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Introduction: surgical care of patients with diagnosis of gastrointestinal malignancies involve ethical conficts and decision making to manage these issues requires specific knowledge and expertise . The four ethical principles as introduced by Beauchamp and Childress (respect for autonomy, beneficence, non maleficence and justice) provide a framework for the solution of these issues when arising in clinical practice
Objective: to examine prospectively the incidence and the cause of ethical conflicts which lead to a surgical ethics consultation during the process of surgical care of patients with diagnosis of gastrointestinal malignancies
Methods: a total of 105 ethical conflicts through the treatment care of 100 patients with gastrointestinal malignancies (of a total of 488) were identified during 2010. Mean age was 58.2 +/- 13.7 years (range: 28 to 96), 56 were females. Two of the authors with expertise in surgical ethics participated when intervention was requested and assisted with the conflict management and resolution.
Results:
The following situations were identified and some patients presented more than one:
1. Issues involving surgical informed consent process (information, refusal to proposed treatment, cognitive status and competency, surrogates role in future decisions): 35 (33.33 %)
2. Implementation of palliative care: 21 (20%)
3. Advance directives: 15 (14.28%)
4. Advice regarding alternative treatments and "miracle cures": 13 (12.38%)
5. Futile treatments: 7 (6.66%)
6. DNR orders: 6 ( 5.71%)
7. Truth telling: 4 (3.80%)
8. Challenges to develop a trustful surgeon-patient relationship: 2 (1.90%)
9. Surgical residents participation in the procedure. 2 (1.90%)
All the conflicts were managed satisfactorily, no need for change of surgical teams was required and no professional liability claims were filed in the following 23 months.
Conclusions:
- Ethical guidelines and expertise are needed in the management of gastrointestinal malignancies to achieve adequate and patient-oriented decision making
- Surgical decision making in these diseases need to include patient preferences, quality of life and contextual issues to provide sound surgical judgement, with preeminence of respect for autonomy
- Ethical conflicts will probably increase in the future and surgical ethics knowledge will prove to be at the core of surgical training
- A change of paradigm is envisioned to achieve and provide an optimal surgical care: from the curative model with the goal of curing to the palliative model with the concern to relief suffering