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Current Opinion in Anaesthesiology:
doi: 10.1097/ACO.0000000000000066
ETHICS, ECONOMICS AND OUTCOME: Edited by David M. Rothenberg

Editorial: ethics, economics and outcomes

Rothenberg, David M.

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Deptarment of Anesthesiology, Rush University Medical Center, Chicago, Illinois, USA

Correspondence to David M. Rothenberg, MD, FCCM, The Max S. Sadove Professor of Anesthesiology, Residency Program Director, Department of Anesthesiology, Associate Dean, Academic Affiliations, Rush University Medical Center, 1653 W. Congress Parkway, Chicago, IL 60612, USA. Tel: +1 312 942 6504; page # 312 942 3263 # 4619; fax: +1 312 942-8858; e-mail: David_M_Rothenberg@rush.edu

I am privileged, once again, to have had the opportunity to bring together a distinguished group of clinicians and researchers to review this year's selected topics as they relate to perioperative medical ethics, economic considerations of anesthesia practice and postoperative clinical outcomes.

Dr James West (pp. 170–176) reviews the past and current ethical concerns surrounding the perioperative care of the Jehovah's Witness patient. The premise of the 1960s US television game show Password, was for a contestant to convey a secret ‘password’ to another contestant using only one-word clues. Should there have been a medical version of this show, and the secret word(s) being conveyed was Jehovah's Witness, the invariable response would be ‘no blood transfusion’. Dr West discusses the historical nature of this religious sect's prohibition against such practice, detailing the biblical passages by which the Watchtower's hierarchy has promulgated their tenets over the past 70 years. Anesthesiologists who are at the forefront of perioperative transfusion medicine must be keenly aware of their respective state (USA) or country laws governing the circumstances in which a Jehovah's Witness may refuse a potentially to life-saving blood transfusion. In this regard, there is no other area wherein the practice of medicine is so intertwined with the law. The development of ‘bloodless’ surgical and anesthesia techniques have allowed for the Jehovah's Witness to have similar outcomes when compared with the non-Jehovah's Witness population, even for procedures, such as open-heart surgery. Society as a whole has benefited from having adopted these techniques into every practice for the non-Jehovah's Witness. In this regard, all Jehovah Witness's when undergoing surgery, in the sense that none desire inherently risky blood transfusion, but unlike the Jehovah's Witness, most would rather not die than be transfused. Finally, the religion itself is evolving in that many of the Jehovah's Witness faith are calling into question (anonymously online and in print) the original doctrine forbidding transfusion. As such, it is imperative that each patient be questioned privately by their treating surgeon and anesthesiologist to clearly delineate their transfusion beliefs.

Dr Van Norman (pp. 177–182) discusses one of the most controversial end-of-life (EOL) topics, that of physician-assisted death (PAD) and euthanasia. As a well renowned medical ethicist (and an anesthesiologist who happens to deliver care in Washington State where PAD is legal), she reviews the pitfalls and benefits of its current international practice. Confusion continues to exist in the global medical community, as it relates to medical practice at the EOL. The ‘double effect’ often gets misconstrued, as PAD and the DNR order as an acronym for ‘Do-Not-Round’. When the intent of caregivers is called into question, ethical concerns become more than troublesome. Nowhere was this more prominently displayed than during the evacuation of patients at Memorial Medical Center in New Orleans during Hurricane Katrina in 2005. Decisions were made to delay evacuation of patients who had DNR orders, as it was determined that these patients would be less likely to survive the ordeal. In many circumstances, opiates were administered to these patients presumably to ease suffering, but many, including the state's attorney, assumed that this was done to hasten death. Murder charges were actually filed against a physician, but a grand jury dismissed the charges [1]. Many would argue that such extremes of medical judgment are clear examples of the ‘slippery slope’ theory of why PAD should never be allowed. An elegant argument in favor of PAD has, however, been made by Shaw [2]. He stated that if one believes in the ethics of organ transplantation, then one must believe in the concept of brain death. It would then follow, that a person is defined by one's mind and not by one's body. In keeping with this premise, a patient would, therefore, have the right to relieve him or herself of the burden of his or her body, analogous to the burden of a mechanical ventilator, and thus be granted merciful relief of suffering by PAD. It is a compelling argument that is difficult to refute, without imploring religious objection. In our disagreement about participation in PAD, it is clear that physicians simply reflect the diversity of social attitudes toward these practices in Western countries [3]. And yet, as those most familiar with the alternatives to hastening death, (especially as it relates to the practice of palliative care), we have a unique responsibility to ensure that neither individuals, nor society in general, universally embrace PAD as an appropriate means of dealing with suffering. In carrying out this task, we need to explore more deeply the meaning of suffering and its existential significance. Therefore, the best response we as anesthesiologists can have to the PAD/euthanasia movement is to provide better terminal care. Intensivists must reject the technological imperative that compels them to use whatever treatments are available, knowing that they are unlikely to offer patients genuine benefit. Above all, it must be recognized that dying is a part of life and should be an occasion for patients and their loved ones to come together.

