Ethical Challenges in the Operating Room, Part II

Editor’s note: This is part 2 of a two-part series on ethics in the operating room. The first installment was published in the October 2016 issue.

Scenario

The ethical scenario published in part 1 of “Ethics in the Operating Room” imagined that you served as chair of your medical center’s ethics committee and provided guidance and recommendations to the center’s leadership on issues of ethical concern in the operating room.

In that scenario, your comments to the leadership dealt with informing patients about the roles of the various surgical team members participating in the patient’s surgery, along with the ethics of overlapping, concomitant/concurrent, and sequenced surgical procedures. The next major topic on which the leadership would like your input involves the professional and ethical care of patients in the perioperative period, particularly the interaction of the surgeon with the patient at the bedside.

Discussion

The specialty of otolaryngology-head and neck surgery has, for various reasons, moved away from inpatient care to predominantly outpatient care, save for head and neck oncology, neurotology, trauma surgery, and specific circumstances of other subspecialties for which patients are hospitalized longer than overnight.

Generally speaking, however, hospital rounds with faculty, residents, and medical students in our specialty have largely been replaced by in vitro rounds in a conference room, involving Powerpoint presentations, imaging studies, patient photographs, and other data pertinent to a patient’s disorder. Teaching in the presence of patients can still take place during the clinic evaluation, which can be referred to as “chair-side rounds,” and in the emergency center, where the focus is generally on expediency.

When it comes to strengthening the patient-physician relationship, however, there may be no better way to do so than with the true “bedside” encounter, when the patient is most vulnerable and the physician can be most caring and compassionate.

The unique circumstances of the perioperative period should be viewed from the patient’s perspective to get a sense of the anxieties experienced by most surgical patients as they are being prepared for surgery, entering the operating room, and then recovering from the surgery. The compassionate surgeon can help alleviate these concerns with her/his bedside manner. The ethical responsibility to address the vulnerabilities of surgical patients rests not just with the surgeon, but with the entire team caring for the patient in the perioperative period.

Because the otolaryngologist-head and neck surgeon is the de facto leader of the patient care team, it falls to her/him to set the proper expectations for an ethical and professional interaction with the patient. It is important to resist the desensitization and cynicism that can be observed in all quarters of the surgical profession, which can lead to an indifference that can be sensed by patients at the time they most require caring attention at the bedside. This responsibility is well stated in the Code of Ethics of the American Academy of Otolaryngology–Head and Neck Surgery: “The Physician-Patient Relationship—‘Each patient must be treated with respect, dignity, compassion, and honesty’” (available at entnet.org/content/ethics).

While this is a professional goal each of us strives to reach, the circumstances of a busy operative schedule can be distracting, resulting in short visits with the

When it comes to strengthening the patient–physician relationship, there may be no better way to do so than with the true “bedside” encounter, when the patient is most vulnerable and the physician can be most caring and compassionate.

patient in the holding area and delegation of patient contact to others on the surgical team until the patient is asleep and prepared for surgery. It should be stated that while this is not necessarily unprofessional behavior, valuable opportunities to put the patient at ease and strengthen the patient–physician relationship may be missed. This relationship is an ongoing, dynamic one, begun at first contact and built upon throughout the length of the professional relationship. It is strengthened through mutual respect, along with attentiveness to visual and oral cues, and is primarily the responsibility of the surgeon/physician.

Although emergency department interactions often afford limited time for the establishment of a relationship between patient and physician, a patient who is awake and alert wants to know that the surgical procedure(s) will be undertaken by a surgeon who believes in the sanctity of human life and will care for the patient to the fullest of her/his capabilities. This relationship can be further developed in the postoperative period, when the patient needs reassurance and attention.

Sympathy versus Empathy

In approaching the best way to support and encourage the surgical patient in the perioperative period, it is important to consider the commonly utilized—but actually poorly understood—capacity for “empathy.” Indeed, even though most physicians may feel they understand the difference between empathy and sympathy and realize that sympathy may not be the appropriate mindset for a surgeon, in truth, we often feel sympathy for a patient or his family in very sad and distressing circumstances.

