Article

Ethical Issues in Surgical Critical Care: The Complexity of Interpersonal Relationships in the Surgical Intensive Care Unit

Journal of Intensive Care Medicine 1-9 ª The Author(s) 2015 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/0885066615585953 jic.sagepub.com

Malini D. Sur, MD1,2 and Peter Angelos, MD, PhD1,2,3

Abstract A major challenge in the era of shared medical decision making is the navigation of complex relationships between the physicians, patients, and surrogates who guide treatment plans for critically ill patients. This review of ethical issues in adult surgical critical care explores factors influencing interactions among the characters most prominently involved in health care decisions in the surgical intensive care unit: the patient, the surrogate, the surgeon, and the intensivist. Ethical tensions in the surgeon–patient relationship in the elective setting may arise from the preoperative surgical covenant and the development of surgical complications. Unlike that of the surgeon, the intensivist’s relationship with the individual patient must be balanced with the need to serve other acutely ill patients. Due to their unique perspectives, surgeons and intensivists may disagree about decisions to pursue life-sustaining therapies for critically ill postoperative patients. Finally, although surrogates are asked to make decisions for patients on the basis of the substituted judgment or best interest standards, these models may underestimate the nuances of postoperative surrogate decision making. Strategies to minimize conflicts regarding treatment decisions are centered on early, honest, and consistent communication between all parties. Keywords surgical ethics, ethical issues, surgical critical care, surgical intensive care unit, surgeon–intensivist relationship, futility, surrogate decision making

Introduction The evolution of the modern surgical intensive care unit (ICU) has enabled critically ill patients who otherwise would have perished to survive. Yet it has also created a set of interpersonal relationships far more complex than the traditional surgeon– patient dyad. With the mounting use of intensive care at the end of life,1 the study of ethical issues specific to surgical critical care is increasingly relevant to surgeons performing high-risk operations as well as those trained to provide dedicated intensive care. In this review, we will explore the relationships among the 4 characters most prominently involved in decision making for the surgical ICU patients: the patient, the surrogate, the surgeon, and the intensivist. Although these are not the only participants in the care of critically ill surgical patients, an examination of other influences such as those of nursing and consultant teams is beyond the scope of this article. Central to the most challenging ethical situations in the surgical ICU is the question of when to transition from a curative to a palliative model of care for a postoperative patient who may be near the end of life but intubated, sedated, and unable to actively participate in ongoing care decisions. Under such circumstances, the judgments of physicians and surrogates are informed by preexisting relationships with the patient. With a focus on the tensions between relevant ethical principles, we

will examine in turn the surgeon–patient relationship, the intensivist–patient relationship, the surgeon–intensivist relationship, the patient–surrogate relationship, and the physician–surrogate relationship. We will conclude with potential approaches to minimizing conflicts among these key players.

Ethical Issues in the Surgeon–Patient Relationship Much has been written about the personality traits and work ethic of surgeons. Surgical residencies are among the longest 1 Department of Surgery, The University of Chicago Medicine, Chicago, IL, USA 2 MacLean Center for Clinical Medical Ethics, The University of Chicago, Chicago, IL, USA 3 Bucksbaum Institute for Clinical Excellence, The University of Chicago Medicine, Chicago, IL, USA

Received November 24, 2014, and in revised form March 14, 2015. Accepted for publication April 13, 2015. Corresponding Author: Malini D. Sur, Department of Surgery, The University of Chicago Medicine, 5841S, Maryland Avenue (MC-6040), Chicago, IL 60637, USA. Email: [email protected]

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in duration and hours, demanding a high level of commitment to patient care. Moreover, the ability of surgeons to help or hurt patients directly with their hands leads to a strong sense of personal responsibility for surgical outcomes. In his ethnographic study of surgeons at an academic medical center in the 1970s, sociologist Charles Bosk described the heightened sense of ownership surgeons feel for their patients.2 Operative cures and smooth recoveries are seen as personal successes, while intraoperative complications and poor outcomes are seen as personal failures. When surgical residents across the country present complications at morbidity and mortality conferences each week, they are asked to identify what was done wrong and what could have been done differently. They are taught to avoid ‘‘blaming the patient’’ with suggestions that the patient’s own disease-related factors caused a negative outcome. Complications are usually attributed to technical and judgment errors by the surgical team, no matter how serious the underlying disease process.

