Trauma Surgeons’ Perceptions of Resuscitating Lethally Injured Patients for Organ Preservation

Abstract

Background Trauma surgeons face a challenge when deciding whether to resuscitate lethally injured patients whose organ donor status is unknown. Data suggests practice pattern variability in this setting, but little is known about why. Materials and Methods We conducted semi-structured interviews with trauma surgeons practicing in Level 1 or 2 trauma centers in Tennessee. Interviews focused on ethical dilemmas and resource constraints. Analysis was performed using inductive thematic analysis. Results Response rate was 73% (11/15). Four key themes emerged. All described resuscitating patients to buy time to collect more definitive clinical information and to identify family. Some acknowledged this served the secondary purpose of organ preservation. 11/11 participants felt a primacy of obligation to the patient in front of them even after it became apparent, they could not personally benefit. For 9/11 (82%), the moral obligation to consider organ preservation was secondary/balancing; 2/11 (18%) felt it was irrelevant/immoral. Resource allocation was commonly considered. All participants expressed some limitation to resources they would allocate. All participants conveyed clear moral agency in determining resuscitation extent when the goal was to save the patient’s life, however this was less clear when resuscitating for organ preservation. Across themes, perceptions of a “standard practice” existed but the described practices were not consistent across interviewees. Discussion Widely ranging perceptions regarding ethical and resource considerations underlie practices resuscitating toward organ preservation. Common themes suggest a lack of consensus. Despite expressed beliefs, there is no identifiable standard of practice amongst trauma surgeons resuscitating in this setting.

To feel or not to feel: a scoping review and mixed-methods meta-synthesis of moral distress among surgeons

“…Another study expanded on Jameton's original definition, noting that distress may occur following a moral decision as individuals struggle with the sequelae of forgoing choices justified by alternative ethical principles, implying distress caused by ethical "opportunity costs" (33). Several studies discussing moral distress did not include any explicit definition of moral distress (2)(3)(4)(5)(6)9,34,35).…”

“…In 19 articles, individual factors were considered in relation to their association with moral distress among surgeons (2)(3)(4)(5)(6)8,10,25,(27)(28)(29)(30)(31)(32)(33)(34)(35)(36)(37). In some instances, this was in connection to demographic characteristics such as gender (2,8,30,31), years in practice (2,29,(31)(32)(33)36), and the impact of being in a leadership or supervisory position (30).…”

“…While greater experience level was generally associated with decreased moral distress, working in a leadership or supervisory role predisposed individuals to distress, placing the traditional correlation of seniority and acquiring increasing responsibility in direct conflict with each other as it relates to moral distress. In other instances, moral distress was a result of more personal factors such as the religious views of the provider (32), personal beliefs on organ donation (6), and acting or witnessing actions that betrayed their morals (10,29). Other studies focused on aspects that were connected to mental health, including the emotional weight of watching patients die alone (32), coping mechanisms in place for managing moral distress (10), baseline moral injury (28), and the need to have time to reflect and process events and experiences that are distressing (29).…”

“…Interpersonal factors were also explored in relation to the moral distress among surgeons (3,(5)(6)(7)(8)(9)(25)(26)(27)(31)(32)(33)(34)(35)(36)(37)(38)(39). In some instances, these interpersonal factors arose in connection to the care provided, such as having unclear or inconsistent goals of care (7,25,34,37), discordance among and between teams or families (3,5,8,26,38), disruptions to the doctorpatient relationship (32), providing life prolonging intervention for terminally ill patients (3,(6)(7)(8)(9)25,33,34,37,39) and pressure from others to drive care (7,8,25,26,33,34,37). In studies assessing surgeons, interpersonal factors' impact on moral distress appear to differ based on surgeon roles.…”

“…However, assessment of moral distress among surgeons is limited. The majority of studies that include a surgeon cohort tend to generalize their findings to all healthcare providers, and even fewer focus on surgeons and the field of surgery specifically (2)(3)(4)(5)(6)(7)(8)(9). The invasive nature of a surgeon's craft and the responsibility surgeons have over patients place this group at unique risk for moral distress.…”