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Ethics in Cardiothoracic Surgery

No Heroic Measures: How Soon Is Too Soon to Stop?

^a Division of Thoracic Surgery, Duke University Medical Center, Duke University Health System, Durham, North Carolina
^b St. Joseph Cancer Institute, Towson, Maryland
^c Surgicenter of Baltimore, Baltimore, Maryland
^d Department of Surgery, Institute of Human Values in Health Care, Medical University of South Carolina, Charleston, South Carolina

^_* Address correspondence to Dr Sade, Department of Surgery, Medical University of South Carolina, 96 Jonathan Lucas St, Suite 409, PO Box 250612, Charleston, SC 29425 (Email: sader@musc.edu).

Presented at the Forty-fourth Annual Meeting of The Society of Thoracic Surgeons, Fort Lauderdale, FL, Jan 28–30, 2008.

The first 300 words of the full text of this article appear below.

	Introduction

 
Robert M. Sade, MD
As cardiothoracic surgeons, we face many difficult problems in our professional lives, and base most decisions on clinical judgment developed and honed during many years of training and experience. Some decisions, however, are based on more than weighing scientific evidence and outcome probabilities, and they require value judgments on such matters as the desirability of alternative outcomes. Among the most difficult judgments we make are those that conflict with the views of the patient or the patient's proxy (ie, agent appointed in advance by the patient) or surrogate (ie, agent authorized by law) decision maker.

In cases of critical illness with low survival probability, discordant judgments about withdrawing life support are often based on perceived acceptability of the projected quantity and quality of life if the patient survives. The surgeon and the proxy or surrogate might find themselves on either of the opposing sides of the issue.

In such decisions, much hinges on what the patient would have wanted. In both law and ethics, proxy or surrogate decisions generally should be based on substituted judgment, that is, a judgment that answers the question: "What would the patient have wanted?" The most wrenching of such conflicts occurs when the surgeon wants to continue treatment and the proxy or surrogate wants to stop, presumably because the patient would have chosen to stop. In the absence of a written advance directive that clearly specifies what the patient wants done in a life-threatening situation, acceptability of the decision of a proxy or surrogate turns on the weight of evidence that the decision of the surrogate or proxy accurately reflects the patient's wishes. The case below illustrates just such a difficult surgeon–family conflict and it is the focus of the debate that follows.

	The Case of the Resolute Wife

 
John Cooper is a 40-year-old restaurant owner, who has a wife and . . . [Full Text of this Article]

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				K. Prager When is the request of a surrogate too unreasonable to follow? Ann. Thorac. Surg., November 1, 2009; 88(5): 1723 - 1723. [Full Text] [PDF]

				T. D'Amico, M. J. Krasna, D. Krasna, and R. M. Sade Reply. Ann. Thorac. Surg., November 1, 2009; 88(5): 1723 - 1724. [Full Text] [PDF]