567 Results from a Survey About the Ethical Challenges of Treating a Medically and Socially Complicated Patient

Abstract

Introduction Medically complicated burn patients can present with complex social situations that lead to difficult ethical decision. While the four principles of biomedical ethics, viz., respect for autonomy, nonmaleficence, beneficence, and justice, offer guidance, they may not lead to a clear resolution. Instead, providers may be faced with making a recommendation that is ethically uncomfortable. Methods At the 2109 ABA Annual Meeting, we presented a poster of the following real-life case: Patient is a 47-year-old male who has an 81% TBSA burn, is intubated, and is unable to participate in medical decision making. He needs four limb amputations. His chance of long-term survival with amputation is less than 20%, and the best case scenario is a vent-dependent life with tetraplegia. His complicated family, which include his wife, ex-wife, children, and siblings, is unable to agree on what interventions should be provided. The poster included a QR code and a link, both of which took respondents to a 10-item survey. Later in 2019, we asked the organizers of our regional burn conference to email a case summary and a link to the same survey to registered participants. The survey addressed medical appropriateness and various factors that might affect decision making. Results We received responses from 12 attendees at the ABA Annual Meeting and 18 regional conference registrants. On the 8 questions for which only a single response was permitted, 64% of respondents on average chose the same answer. This number goes up to 72% if we restrict to the 5 questions with only two options. Though these numbers indicate a degree of consensus, they also reflect a notable lack of agreement. In fact, less than 77% of respondents agreed about the medical appropriateness of not amputating, the roles that quality of life and justice (resource allocation) should play in decision making, whether the level of evidence needed to withdraw treatment is the same as is needed to continue, how to handle the conflicting claims of family members, and the level of importance that should be attached to the team’s comfort. In the case of the last two issues, none of the 5 available responses for each question received more than a third of the votes. The only position unanimously endorsed on the survey was that comfort care should be an option for the patient/family. Conclusions Our data suggest that there is substantial disagreement among those involved in burn care regarding important aspects of decision making for a patient who is medically, socially, and ethically complicated.