Elective Surgery The role of the preoperative covenant. The surgeon’s relationship with his or her patient is significantly shaped by the circumstances under which the two parties meet. A clear distinction exists between patients undergoing elective surgery and those undergoing emergency surgery. In preparing for a typical elective case, a surgeon meets his or her patient at least once in the outpatient setting. Most commonly, the patient is ambulatory, cognitively intact, and able to actively engage in the discussion regarding surgery. In turn, the surgeon has the opportunity to learn about the patient as a whole person—where he or she is from, what he or she does for a living, and whom he or she trusts to accompany him or her to the visit. The surgeon hears a live narrative of the patient’s personal and clinical history that will inform the surgeon’s interactions with him or her and his or her surrogates throughout the perioperative period. After the surgeon has heard the relevant elements of the preoperative narrative and reviewed the necessary physical, laboratory, and radiographic findings, the surgeon lays out the indications and technical aspects of the proposed operation. In doing so, the surgeon actively seeks authorization to conduct carefully coordinated penetrating trauma upon another human being. Bosk came to see this permissible traumatic intervention as the basis of the profoundly intimate doctor–patient relationship that sets surgeons apart from other physicians. Moreover, the only rationale for such an intervention is anticipation of a good outcome: ‘‘The expectation of success is the background understanding which legitimates surgical action.’’2 In return for the patient’s complete trust in his or her skills and clinical judgment, the surgeon pledges to fight for the patient’s well-being. In more recent studies of critical care physicians and surgeons in the United States, anthropologist Joan Cassell depicts surgeons as maintaining a ‘‘covenantal ethic’’ in which they make a lasting ‘‘promise to battle death on behalf of [their] patient.’’3 Although Cassell focuses on the ‘‘covenant of care’’ as it plays out in the management of postoperative surgical ICU

patients, the initial terms of the contract between the surgeon and the patient are undoubtedly set in the first office visit when the risks and benefits of surgery are discussed. Through individual interviews and national surveys, Schwarze et al demonstrated that surgeons in high-risk fields attempt to gain surgical ‘‘buy-in’’ during the preoperative encounter. In return for vowing to defend life and limb, surgeons ask their patients not only to undergo the high-risk operation itself but also to accept the perioperative care necessary to allow the operation to ultimately succeed.4 Feeling personally responsible for the ultimate success or failure of the operation, the surgeon needs to believe that the patient will stick with him or her through the potential setbacks of the postoperative course until full recovery is achieved. This need reflects the tension between beneficence, nonmaleficence, and respect for persons. Patients’ autonomous decisions affect the balance between health risk and health benefit of a given operation. For example, if a patient with chronic lung disease wishes to undergo major abdominal surgery for a cancer but refuses any mechanical ventilation in the postoperative period, the risk of short-term respiratory compromise and death may outweigh the benefit of long-term cancer-free survival. It has been shown that when a patient requests to preemptively limit life-sustaining postoperative treatments, some surgeons report they refuse to perform the surgery altogether.4,5 Individual surgeons appear to evaluate the appropriateness of such requests, sometimes granting more rights to limit life-sustaining therapies to patients with terminal illnesses than to those with better prognoses.4 These judgments might be seen as undermining patient autonomy by eliminating the patient’s opportunity to alter goals of treatment based on specific postoperative outcomes.6 Nonetheless, physicians have historically been granted the right to withhold unreasonable care even when this conflicts with patients’ or surrogates’ wishes.7 Unfortunately, detailed preoperative discussions explicitly addressing wishes regarding life-sustaining therapies measures after elective high-risk surgery appear to be infrequent. In a qualitative study of preoperative conversations, surgeons often alluded to the heavy commitment required of the patient to get through ‘‘big surgery’’ and its associated complications, including the possibility of an ICU stay, but rarely explicitly discussed the likelihood of prolonged life support.8 A larger survey found that only half of responding surgeons reported regularly discussing advance directives in the preoperative setting.5 Meanwhile, patients expressed vague fears and raised procedural questions but tended to avoid specifically asking about the use of life-sustaining therapies. By the end of the encounter, surgeons had generally assumed that their patients had adequately understood the perioperative risks and had committed to the operation—that is, they felt that surgical buy-in had been achieved.8 Deconstructing the preoperative discussion offers insight into how it might influence the surgeon’s approach to the patient in the event of a complicated postoperative course requiring extended life support. Surgeons who believe that their patients fully bought into the operation and its attendant risks during the preoperative visit may be less comfortable