In the economic arena, Drs Szokol and Stead (pp. 183–189) provide a detailed analysis of the economical landscape of the practice of anesthesiology, especially as it relates to US healthcare and the newly adopted Patient Protection and Affordable Care Act. Similar to the mantra chanted by many members of the American Society of Anesthesiologists in the mid-1990s that called for the renaming of our specialty from Anesthesiology to ‘Perioperative Medicine’, there is a renewed interest in promoting anesthesiologists as perioperative physicians. The most recent ‘Kool-Aid’ being served is being labeled the "perioperative surgical home". Drinking this is being touted as an elixir to improve quality of patient care and potentially to increase provider revenue. Whether this is the time for us to embrace this model will remain to be determined, as most practicing anesthesiologists were neither never trained as ‘perioperative physicians’, nor did they have a desire to practice anywhere but within the confines of the operating room. It is clear, however, that US residency training programs need to emphasize the importance of future anesthesiologists becoming more professionally recognized outside of the operating room. A high premium should be placed on recommending additional training in fields, such as critical care, palliative care, pain management and informatics. Becoming invaluable members of Hospital Medical Staffs and Universities is a critical message to send to our trainees, especially when our current practice model is being threatened by other nonanesthesiologists and nonphysician providers.

R. Struck, and Drs Baumgarten and Wittman (pp. 190–194) describe an interesting perspective on the cost-efficiency aspects of randomized controlled trials (RCTs) and of observational studies. The authors discuss the merits of each research design method and review the pitfalls and benefits of each. An RCT, while touted as research model ‘gold standard’, tends to lead to far more budgetary expense from both a human and technical resource perspective, and often fails to offer new insight provided by a less costly and cumbersome observational study. As the authors note, studies considered to be ‘merely’ observational, should not mean that its results are not worthy of acceptance.

Finally, two outcome reviews conclude this year's section. First is the outstanding summary regarding perioperative renal outcome authored by Drs Mooney, Chow and Hillis (pp. 195–200). The authors discuss modern techniques to assess preoperative renal risk and to monitor for acute kidney injury (AKI). The antiquated method of determining if a patient has renal insufficiency is to note if his or her serum creatinine is ‘outside of the asterisks’. Most clinicians fail to recognize that a patient, whose serum creatinine rises from 0.7 to 1.4 mg%, has a 50% diminution in his glomerular filtration rate, albeit within the normal range of most laboratories. Modern methods of assessing preoperative renal risk rely on estimated glomerular filtration rate, serum cystatin C level or a combination of both measurements. In utilizing these measurements, a better assessment of renal risk may be obtained. As the authors note, this is a critical risk assessment, as postoperative AKI has been associated with considerable morbidity and mortality. Monitoring intraoperative renal function still remains problematic with clinicians continuing to rely on the inadequate and often meaningless parameter of urine output.

Drs Sabaté, Mazo and Canet (pp. 201–209) conclude this section with an updated review of the risks of developing postoperative pulmonary complications (PPCs) and methods to treat them. Recent studies describing low tidal volume, high positive end-expiratory pressure ventilation, coupled with those describing the benefit of recruitment maneuvers are gaining acceptance as validated practices to minimize atelectasis. In addition to recruiting alveoli following endotracheal intubation at the onset of initiating general anesthesia, maintaining positive end-expiratory pressure as well as pressure support ventilation upon emergence may also improve postoperative oxygenation. Utilizing a preoperative ‘cough test’ and the postoperative I COUGH [Incentive spirometry, Coughing/deep breathing, Oral care, Understanding (patient and staff education), Getting out of bed at least 3 times/day, Head of bead elevation] protocol also appear to be simple and inexpensive means to prevent and treat PPCs, and warrant further scrutiny.

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Acknowledgements

None.

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Conflicts of interest

There are no conflicts of interest.

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REFERENCES

1. Fink Sheri., 25 August 2009;,

NYT


2. Shaw D. The body as unwarranted life support: a new perspective on euthanasia. J Med Ethics. 2007; 33:519–521.

3. Colbert JA, Schulte J, Adler JN. Physician-assisted suicide-polling results. N Engl J Med. 2013; 369:11

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