Putting the “No” in Non Nocere: Surgery, Anesthesia, and a Patient's Right to Withdraw Consent

MEDICAL ETHICS Putting the “No” in Non Nocere: Surgery, Anesthesia, and a Patient’s Right to Withdraw Consent CLAUDINE YEE, BS; REBECCA S. HIMMELWRIGHT, BS; WALTER KLYCE, BA; TINA SANKHLA, MD; GEORGE P. BAYLISS, MD THE CASE specifically asking that the procedure be aborted. Many Ms. K is a 53-year-old G2P1 with Stage IIIA endometrial ethics analyses center on the presence or absence of proper cancer who presented to the Women & Infants ambula- informed consent; fewer discuss withdrawal of consent.1 tory surgical unit for a bilateral salpingo-oopherectomy and However, the right to withdraw consent remains a standard lymph node dissection. In the pre-operative unit, a resident component of every informed consent protocol.2,3,4 The UK reviewed the standard informed consent protocol with the Department of Health offers a useful paradigm for such sit- patient, outlining the reasons for the procedure, the risks uations: “A person with capacity is entitled to withdraw and benefits of proceeding, and the risks and benefits of consent at any time, including during performance of a pro- doing nothing. The resident emphasized the necessity of cedure. Where a person does object during treatment, it is surgery to stage the cancer and prevent further spread. Ms. K good practice for the practitioner, if at all possible, to stop appeared anxious, but signed the consent form. The anesthe- the procedure, establish the person’s concerns and explain sia team then proceeded with their evaluation, determining the consequences of not completing the procedure.” It has that she had hypertension, type 2 diabetes, an anxiety disor- in fact been deemed more than just “good practice” for the der, a BMI of 58.2 kg/m2 and a Mallampati Class IV airway practitioner to stop the procedure – in a 2012 case, Pallaco- difficult for intubation. The team thus decided to proceed vitch v. Waterbury Hospital, the plaintiff sued on grounds of with an awake intubation, using video laryngoscopy to visu- battery after her request to stop a blood draw was ignored.5 alize the larynx with minimal sedation to reduce the risk of In this case, the patient’s initial refusal occurred before med- airway collapse. Ms. K agreed to the plan. ications which might interfere with her capacity had been The nursing staff then began preparing her for surgery, administered. At that moment, pausing preparations for the including inserting a peripheral IV for fluid and medication procedure would have been safe and possible from a medical delivery. On the first failed attempt, Ms. K cringed. After standpoint. Presuming that this patient was indeed attempt- the fourth unsuccessful needle stick, she became agitated ing to withdraw her consent, the team would have been vio- and said, “I don’t want to do this anymore” multiple times. lating her basic rights to autonomy and self-determination The crowd of IV nurses now assembled at her bedside reas- as well as opening themselves to medicolegal culpability. sured her and finally established access. The first medica- The argument could be made that the patient did not have tion through her IV was midazolam for mild sedation. She capacity to withdraw consent. Evidence that decision-mak- was then given pre-operative antacid but regurgitated half ing capacity is intact includes the ability to understand the the solution. She was instructed to drink another cup, which current situation, use relevant information, and communi- she eventually swallowed through a steady stream of tears. cate preferences supported by reasons.6 The American Soci- In the operating room (OR), the anesthesiologist began ety of Anesthesiologists identifies groups of patients with intubation. Despite the video camera attachment, the first “limited” decision-making capacity, including patients who few attempts were unsuccessful. She gagged multiple times can usually make decisions but whose decision-making and regurgitated fluid that obscured view of her airway. Over capacity is temporarily altered. In these cases, physicians and over, she cried, “I don’t want to do this – I want to go must use clinical judgment to determine a patient’s capac- home,” to which the anesthesiologist and nurses replied, ity, taking into account altering agents such as preoperative “It’s ok, we’re almost there.” Finally, with a collective sigh sedation and pain medication, as well as non-pharmaco- of relief, the endotracheal tube was properly inserted. Med- logic factors such as pain, panic, and shock. As previously ications for full sedation were administered and when the mentioned, this patient’s initial refusal occurred before the patient was fully sedated, the operation proceeded. administration of any medication. Perhaps, then, the clinical judgment of the team deemed that panic or pain diminished her decision-making capacity. However, should her mental STUDENT ANALYSIS (CY, RH, WK) state