Interdisciplinary Team Issues

Interdisciplinary Team Issues: Case 2

A 28-year-old woman presents for diagnostic laparoscopy for pelvic pain. During laparoscopy, the surgeon announces that she intends to proceed to hysterectomy for multiple uterine myomata. The anesthesiologist then declares that he will "wake the patient up" rather than allow the surgeon to proceed, due to lack of consent for the procedure, and questionable medical necessity.

Can the anesthesiologist "tell" the surgeon what to do?
Who is in charge when two physicians on the team disagree?

Interdisciplinary Team Issues: Case 1

An otherwise healthy 54-year-old man presents for radical retropubic prostatectomy, and expresses interest to his anesthesiologist in having postoperative epidural narcotic pain management. The anesthesiologist believes it provides superior pain control, but is informed by the surgeon that the patient "is not to have an epidural."

Is the anesthesiologist obliged to "take an order" from the surgeon? 
Should the anesthesiologist provide the anesthetic he feels is best, regardless of the surgeon's input?

CASE STUDIES

An otherwise healthy 54-year-old man presents for radical retropubic prostatectomy, and expresses interest to his anesthesiologist in having postoperative epidural narcotic pain management. The anesthesiologist believes it provides superior pain control, but is informed by the surgeon that the patient "is not to have an epidural."

Is the anesthesiologist obliged to "take an order" from the surgeon? 
Should the anesthesiologist provide the anesthetic he feels is best, regardless of the surgeon's input?

Case Discussion

The answer to both questions is no. Anesthesiologists have special knowledge and training which are not shared by the surgeon with regard to the safe administration of anesthesia. They also have direct obligations to the patient to provide safe medical care which is as far as possible in keeping with the patient's wishes. When medical issues of safety, or specific patient goals are in conflict with the surgeon's desires, the anesthesiologist is first ethically obliged to provide the best care to the patient. But the anesthesiologist would be incorrect to proceed at this point without some discussion with the surgeon, for at least two reasons. First, ignoring the surgeon's communication is disrespectful. Second, the surgeon may have valuable information to impart, such as "my patients achieve very good pain control with intravenous and oral medication, and end up being discharged two days sooner than epidural patients, because they do not require prolonged urinary catheterization from epidural-associated urinary retention." This dialogue between team members can result in improved team relations, and better care for the patient.  

A 28-year-old woman presents for diagnostic laparoscopy for pelvic pain. During laparoscopy, the surgeon announces that she intends to proceed to hysterectomy for multiple uterine myomata. The anesthesiologist then declares that he will "wake the patient up" rather than allow the surgeon to proceed, due to lack of consent for the procedure, and questionable medical necessity.

Can the anesthesiologist "tell" the surgeon what to do?
Who is in charge when two physicians on the team disagree?

Case Discussion

The anesthesiologist can stop the surgery, and may even have an ethical obligation to the patient to do so, but should take such action only after discussing several issues with the surgeon. 

Is the surgery in fact included in the consent?
If not, is the surgery medically necessary at this moment (i.e., would delay place the patient's life in significant danger) or can it be postponed until the patient can be awakened and asked for consent?

If the surgery is not emergent, and there is no consent, the anesthesiologist is morally obliged to protect the patient's autonomy and right to give consent. Anesthesiologists have been also held legally liable for harm done to patients during elective surgery for which they did not consent, because the anesthesiologist renders the patient insensate and unable to protect themselves from unwanted intrusion.

Often, in a case like this one, consensus can be obtained from the health care team, which in this case could consult the hospital legal counsel and the hospital ethics committee prior to proceeding.