Ethics in Anesthesia: Intraoperative and Postoperative Considerations

Ethics in Anesthesia: Intraoperative and Postoperative Considerations

During an operation, ethical issues pertaining to the administration of anesthesia frequently emerge. Indeed, many concerns from the preoperative consultation have impacts on the intraoperative period. Furthermore, as anesthesia becomes increasingly perioperative, the importance of these concerns in the intraoperative period has also grown. Even in the postoperative period, the anesthesiologist continues to have responsibilities to the patient.

The intraoperative period often requires doctors to think quickly, and sometimes conflicting opinions between doctors emerge. A paper by Harahan notes that some surgeons still hold onto a “captain of the ship” tendency, which anesthesiologists should be careful to manage [1]. Throughout the procedure, Harahan suggests, anesthesiologists should keep a positive and team-oriented demeanor.

The importance and implications of professional communication in the perioperative period also extend to the patient. Even when a patient is under anesthesia and unconscious, doctors should be mindful of what they say in the operating room [2]. Indeed, while the failure rates for amnestic drugs are low—around 0.1% according to a paper by Pryor et al., the extent of conscious processing under amnestic drugs is not fully understood [3]. Indeed, there have been rare cases where patients under amnestic drugs have heard doctors’ comments and suffered psychological harm as a result [4].

An anesthesiologist’s workload during an operation is often inconsistent, alternating between moments of intensive work and long periods with low clinical workload. Indeed, a study performed by Weinger et al. found that idle time accounts for approximately 40% of a surgery [5]. During these periods, doctors often engage in non-operative tasks. In a study by Slagle et al., 35% of anesthesiologists spent at least part of the perioperative period reading [6]. While the study did not find a decrease in vigilance among those who read during downtime, the question of what constitutes acceptable behavior during these uneventful periods is one of intense debate in the medical community.

Patients with do-not-resuscitate orders also present significant ethical concerns during the intraoperative period. In a Mayo Clinic study, 18% of anesthesiologists said that they believed that DNRs should be automatically suspended intraoperatively [7]. While many of these concerns can be easily rectified by implementing an alternative DNR during a preoperative consultation, emergency situations may not allow for the creation of a perioperative DNR. In these cases, previously established advance directives can cause ethical issues for anesthesiologists [8]. Inhaled and intravenous anesthetics can both cause myocardial depression, cardiac dysrhythmias, and hemodynamic instability, all of which are normally followed by routine resuscitation from the anesthesiologist. If the patient has a DNR that specifies no resuscitation, doctors may find themselves conflicted about how to proceed. In these situations, Sumrall et al. suggests that it is important to review a hospital’s procedures, which often encourage doctors to proceed as though no DNR is in place until alternative guidance can be provided [8].

While anesthesiologists may be inclined to hand off postoperative consultations to the surgeon, Harahan cautions against this, particularly in the case of pain relief, which he says is best handled by anesthesiologists [1]. Many options exist for pain relief, but the most common postoperative pain therapy is still an opioid such as morphine, hydromorphone and fentanyl. However, a study by Brummett et al indicates that between 5.9 and 6.5% of cases where opioids are prescribed to opioid-naïve patients result in long-term opioid use [9]. According to an article by Rieder, doctors who manage patient pain should assume responsibility for ethically prescribing and managing their patients’ use of opioids [10]. By preparing for potential ethical conundrums, maintaining professional behavior during the operation, and continuing care after the surgery, doctors can mitigate ethical concerns related to anesthesia.

References

[1] Hariharan, Seetharaman. “Ethical Issues in Anesthesia: the Need for a More Practical and Contextual Approach in Teaching.” Journal of Anesthesia, vol. 23, no. 3, 2009, pp. 409–412.

[2] Kopp, Vincent J, and Audrey Shafer. “Anesthesiologists and Perioperative Communication.” Anesthesiology, The American Society of Anesthesiologists, Aug. 2000.

[3] Pryor, Kane O, and James C Root. “Chasing the Shadows of Implicit Memory Under Anesthesia : Anesthesia & Analgesia.” LWW, Anesthesia and Analgesia, Nov. 2014.

[4] Glannon, Walter. “Anaesthesia, Amnesia and Harm.” Semantic Scholar, Medical Ethics, 2014.

[5] Weinger MB, Herndon OW, Paulus MP, Gaba D, Zornow MH, Dallen LD: Objective task analysis and workload assessment of anesthesia providers. Anesthesiology 1994; 80:77–92.

[6] Slagle, Jason M, and Matthew B Weinger. “Effects of Intraoperative Reading on Vigilance and Workload during Anesthesia Care in an Academic Medical Center.” Anesthesiology, The American Society of Anesthesiologists, 1 Feb. 2009.

[7] Clemency, Mary V, and Nancy J Thompson. “Do Not Resuscitate Orders in the Perioperative Period:… : Anesthesia & Analgesia.” Anesthesia & Analgesia, International Anesthesia Research Society, Apr. 1997.

[8] Sumrall, William D, et al. “Do Not Resuscitate, Anesthesia, and Perioperative Care: A Not So Clear Order.” The Ochsner Journal, The Academic Division of Ochsner Clinic Foundation, 2016.

[9] Brummett, Chad M, et al. “New Persistent Opioid Use After Minor and Major Surgical Procedures in US Adults.” JAMA Surgery, U.S. National Library of Medicine, 21 June 2017.

[10] Reider, Travis N. “Opioids and Ethics: Is Opioid-Free the Only Responsible Arthroplasty?” Springer, HSS Journal, 13 Dec. 2018.