have been called into question, the team should have This case involves a patient originally deemed to have full attempted to re-evaluate her capacity at that moment.7 This capacity who has consented to potentially life-extending would involve a complete stop in the procedure to allow surgery. In the process of preparing her for the operation, thorough reassessment of the patient’s understanding of she expresses reluctance with continuing, to the point of her current situation and rationale regarding her desire to WWW.RIMED.ORG | ARCHIVES | OCTOBER WEBPAGE OCTOBER 2017 RHODE ISLAND MEDICAL JOURNAL 38 MEDICAL ETHICS withdraw consent. Without such an evaluation, a determi- team, as the surgery was a vital component of her cancer nation that she lacked capacity would be hard to defend. treatment, it is not our place as healthcare providers to uni- In this case, all members of the health care team ignored laterally make decisions on behalf of the patient, but rather the patient’s requests to stop the procedure in favor of con- to try to incorporate their values and ideals in shared deci- tinuing as originally planned. That choice could have been sion making which is the basis for a strong doctor-patient made for a myriad of reasons: not wanting to waste time relationship and improved healthcare outcomes.9,10 and resources spent on preparing the operation, reluctance Taking the time to address patient anxieties when trying 36 to delay a busy OR schedule, or interpretation of her state- to make progress with a procedure can be very frustrating, 38 ments as an expression of pain rather than withdrawal of especially when facing a busy day’s schedule and consider- EN consent. However, continuing a procedure in light of such ing the expense of OR time. But if a patient of sound mind statements is in direct opposition to basic ethical principles clearly and repeatedly states that she would like to stop, of autonomy and decision-making capacity. I think we are ethically obligated to at least hit pause. ETHICS COMMITTEE ANALYSIS #1 (TS) ETHICS COMMITTEE ANALYSIS #2 (GB) This case presents an interesting, though unfortunately The vignette raises questions about autonomy, beneficence, common, situation of a patient who consents for a proce- non-maleficence. Was the patient’s autonomy violated? The dure but then has second thoughts when she is experiencing patient gave informed consent to both the surgical proce- physical discomfort. Considering usual practices and for the dure and anesthesia. Informed consent involves providing purposes of this analysis, we will assume that the patient the patient with information about the nature of the surgery, was given a description of the operative plan and potential the expected benefits, possible risks and adverse events, complications before signing the consent form. That said, alternative treatments to the surgery and consequences of no patient can ever be fully informed about what they may not having the surgery.11 It has become standard practice for experience. Hearing a laundry list of possible complica- anesthesiologists to consent patients for anesthesia with a tions and difficulties that “may” arise is a lot more palat- separate consent process.12 able than actually experiencing the pain of multiple failed Autonomy was preserved up until pre-operative discom- IV sticks, the nauseating taste of medication solutions, and fort made the patient cry out that she did not want to go the visceral discomfort of medical instruments being stuck through with surgery. The team may have assumed that this down one’s airway. The reality may end up being more than represented anxiety that would be overcome once the IV and patients had initially thought they were agreeing to endure. endotracheal tube were in place and not an informed with- Accordingly, while the pre-operative consent conversation is drawal of consent. But they did not assess that. an important step in ensuring that we are respecting patient The principle of beneficence was upheld since the patient’s autonomy, we must also consider that a patient’s wishes chances of survival with the surgery seem greater than her may change at any time and we must address their concerns chances without the surgery. Some authors have argued that as they arise.8 beneficence should be seen as balancing the benefits against In this situation, when the patient verbalized “I don’t the risks.13 We do not know whether the surgical consent as want to do this anymore,” taking the time to pause and outlined above described the risks and the consequences of address the patient’s concerns would have been the best way not doing the surgery. to ensure respect of the patient’s wishes if this could be done The need to do no harm was observed in this case. While safely. This patient likely retained decision-making capacity some might see continuing despite her cries as causing tran- at that point in time.

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