Can a Surgeon Refuse to Operate When an Advance Directive Limits Postoperative Care?

Abstract

Robert M. Sade, MD The ethical bedrock of contemporary health care is informed consent. We cannot touch others without their permission to do so. The flip side of the informed consent coin is informed refusal. Patients or their surrogate decision makers can refuse care at any time, even if the proffered treatment is life-saving. The refusal can be stated in advance in the form of limitations on future care. Sometimes limits of this kind can seem to an attending physician to be unwise or even foolish, but if they remain after efforts to change them through persuasion, they cannot be disregarded. The following vignette describes just such a case, in which the surgeon has to make a choice of how to respond. The Case of the Inflexible Wife Eighty-year old M.D. Baker was being treated for diabetes, hypertension, and chronic kidney disease with a creatinine of 2.5. When developed chest pain, a CT scan demonstrated a type A aortic dissection with a false lumen extending into the left common carotid artery and proximal descending aorta. Mr. Baker became confused and was intubated and transferred to the university hospital. On arrival, is sedated but moving all four extremities. He needs urgent surgery and the cardiac surgeon, Dr. Solomon, discusses plans for ascending aortic replacement with Baker’s family. The patient's wife is his health care agent under his health care durable power of attorney; she says that the patient would like everything done, but also that he had lived a good life, doesn’t want CPR, and doesn’t want to be on a respirator. Dr. Solomon tells Mrs. Baker that this is a high risk operation and that complications such as kidney failure and prolonged mechanical ventilation are reasonably likely. She says, OK, but if he’s not better in a week, we will withdraw support — including dialysis. On further discussion, her position remains adamant. Should the surgeon accept these conditions and do the operation?