We are taught not to act on that sympathy out of concern that we may not make “unbiased” recommendations based on science and experience. Rather, we are supposed to base our judgment on empathy, which is believed to be less emotional and less distracting. Empathy, in its broadest sense, involves the physician’s capacity to be cognizant of a patient’s emotions, concerns, family, and any social contexts that affect her and her condition, and to understand, as much as possible, how these factors will play a role in the way the patient will deal with decision-making and her personal response to illness. Empathy can potentially lend great depth and breadth to an understanding of how patients deal with their adversities and medical conditions. While empathy is felt for the circumstances and factors in the patient’s life that can affect the disorder, sympathy is a feeling of sadness and/or compassion directed toward the patient herself, and to the family members who have to deal with the difficulties ahead.

This author believes that empathy and sympathy may not—or should not—be mutually exclusive; they may coexist in the minds of discerning surgeons/physicians. Surgeons are generally capable of recognizing, in the abstract, empathy and sympathy, accepting both emotions, while internalizing sympathy and externalizing empathy to properly recommend courses of therapy that are clearly in the best interests of the patient.

How would this conjoint perspective of empathy and sympathy play out in a clinical scenario? Take, for instance, a situation in which a child has been born with a cleft lip and a cleft palate. As we know from experience, parents may have some internal guilt about the deformity—“What could I have done or not done to prevent this?” We also know how difficult a course the child might have in the years ahead, dealing with speech difficulties, some facial abnormalities until the best result is achieved, and the possibility of unwanted and undeserved negative attention from peers.

For this anguish, real or possible, we are sympathetic. We feel very sorry for the child and the family, knowing they may have to experience such difficulties before things are better. The surgeon should not feel guilty about being sympathetic. At the same time, the action side of this dyad—empathy—informs the surgeon/physician about the patient’s and the family’s capabilities to cope, using their faith, family, or other support systems to contribute in a positive manner in the approach to care, and helps us make recommendations for therapy that utilize our awareness of their social and emotional strengths to maximize the best possible outcome from surgery. In other words, we try to understand the complexities of their circumstances to gain knowledge on how best to help them. To restate, empathy and sympathy need not be mutually exclusive, as long as the physician recognizes them for what they are.

Now, to apply our understanding of the patient and family to the perioperative period, we start with the basic recognition that patients are often at their most vulnerable as they face a surgical procedure. They are likely tired after not having slept well the previous night, are hungry, and are worrying about potential outcomes ranging from pain to death. What patients need at this time is a reassuring, compassionate, caring physician, one who will convey that concern and reassurance by taking the time to speak with them in an unrushed manner before surgery, asking how they are doing, making eye contact, smiling and putting them at ease—in other words, exhibiting the kind of bedside manner each of us would appreciate in similar circumstances. When a surgeon becomes a surgical patient, and has that experience to draw upon later, the notion of empathy and the importance of bedside manner become very real, indeed.

Emotional Reassurance

Two issues related to bedside medicine in the perioperative period often are raised in bioethical discussions: Should the surgeon lay hands upon the patient, and should the surgeon pray with the patient? Regarding the former question, this author believes that patients usually welcome a friendly pat on the shoulder or a hand holding theirs as deemed appropriate at the time, particularly at these vulnerable moments. The patient would also like to see the surgeon waiting to welcome her into the operating suite. Reassurance all along the way, through presence, kind words, and a pat on the shoulder, is part of the “art of medicine,” and surely is also a part of the “art of surgery.”

While it is generally held that the surgeon may recognize the patient’s need to pray before surgery and should be respectful if prayer is carried out in her presence, bowing his or her head as the patient, spiritual leader, and family have a moment of prayer, it is less clear whether it is appropriate to join in, or lead a prayer, at a bedside. Usually, the quiet presence of the surgeon will be sufficient to convey a sense of respect for the importance of this act to the patient.

Finally, the surgeon should be cognizant that her bedside manner does not go unnoticed by the other members of the healthcare team, and this role modeling sets a positive example for every professional who has contact with the patient throughout the perioperative course.

---

Dr. Holt is professor emeritus in the department of otolaryngology–head and neck surgery at the University of Texas Health Science Center in San Antonio.