Ethics consultations in neuro-oncology

Abstract

Background Management of patients with brain tumors can lead to ethical and decisional dilemmas. The aim of this study was to characterize ethical conflicts encountered in neuro-oncologic patients. Methods Retrospective review of ethics consultations performed upon patients with primary and metastatic brain tumors at a tertiary cancer center. An ethics consultation database was examined to characterize ethical conflicts, contextual factors, and interventions by the consultation team. Results Fifty consultations were reviewed; 28(56%) patients were women, median age 54 (range 4-86); 27(54%) patients had a primary central nervous system malignancy; 20(40%) had brain metastasis. At the time of consultations, 41(82%) patients lacked decisional capacity; 48(96%) had a designated surrogate decision maker; 3(6%) had an advance directive outlining wishes regarding medical treatment; 12(24%) had a Do Not Attempt Resuscitation (DNAR) order. Ethical conflicts centered upon management of end-of-life (EOL) circumstances in 37(72%) of cases; of these, 30 did not have decisional capacity. The most common ethical issues were DNAR status, surrogate decision making, and request for non-beneficial treatment. Consultants resolved conflicts by facilitating decision making for incapacitated patients in 30(60%) cases, communication between conflicting parties in 10(20%), and re-articulation of patients’ previously stated wishes in 6(12%). Conclusions Decisional capacity at EOL represents the primary ethical challenge in care of neuro-oncologic patients. Incomplete awareness among surrogate decision makers of patients’ prognosis and preferences contributes to communication gaps and dilemmas. Early facilitation of communication between patients, caregivers, and medical providers may prevent or mitigate conflicts and allow enactment of patients’ goals and values.