The surgical intensivist as mediator of end-of-life issues in the care of critically ill patients.

Abstract

Current practitioners in surgical intensive care need to be versed in a wide variety of roles. These providers must treat complex pathophysiologic insults, investigate causes of organ dysfunction, and counsel grieving families. The term surgical intensivist refers to the individual who practices intensive care in the surgical intensive care unit. Commonly, this individual oversees the surgical intensive care unit (SICU) team, comprised of residents, nurses, students, and therapists, who manage critically ill surgical patients. Consequently, other roles of the surgical intensivist include those of a teacher and manager. In surgical intensive care units, multiple physicians frequently follow and assist in managing critically ill patients. Because different groups of physicians manage and consult on a single patient in the SICU setting, conflicts between different practitioners may invariably arise. As a result, surgical intensivists may also be placed in the additional roles of mediator or arbiter to assist in resolving these conflicts. In this article, we will explore the role of the surgical intensivist in an SICU setting. In particular, we will discuss the surgical intensivist’s involvement in end-oflife care. We will show how the surgical intensivist can act successfully as a mediator of end-of-life disputes by discussing a case where a family’s ambivalence about care options was complicated by disagreement among the patient’s treating physicians. We will especially focus on the role of the surgical intensivist in the circumstance where surgical treatment has been performed. We will show that the surgical intensivist’s background as a trained surgeon positions this individual to help clarify goals of care at the end of life and engage in successful conflict resolution. Case presentation This case is a composite of multiple cases seen by the lead author. A 72-year-old man with metastatic colon cancer was admitted to a university hospital with melena and hematemesis. This upper gastrointestinal bleed was thought to be unrelated to his underlying malignancy. He had prepared a living will stating he did not wish to be kept alive by artificial methods or extraordinary support should he have a minimal chance of meaningful survival. Additionally, he had established his wife as his healthcare proxy and requested a do-not-resuscitate order (DNR) be placed in his medical chart. He was admitted with a hemoglobin of 5.8 g/dL to the medical intensive care unit (MICU). His longstanding primary care internist, who had helped prepare his advance directive, reasoned that the patient should not receive any further therapy, including blood products or invasive interventions. Nonetheless, the patient, who still retained decision making capacity, said he would want initial treatment to determine the cause of his bleeding. To that end he received three units of packed red blood cells and underwent an endoscopic procedure for which he provided consent. The patient hoped that this procedure could definitively control the bleeding. Because of continued hemorrhaging, the patient was intubated for airway protection before endoscopy. On endoscopy a bleeding duodenal ulcer with a visible vessel was identified and cauterized. After the procedure, the patient remained intubated to facilitate a repeat study for the management of further bleeding. Given the patient’s condition, the MICU attending physician or “medical intensivist” also consulted general surgery for potential surgical backup. At this point the medical intensivist approached the patient’s wife regarding care options because the patient lacked decisional capacity and she was his healthcare agent. The medical intensivist now shared the view of the primary care internist and voiced the opinion that no other interventions should be entertained. The patient’s wife understood the situation but at this time wanted the This work is funded by a grant from the Fan Fox and Leslie A Samuels Foundation to the Division of Medical Ethics in the Departments of Medicine and Public Health of the Weill Medical College of Cornell University.