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withdrawing life-sustaining therapies in the setting of an adverse postoperative course. In the absence of specific directives to withhold or terminate treatment at previously agreed upon time intervals, the surgical covenant to get the patient through the operation would favor prolonging aggressive measures. Withdrawal of treatment might more likely be seen as abandoning the patient. Indeed, one survey of American surgeons in high-risk specialties found that those who felt comfortable withdrawing life support on postoperative day 14 also often reported making informal contracts about postoperative limitations of care with their patients.9 Thus, enhanced surgeon–patient communication prior to high-risk elective cases may increase surgeons’ willingness to limit postoperative interventions by reassuring them that such limitations would be consistent with the patients’ goals and values. The role of surgical error. Another consideration in the surgeon– patient relationship is the role of surgical error. The profoundly negative psychological effect of perceived error on the surgeon is not a recent discovery. Full ownership of the patient and personal responsibility for complications is a core aspect of the surgical work ethic. Bosk carefully described the atmosphere of morbidity and mortality conferences in which the responsible attending surgeon is expected to show repentance for his part in a poor clinical outcome. Metaphorically, Bosk called this the act of ‘‘wearing the hair shirt.’’2 The 1999 Institute of Medicine Report, To Err is Human, shed light on the devastating consequences of medical errors on American health care and added momentum to the patient safety movement as well as resident work hour restrictions. More recently, emotional distress arising from personal responsibility for perceived medical errors has been linked to surgeon burnout and suicidal ideation in a nationwide survey.9,10 If surgeons take their complications so personally, it follows that they may perceive their patients’ struggle to endure a difficult postoperative course as their own struggle. This might further discourage termination of prolonged life-sustaining medical treatments in some patients. Indeed, one study found that surgeons reported being considerably less willing to withdraw life support after a hypothetical operation when an error was directly implicated in the poor outcome.11 When the patient’s deterioration is attributed to the surgeon’s failures in technique or judgment, the preoperative covenant might appear threatened. In this situation, maintaining the patient’s life in hopes of some eventual clinical benefit, however minimal, might represent the surgeon’s final attempt to honor the terms of the covenant. When this is attempted despite patient or surrogate preferences to withdraw care, the principles of nonmaleficence and beneficence have been prioritized over respect for persons. The surgeon may have difficulty recognizing that the first two principles lose meaning when the life of the patient, in the eyes of the patient or the surrogate, is no longer worth living.

Emergency Surgery Thus far we have discussed the ethical issues within the surgeon–patient relationship in the elective setting, where an

