Anesthesiology Clinics

No abstract text is available yet for this article.

Physicians may under some circumstances decline to provide a clinical service that is within accepted medical standards due to a deeply held moral belief that to do so would be wrong. Conscience objection in medicine is legally protected, but ethically limited by physician obligations to put patient interests first. Accommodation to conscientious objections, when possible, recognizes the diverse moral perspectives and benefits for both the objectors and the profession as a whole. When these situations arise, physicians have obligations to respectfully resolve the distress of conscientious objectors while still honoring the primacy of patient care needs...

Ethical disclosure of adverse events (AE) presents opportunities and challenges for physicians and has unique ramifications for anesthesiologists. AE disclosure is supported by patients, regulatory organizations, and physicians. Disclosure is part of a physician's ethical duty toward patients, supports fully informed patient decision making, and is a critical component of root cause analysis. Barriers to AE disclosure include disruption of the doctor-patient relationship, fear of litigation, and inadequate training...

Ethical principles regarding respect for patient autonomy in medical decision-making and the impact of religion, culture, and other issues on clinical care have been extensively reviewed in the medical literature. At the same time, despite physicians having an understanding of the underlying ethical principles in clinical decision-making, challenges arise when managing complicated clinical problems for which medical treatment is available, but not acceptable to the patient. For example, many anesthesiologists are challenged when caring for one of Jehohah's Witnesses who refuses to receive blood or blood products despite the potential consequences of doing so...

The 4 basic principles of ethics (beneficence, nonmaleficence, autonomy, and justice) can guide clinical decision-making for the pregnant patient during labor and delivery, as well as when undergoing nonobstetric surgery. An evidence-based decision-making conversation with the patient facilitates obtaining informed consent. When maternal-fetal conflict arises, both during labor and delivery and nonobstetric surgery, beneficence-based obligations to both parties should be considered, with discussions and decisions well documented...

Anesthesia clinicians often navigate a delicate balance between maternal and fetal safety. Interventions for at fetal well-being may introduce risks of harm to the mother and raise ethical dilemmas. Emergency procedures often focus on direct fetal safety, sidelining maternal physical and mental well-being. The clash between ethical principles, particularly nonmaleficence and beneficence, often arises, with maternal autonomy guiding decisions. Fetal surgery exemplifies risking maternal health for fetal benefit, whereas emergent cesarean deliveries pose physical and psychological challenges for both the mother and child...

Some practices require mandatory preoperative laboratory testing for select patients presenting for anesthesia and surgery. Such mandatory preanesthesia laboratory testing has significant ethical implications related to informed consent and patient autonomy. Assumptions that a patient provides "presumed consent" by merely presenting for a test are flawed because such consents are often not informed and do not acknowledge patient autonomy. By placing a condition on access to a medical treatment, mandatory preanesthesia testing may not be ethically justifiable...

Natural or man-made medical disasters have repeatedly affected human communities. The impact on health care resources may vary depending on the magnitude of each crisis, catastrophe or pandemic, and the resources available. Medical triage protocols serve as invaluable tools to address clinical needs, particularly when resources, including supplies, equipment, and personnel, are limited. Although resources should be allocated to maximize the benefit, resource allocations need to be ethically sound. Existing triage protocols have inherent limitations...

Drug shortages remain a serious and widespread problem affecting all health systems and patients. Anesthesiology practice is strongly impacted by shortages of sterile injectable drugs, resulting in a negative impact on the quality of care. Understanding the root causes of drug shortages guides the anesthesiologist toward an ethical response. While rationing is a common consideration in secular ethics, and indeed rationing strategies are utilized, the use of rationing alone risks normalizing and perpetuating the drug shortage problem...

Because modern surgical and medical care have advanced, patients increasingly present for procedural and surgical intervention with life-limiting diagnoses and/or advanced care goals such as "do not resuscitate." Anesthesiologists now care for these patients across the complete perioperative setting and frequently find themselves at the crossroads of these mounting pressures. As the boundaries and capabilities of anesthetic care and critical care anesthesiology expand so too do the specialty's needs for support in ethical decision-making...

The development of critical care stimulated brain death criteria formulation in response to concerns on treatment resources and unregulated organ procurement. The diagnosis centered on irreversible loss of brain function and subsequent systemic physiologic collapse and was subsequently codified into law. With improved critical care, physiologic collapse (while predominant) is not inevitable-provoking criticisms of the ethical and legal foundation for brain death. Other criteria have been unsuccessfully proposed, but irreversibility remains the conceptual foundation...

The medical progress has produced improvements in critically ill patients' survival to early phases of life-threatening diseases, thus producing long intensive care stays and persisting disability, with uncertain long-term survival rates and quality of life. Thus, compassionate end-of-life care and the provision of palliative care, even overlapping with the most aggressive of curative intensive care unit (ICU) care has become crucial. Moreover, withdrawal or withholding of life-sustaining treatment may be adopted, allowing unavoidable deaths to occur, without prolonging agony or ICU stay...

Like most complex aspects of procedural care, sound perioperative management of limits to life-sustaining medical therapy requires a multidisciplinary team-based approach bolstered by appropriate care management strategies. This article discusses the implications of care for the patient for whom limitations of life-sustaining care are in place and the roles and responsibilities of each provider in supporting quality procedural care compatible with patients' right to self-determination. The authors focus on the roles of the surgeon, preoperative clinic provider, anesthesiologist, and postoperative care consultants and discuss how the health care system and care pathways can support and improve adherence to best practices...

Preoperative review of existing advance directives and a discussion of patient goals should be routinely done to address any potential limitations on resuscitative therapies during perioperative care. Both surgeons and anesthesiologists should be collaboratively involved in these discussions, and all perioperative physicians should receive training in shared decision making and goals of care discussions. These discussions should center around patient preferences for limitations on life-sustaining medical therapy, which should be accurately documented and adhered to during the perioperative period...

In 1992, the American Society of Anesthesiologists Committee on Ethics was formed primarily to address the rights of patients with existing Do-Not-Resuscitate orders presenting for anesthesia. Guidelines written for the ethical management of these patients stated that such orders should be reconsidered-not rescinded-thus respecting patient self-determination. The Committee also rewrote the reigning Guidelines for the Ethical Practice of Anesthesiology by expanding its ethical foundations to reflect the evolving climate of ethical opinions...

Facing ethical dilemmas is challenging and sometimes becomes a real burden for anesthesiologists, particularly because they rarely have previous or long-standing patient relationships that help inform clinical decision-making. Although there is no ideal algorithm that can fit all clinical situations, some basic moral and ethical principles, which should be part of every clinician's armamentarium, can guide the decision-making process. Dealing with conflicting views among providers and/or patients can be distressing but can lead to meaningful professional and personal growth for each clinician...

No abstract text is available yet for this article.

No abstract text is available yet for this article.

The success of enhanced recovery after surgery (ERAS) protocols in improving patient outcomes and reducing costs in general surgery are widely recognized. ERAS guidelines have now been developed in orthopedics with the following recommendations. Preoperatively, patients should be medically optimized with a focus on smoking cessation, education, and anxiety reduction. Intraoperatively, using multimodal and regional therapies like neuraxial anesthesia and peripheral nerve blocks facilitates same-day discharge...

Regional anesthesia has a strong role in minimizing post-operative pain, decreasing narcotic use and PONV, and, therefore, speeding discharge times. However, as with any procedure, regional anesthesia has both benefits and risks. It is important to identify the complications and contraindications related to regional anesthesia, which patient populations are at highest risk, and how to mitigate those risks to the greatest extent possible. Overall, significant complications secondary to regional anesthesia remain low...