Is our level of professionalism where it should be? Bull Americ Coll Surg. 2004:89:21-25.

Medical Error

  1. Lazare, Aaron. Apology in Medical Practice: An Emerging Clinical Skill.  JAMA 2006; 296 (11); 1401-4.

  2. Mazor, KM; Reed, GW; Yood, RA; et. al. Disclosure of Medical Errors: What Factors Influence How Patients Respond? J Gen Intern Med. 2006; 21(7); 704-710.

  3. Berlinger N. Avoiding cheap grace: medical harm, patient safety and culture of forgivness. Hasting Cent Report 2003 Nov-Dec 28-36

  4. Krizek T.J. Surgical error: ethical issues of adverse events. Arch Surg 2000; 138: 1359- 1366

  5. Manzor KM, Simon SR, Gurvitz JH. Communicating with patients about medical errors; a review of the literature. Arch Intern Med 2004; 164: 1690-1697.

The Disruptive Surgeon

  1. Samenow CP, etal.  A CME course aimed at addressing Disruptive Physician behavior, The Physician Executive, Jan-Feb 2008, pgs 32-40)

  2. Leape LL and Fromson JA.  Problem Doctors: Is there a system-level solution?  Ann Intern Med. 2006;144:107-115.

  3. Hafferty FW, Franks R. The hidden curriculum, ethics teaching, and the structure of medical education. Acad Med. 1994; 69(11): 861-871.

  4. Inui TS. A Flag in the Wind: Educating for Professionalism in Medicine. Washington, DC: Association of American Medical Colleges; 2003

  5. The No Asshole Rule,  Robert I Sutton, PhD, Warner Business Books 2007

  6. Take the Bully by the Horns, Sam Horn, St Martins Griffin 2002

End of Life Care

  1. Lantos J: When Parents Request Seemingly Futile Treatments for Their Children. Mount Sinai Journal of Medicine 73:587-589, 2006.

  2. Clarke CM: Do Parents or Surrogates Have the Right to Demand Treatment Deemed Futile? An Analysis of the Case of Baby L. Journal of Advanced Nursing 32:757-763, 2000.