implicit preoperative covenant often weighs heavily on subsequent critical care decision making. When meeting a critically ill patient in the emergency department, however, the surgeon establishes the relationship in a rather different context. Two aspects of that encounter are especially challenging. First, because surgical emergencies demand immediate assessment and intervention to protect life and limb, time is usually limited. Second, surgeons and patients are usually meeting for the first time in an emotional situation with no prior understanding of each other. When a young, previously healthy patient is found to have a surgically curable pathology, all involved parties usually favor proceeding with emergency surgery. However, when a surgical emergency occurs in a geriatric patient or a patient with severe, preexisting chronic illnesses, surgical decision making is more complex. In emergencies involving a frail, elderly patient, the ability of the surgeon to assess the patient’s risk of tolerating surgery is usually inadequate. Frequently, there is no time for formal evaluation by cardiac or pulmonary specialists to help with medical optimization prior to a high-risk procedure. Time also constrains patients and surrogates who may have little opportunity to thoughtfully weigh risks and benefits in the context of life goals and values. Because there is little opportunity to learn more about treatment options or obtain a second opinion, the patient is more vulnerable in the emergency setting than in the elective setting. To complicate matters, many critically ill patients are unable to speak for themselves. In cases of blunt and penetrating trauma requiring emergency surgery, the patient is often brought to the emergency department alone. Even when family members are present, the surgical team may not be able to confirm that an accompanying relative is indeed the patient’s intended surrogate. If advance directives have not been previously discussed, surrogates may struggle with the weight of having to make an immediate decision regarding life or death and bear the consequences of such a decision. In the emergency setting, then, the terms of the preoperative covenant are altered. Because the surgeon must accept the case with incomplete information about the patient’s underlying disease process and overall level of resilience, the sense of personal responsibility for outcomes may be diminished. The surgeon hopefully discusses important postoperative complications including that of prolonged life support, but given the known challenges with nuanced preoperative conversations in the elective setting, it is likely that comprehensive communication in the emergency setting is less frequently performed. To ease a tense situation, some surgeons might avoid a detailed listing of all possible outcomes that may further frighten the patient and family, stressing the need for immediate surgery in fending off imminent death. Others might instead ‘‘hang the crepe,’’ exaggerating risks to shift responsibility for negative outcomes onto the decision maker and away from the surgeon. Accurate prognostication would be preferred over such a strategy.12 It should also be acceptable for patients and surrogates to pursue surgery upfront while maintaining the option to shift goals of care if operative findings are catastrophic or the postoperative response poor.13 Interestingly, evidence suggests that

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practitioners of high-risk surgery do indeed feel significantly more comfortable withdrawing life-sustaining therapies after emergency surgery than after elective cases.11 Further research is needed to better understand the surgeon–patient relationship in emergency cases.

Ethical Issues in the Intensivist–Patient Relationship The typical surgical ICU patient typically has not one but two primary doctors, for the surgeon’s principal partner in medical decision making is the intensivist. In the majority of hospitals in the United States, intensivists are trained in internal medicine with additional specialization in critical care. In 1997, less than 10% of intensivists reported primary training in anesthesiology or surgery.14 Although the fraction may be larger today, surgical intensivists remain a minority in the field. Regardless of their background, intensivists bring unique concerns to patient management. From her ethnographic studies, Cassell deduced that the primary distinguishing feature of intensivists is that they ‘‘think in terms of distributing a limited resource among members of a community.’’15 Unlike the surgeon, the intensivist must regularly weigh duties to promote beneficence, nonmaleficence, and respect for persons against the fourth bioethical principle—justice. An intensivist is typically responsible for multiple active, critically ill patients as well as deteriorating floor patients needing increased monitoring. An intensivist may reject a patient referred for admission to the ICU care if he or she judges that the patient does not meet certain criteria for clinical acuity. Such judgments may be influenced by resource availability. Beds, nursing care, medications, and supplies are vital but finite resources that must be reserved for those whom they will benefit the most. Appropriate triage is crucial, as patients admitted to the ICU have significantly lower mortality rates than those who are referred but not accepted.16 It should be noted that perspectives on resource allocation ethics differ across nations.17 Although intensivists in countries with universal publically funded health care tend to have broad powers to make care decisions using rationing arguments, those in a market-based system are deterred from using the ‘‘R-word’’ explicitly in clinical decisions.18 Nonetheless, a United States task force investigation identified 3 major influences on decisions to allocate care in the ICU: external constraints, medical indications, and clinical judgment.19 The last category merits special attention, since subjective factors may be at play. If surgeons may be seen as warriors against death, intensivists may be seen as warriors against suffering.15 They tend to view a relentless battle against death in the face of overwhelming odds not as heroic and honorable but as expensive, painful, and potentially disrespectful to the patient.20 This perspective values quality of life over quantity of life. Judgments about quality of life, however, are inherently value laden and risk compromising the patient’s right to decide what constitutes a good life for themselves. In one study of patients who had survived an ICU stay and families of patients

who had died in the ICU, the vast majority reported they would undergo ICU care again to achieve just one additional month of life, regardless of age or functional status.21 Physicians’ evaluations of the appropriateness of ICU care, however, mirrored their own personal preferences.22 Having passed rigorous intellectual tests in order to practice medicine, physicians may disproportionately value cognitive abilities. Some patients and surrogates may instead value even the most basic forms of conscious engagement and interaction. Therefore, intensivists must remain particularly vigilant against encroaching on patient autonomy as they try to avoid perceived suffering. Finally, a unique feature of the intensivist–patient relationship arises from the common practice of rotating physician coverage in many ICUs. While the surgeon performing elective surgery meets the patient in the outpatient setting, sees his or her disease firsthand in the operating room, and follows him or her postoperatively, the intensivist cares for the patient for shorter periods of time determined by institutional arrangement. Cassell observed that individual intensivists had different styles of management such that care plans could change significantly from week to week.15 Some evidence does suggest that fragmentation of care, defined as the fraction of care given by physicians other than the primary inpatient physician, significantly increases length of stay.23 Standardized hand offs between intensivists are rare24 and continuity of care has also been proposed as a quality indicator for end-of-life care in the ICU.25 But like their surgical colleagues, intensivists face ethical tensions between the obligation to provide the best patient care and the need to prevent professional burnout from nonstop coverage.26 Interestingly, one prospective study found decreased burnout but no significant differences in mortality with an interrupted schedule compared to a continuous schedule.27 The impact of interrupted coverage on the intensivist–patient relationship, however, remains uncharacterized.

Ethical Issues in the Surgeon–Intensivist Relationship The dynamic between surgeons and intensivists depends on the organizational structure of the ICU. In an open unit, the surgeon remains in charge of the patient’s postoperative care while the intensivist is available for consultation. In a closed or intensivist-led format, the intensivist takes over primary care of the patient while the surgeon makes recommendations. A mixed model allows for both attending physicians to collaboratively care for the patient. Around the world, closed formats are associated with decreased mortality and improved resource utilization.28-31 Yet they are also fertile ground for physician disagreements, with conflict reported by 60% of surgeons in closed units versus 41% of those in open units.32 Because intensivist-led care has been increasingly promoted as a quality measure, surgeons and intensivists will need to work side by side more often in the future. A hypothetical case that might stir disagreement between the surgeon and the intensivist involves an older patient with

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multiple comorbidities who undergoes high-risk elective surgery and develops complications requiring critical care management.20 Two weeks pass, but ventilator settings fail to improve and a tracheostomy must be considered. Artificial feeds are started or total parenteral nutrition is initiated via a central line. Low-dose vasopressors, intermittent dialysis, or other intensive therapies may be needed as well. Talk of transitioning goals of care from cure to comfort begins. The surgeon adheres to the preoperative contract, fighting to get the patient through the risky postoperative period and eventually regain some measure of quality of life. A sense of personal responsibility for the negative postoperative course further strengthens the resolve to pursue maximal interventions and avoid premature withdrawal of care. Meanwhile, the intensivist sees a patient who is unlikely to regain an already limited baseline functional status. Knowing that other sick patients may receive greater benefit from critical care resources, it may seem wasteful—if not futile—to allocate resources such as nursing care, medications, and transfusions to a patient with a poor anticipated outcome. Discordant definitions of futility, then, is a key potential source of conflict in the surgeon–intensivist relationship. The ‘‘futility movement’’ gained momentum in the 1990s as a professional response to frustrating cases in which physicians felt forced to deliver nonbeneficial treatment to respect the autonomy of patients and surrogates.33 Hoping to reduce inefficient resource utilization, some hospitals created policies allowing physicians to withdraw or withhold treatments they considered futile even without consent from patients and surrogates. There was just one hitch—who and what defined futility? Some proposed that a therapy should be considered futile if it had failed in the last 100 cases.34 Based on the premise that ‘‘medical futility must rest upon probability estimates,’’ prognostic scoring systems such as the Acute Physiology and Chronic Health Evaluation (APACHE) were designed.35 Through good use of statistics, it seemed, the ethical dilemmas of end-of-life care decisions could be more easily resolved. Yet complex mathematical analyses are problematic for several reasons. First, as noted earlier, treatments perceived as futile by a physician may not be seen as futile by a patient or surrogate.36 Futility can only be defined relative to a specific goal and such goals are unique to each patient. Second, physicians often overestimate their ability to prognosticate accurately. Scoring systems help predict the likelihood of an outcome within a population but fail to determine the outcome of the individual at hand. In one study, the ability of ICU staff at a Level One Trauma Center to predict survival of patients with trauma was poor on initial evaluation and unrelated to team members’ level of experience.37 Another analysis found that only 52% of the medical ICU patients predicted by at least one staff member to die before discharge actually went on to die while in the hospital.38 Data from the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) showed that nearly half of the patients deemed ‘‘moribund’’ preoperatively were actually alive one month

after surgery.39 In short, physicians’ expectations of patient survival do not universally match actual outcomes. Unsurprisingly, physicians also disagree about prognosis. In one medical ICU study, 75% of patients had discordant predictions—with one clinician predicting survival and another predicting death—while 15% of patients unanimously predicted to die survived to discharge.38 Such prognostic disagreements may contribute to surgeon–intensivist conflict. In a qualitative study of surgical ICU staff, surgeons had a 90% rate of satisfaction with their own communication to patients and families regarding prognosis, while intensivists had a mere 23% rate of satisfaction with surgeons’ communication about the topic.40 Surely, it is plausible that this discrepancy is related to divergent expectations of the patient’s life span and quality of life. The prevalence of such conflict further supports the role of detailed preoperative discussions in which surgeons and patients speak frankly about evidence-based estimates of long-term survival and risks of rare complications requiring prolonged life-sustaining therapies while identifying surrogates and clarifying advance directives. It should be noted that the surgeon–intensivist cultural dichotomy might eventually be bridged by the growing presence of surgical intensivists. Care in units led by surgical intensivists has been linked to lower mortality rates after trauma.41 As a trained ‘‘bystander’’ surgeon, the surgical intensivist can appreciate the bond between the patient and the operating surgeon in terms of the preoperative covenant. Given their training, surgical intensivists may have an ideal understanding of the surgical pathology, details of the intraoperative course, and expected outcomes. Simultaneously, as physicians specially trained in critical care management, they may have a deeper appreciation for the finitude of ICU resources and the suffering caused by repeated invasive procedures of unclear benefit. As some have suggested, surgical intensivists may be ‘‘uniquely qualified . . . to mediate the choice of a satisfactory management plan’’ for critically ill surgical patients.42 Further studies are needed to understand surgical intensivists’ negotiation of end-of-life issues and the relatively recent relationship between primary surgeons and surgical intensivists.

Ethical Issues in the Patient–Surrogate Relationship We have thus far examined ethical issues affecting the interactions between patients, surgeons, and intensivists. Since critically ill patients are typically unable to make decisions for themselves, we turn now to consider the role of the surrogate decision maker. Although the Patient Self-Determination Act requires hospitals to provide patients with information about their right to have an advance directive, most institutions do not require patients undergoing surgery to name a surrogate or have directives in place. One prospective study of hospitalized older adults demonstrated that only 7.4% had a living will and 25% had a documented surrogate.43 Responsibility for surrogate

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decision making overwhelmingly fell to adult children or spouses. Two models have traditionally been used for surrogates to make decisions on behalf of patients: the substituted judgment standard and the best interests standard. Ideally, the surrogate makes decisions for the patient based on substituted judgment by using the patient’s previously stated wishes to choose treatments on behalf of the patient. However, clear verbal or written advance directives are often missing and surrogates predict patients’ preferences with only 68% accuracy, leaving considerable room for error.44 Patients’ preferences for life-sustaining therapies are also contextually dependent and may change with health status.45 When substituted judgment is not possible to perform, the best interests standard may be invoked. Here, the surrogate makes decisions based on what is deemed best for the patient—a concept fraught with subjectivity and frequently perceived differently by clinicians and surrogates. These two traditional ethical models of surrogate decision making emphasize the duty of surrogates, like physicians, to respect patient autonomy and promote beneficence. Both may fall short of accounting for the complexity of surrogate decision–making in the postoperative setting. Surrogates, much like health care providers, often have special considerations that influence their relationship with patients. In interviews with surrogates of older admitted patients, Fritsch et al showed that both patient-centered factors and surrogate-centered factors influenced the decision-making process. Patient-centered factors include aspects of the traditional models: prior input from the patient, past knowledge of the patient that could be used to infer wishes, and assessments of the patient’s best interests. Surrogate-centered factors include the surrogate’s own interests, personal health care preferences, feelings of obligation and guilt, religious or spiritual beliefs, and family consensus.46 For example, a surrogate who feels he or she is personally unable to care for a chronically ill patient might permit transfer to a skilled nursing facility, even if the patient would have specifically opposed such a decision. Numerous studies have further explored ethnic and religious influences on surrogates’ decisions, noting that certain cultures seem to favor interventions at the end of life more than others.47,48 Some cultures outright reject the West’s reverence for patient autonomy and the idea that one relative can serve as the sole decision maker.49,50 Birth order and associated filial expectations have also been shown to affect the decision-making process.51 Thus, every patient–surrogate relationship has a unique social history that may in turn inform the physician–surrogate relationship.

the surgeon, and understands the operative risks. Spouses and adult children who had discussed the decision to undergo surgery with the patient may even be regarded as participants in the informed consent process. The intensivist, on the other hand, meets the surrogate for the first time in the emotionally charged ICU setting. Without the benefit of well-established trust, the intensivist must start from scratch to build a relationship and gain the surrogate’s confidence. As presented earlier, a typical challenging surgical ICU case features an older patient with multiple comorbidities who requires prolonged life-sustaining treatment postoperatively. If this occurs early after complications from elective surgery, there may be surgeon–intensivist discordance about prognosis that is undoubtedly agonizing for the surrogate. Such a situation often breeds distrust in physicians, which has been linked to surrogates preferring even more control over life support decisions.52 On the other hand, surrogates may doubt predictions of outcomes even when surgeons and intensivists agree. Surveys of surrogates of critically ill patients found that 64% expressed such doubts, with 32% favoring continued life support when given a less than 1% survival estimate and 18% choosing the same when the patient was given no chance of survival.53 Surrogates’ perceptions of prognosis are not only based on physicians’ estimates but also on considerations of the patient’s character, prior struggles with illness, and physical appearance, as well as surrogate’s own optimism, intuition, and faith.54 Therefore, even in the setting of consistent predictions of prognosis, surrogate decision making is not straightforward. Additionally, physicians do not always relate to surrogates for different patients in a consistent manner. When presented with hypothetical vignettes in one large survey, critical care physicians’ perceptions of appropriateness of care were linked to judgments about surrogates. Resuscitation was deemed less indicated if the patient–surrogate relationship was not close or if the surrogate’s understanding of the medical situation seemed to be poor.55 Some have argued that physicians actually have an obligation to protect the patient by evaluating surrogates for decisional capacity and surrogate decisions for appropriateness.56 However, physicians must be careful to avoid alienating surrogates while making these subjective judgments. Research suggests that conflict in the ICU is associated with surrogates’ dissatisfaction with the physician’s bedside manner and by the perception of discrimination within the health care setting.57

Ethical Issues in the Physician–Surrogate Relationship

Conflict that results from ethical tensions in the complex relationships between surgeon, intensivist, patient, and surrogate may be potentially minimized through a few potential strategies. Good communication between all parties should begin preoperatively whenever possible. This is the ideal time for the surgeon to characterize the nature of the disease, discuss the risks of life-altering surgical complications, clarify the identity of the surrogate, and review advance directives. Patients undergoing high-risk surgery should be prepared for the possible

Perhaps the most challenging interpersonal dynamic in the ICU is the physician–surrogate relationship. If the postoperative surrogate decision maker had been present at the patient’s preoperative visit, the surgeon is fortunate to have a preexisting relationship with him or her. Such a surrogate had hopefully witnessed the development of the preoperative contract, trusts

Conclusion

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need for an ICU admission, prolonged mechanical ventilation, and other life-sustaining therapies. Several criteria for defining high-risk surgical patients and high-risk operations may be utilized.58,59 Patients with significant underlying cardiovascular, pulmonary or renal disease, and those undergoing operations with the potential for significant blood loss, operative time, or anatomic challenges should appreciate the rare but distinct possibility of an untoward outcome that will require surrogates to make decisions about life-sustaining therapies. Patients with underlying life-limiting illnesses should be aware of their baseline prognosis prior to contemplating elective surgery. Surgeons’ and patients’ comprehension of perioperative risks may be aided with the use of online resources such as the ACS NSQIP surgical risk calculator and comprehensive geriatric assessments.60,61 Whenever possible, the surgical team should attempt to alert the surgical ICU staff to a potential new admission prior to rather than during an operation to maximize communication between teams. This offers the intensivist time to review the patient’s history and make arrangements for bed availability if needed. Operative participation or observation by ICU staff, when feasible, might also help with shared understanding of the disease, the operation, and the specific anticipated critical care needs. When caring for patients who become critically ill after surgery, members of the multidisciplinary health care team should aim to communicate regularly with each other in an honest and respectful manner. Personal animosity, mistrust, and communication gaps were the most common conflict-causing behaviors noted in a large survey of ICU clinicians.62 When possible, physician disagreements about treatment plans should be resolved before contradictory statements are given to the surrogate. Relevant evidence-based literature may be reviewed to help resolve differences in perceived prognosis. If two physicians cannot come to consensus after extensive discussion, consultation with a third physician or an ethics committee should be pursued. Interdisciplinary family meetings should be conducted early and repeated as often as deemed necessary. Ideally, these meetings involve the attending surgeon and intensivist as well as house staff, nurses, and social workers. All members may communicate beforehand to set a shared tentative agenda that remains flexible to adjust to surrogates’ needs.63 A checklist may be useful to ensure that discussions occur in a standardized fashion touching on all salient issues.64 Any written advance directives should be obtained and the legal surrogate should be identified. Discussion should aim to characterize the patient’s prior expressed wishes, values, and beliefs and the surrogate’s understanding of the patient’s condition and prognosis. If the patient’s prior wishes are not known, substituted judgment cannot be used, and the best interests standard may be drawn upon. Additional factors such as the surrogate’s own beliefs should be acknowledged. Treatment plans should be discussed with an explanation of realistic risks and benefits. If withdrawal of care is to be proposed, it is helpful to frame interventions as having a high risk-benefit ratio rather than introducing value-laden terms such as ‘‘futile’’ or ‘‘useless.’’

Data to support these recommendations should be shared when available. For example, a large investigation showed that feeding tube insertion does not improve survival in nursing home patients with dementia.65 Additionally, the idea of the ‘‘timelimited trial’’ of interventions should be explained to surrogates. For example, interventions such as dialysis for presumed temporary renal failure can be initiated with a plan to reassess the value of the intervention after a predetermined number of days. This can be a valuable way to frequently review and refocus the goals of care for the patient. If both the surgeon and the intensivist propose withdrawal of care but the surrogate is unwilling to proceed, it is useful to have a comprehensive understanding of the factors contributing to the surrogate’s perspective. The emotional burden of surrogate decision making should be acknowledged and chaplain support services should be proactively offered. Depending on the clinical scenario, it may be reasonable to allow the surrogate a period of time to cope with the patient’s deterioration. Multiple, daily, forced discussions about withdrawal of care risk isolating the surrogate and increasing hostility. Consultation with palliative care services may be helpful for surrogates who are open to transitioning to comfort care measures. If conflict remains after a trial period, ethics consultation is recommended. Although the advances of the last 3 centuries have radically enhanced our ability to treat and cure disease, they have also given rise to challenging ethical dilemmas within clinical medicine. In today’s ICU, the definition of a life worth living is revisited nearly every day. We are sure to face new questions and new conflicts as life-sustaining technology is further developed. It is our hope that understanding the ethical issues that impact the relationships between surgeon, intensivist, patient, and surrogate can foster good communication and informed decision making—human skills that enhance our health care system and cannot be easily replaced by technologic innovations. Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.

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