Regional ethics of surgeon resuscitation for organ transplantation after lethal injury.

BACKGROUND: Trauma patients may present with nonsurvivable injuries, which could be resuscitated for future organ transplantation. Trauma surgeons face an ethical dilemma of deciding whether, when, and how to resuscitate a patient who will not directly benefit from it. As there are no established guidelines to follow, we aimed to describe resuscitation practices for organ transplantation; we hypothesized that resuscitation practices vary regionally. METHOD: Over a 3-month period, we surveyed trauma surgeons practicing in Levels I and II trauma centers within a single state using an instrument to measure resuscitation attitudes and practices for organ preservation. Descriptive statistics were calculated for practice patterns. RESULTS: The survey response rate was 51% (31/60). Many (81%) had experience with resuscitations where the primary goal was to preserve potential for organ transplantation. Many (90%) said they encountered this dilemma at least monthly. All respondents were willing to intubate; most were willing to start vasopressors (94%) and to transfuse blood (84%) (range, 1 unit to >10 units). Of respondents, 29% would resuscitate for ≥24 hours, and 6% would perform a resuscitative thoracotomy. Respect for patients' dying process and future organ quality were the factors most frequently considered very important or important when deciding to stop or forgo resuscitation, followed closely by concerns about excessive resource use. CONCLUSION: Trauma surgeons' regional resuscitation practices vary widely for this patient population. This variation implies a lack of professional consensus regarding initiation and extent of resuscitations in this setting. These data suggest this is a common clinical challenge, which would benefit from further study to determine national variability, areas of equipoise, and features amenable to practice guidelines.

Decision-Making in Management of the Complex Trauma Patient: Changing the Mindset of the non-trauma Surgeon.

BACKGROUND: European surgeons are frequently subspecialized and trained primarily in elective surgical techniques. As trauma leaders, they may occasionally have to deal with complex polytrauma, advanced management techniques, differing priorities, and the need for multidisciplinary care. There is a lack of expertise, experience, and a low trauma volume, as well as a lack of research, with limited support as to the decision-making and teaching challenges present. We studied what experienced trauma experts describe as the challenges that are specific to the advanced surgical decision-making required, whether civilian, humanitarian, or military. METHODS: Design-based research using combined methods including interviews, reviews of authentic trauma cases, and video-recorded resuscitations performed at a high-volume civilian academic trauma center. RESULTS: Several educational dilemmas were identified: (1) thinking physiologically, (2) the application of damage control resuscitation and surgery, (3) differing priorities and time management, (4) impact of environment, (5) managing limited resources, (6) lack of general surgical skills, (7) different cultural behavior, and (8) ethical issues. CONCLUSION: The challenges presented, and the educational domains identified, constitute a basis for improved development of education and training in complex surgical decision-making. This study contributes new knowledge about the mindset required for decision-making in patients with complex multisystem trauma and competing priorities of care. This is, especially important in countries having a low intensity of trauma in both military and civilian environments, and consequential limited skills, and lack of expertise. Guidelines focused on the same decision-making process, using virtual patients and blended learning, can be developed.

Evidence-Based Care of Geriatric Trauma Patients.

The doubling of the geriatric population over the next 20 years will challenge the existing health care system. Optimal care of geriatric trauma patients will be of paramount importance to the health care discussion in America. These patients warrant special consideration because of altered anatomy, physiology, and the resultant decreased ability to tolerate the stresses imposed by traumatic insult. Despite increased risk for worsened outcomes, nearly half of all geriatric trauma patients will be cared for at nondesignated trauma centers. Effective communication is crucial in determining goals of care and arriving at what patients would consider a meaningful outcome.

[Ethical decisions in surgery. Foundations for a principle-oriented case discussion]. / Ethische Entscheidungen in der Chirurgie. Grundlagen einer prinzipienorientierten Falldiskussion.

BACKGROUND: Due to advanced medical interventions, the multitude of beliefs in our society, and increasing economic pressure, difficult ethical decisions are also part of the surgical care of patients. QUESTION: How can health care personnel address the ethical challenges in a structured, well-founded ethical manner? MATERIALS AND METHODS: Based on the four principles of biomedical ethics beneficence, nonmaleficence, respect for autonomy, and justice, we present a model for the step-wise ethical evaluation of difficult cases. RESULTS: The principle-based model of ethical case discussions consists of five steps: 1) In the medical analysis of the case, the available management strategies are identified, including a detailed description of their benefits and risks. 2) The evaluation starts with the ethical obligations towards the patient: Which treatment strategy is in the patient's best interest? And: Which option does the patient prefer herself after appropriate disclosure? 3) Then it has to be examined whether obligations to third parties (family members, other patients, etc.) have to be taken into account. 4) In the synthesis, the individual evaluations are integrated into an overall assessment of the case; conflicting obligations have to be balanced based on good reasons. 5) A critical review of the case concludes the case discussion. The application of the model is exemplified based on a surgical case discussion. CONCLUSION: Difficult ethical decisions can be supported by structured case discussions, in which all medical disciplines and professional groups involved in the care of the patient should participate.

[Changing the therapeutic goal in critically ill patients. Ethical analysis of a surgical case]. / Änderung des Therapieziels bei kritisch Kranken. Ethische Analyse eines chirurgischen Falles.

We report on a 32-year-old patient, who developed septic shock, toxic shock-like syndrome, and multiple organ failure following nectrotizing fasciitis. Amputations had to be performed on all extremities. Subsequently, she developed secondary sclerosing cholangitis. Treatment goals had to be reassessed, since long-term survival seemed doubtful and, in the best case, burdened with severe handicap. We discuss the evaluation of the treatment goals, utilizing a structured model of goal-setting. In the first step the treatment goal is identified based on the patient's wishes. This goal's realistic achievability is verified considering scientific evidence and medical experience. The benefit of the aspired goal is set in relation to risks and burden of the necessary treatment measures in a third step. The resulting benefit-risk ratio must be evaluated by the patient or her representative. Treatment goals have to be reevaluated if the assessment of achievability or the benefit-risk ratio are disadvantageous. In this case, the initial therapeutic goal was retained. After an extraordinarily prolonged and complex therapy including reconstructive surgery the patient is now living independently at home.

Bone regeneration: stem cell therapies and clinical studies in orthopaedics and traumatology.

Regenerative medicine seeks to repair or replace damaged tissues or organs, with the goal to fully restore structure and function without the formation of scar tissue. Cell based therapies are promising new therapeutic approaches in regenerative medicine. By using mesenchymal stem cells, good results have been reported for bone engineering in a number of clinical studies, most of them investigator initiated trials with limited scope with respect to controls and outcome. With the implementation of a new regulatory framework for advanced therapeutic medicinal products, the stage is set to improve both the characterization of the cells and combination products, and pave the way for improved controlled and well-designed clinical trials. The incorporation of more personalized medicine approaches, including the use of biomarkers to identify the proper patients and the responders to treatment, will be contributing to progress in the field. Both translational and clinical research will move the boundaries in the field of regenerative medicine, and a coordinated effort will provide the clinical breakthroughs, particularly in the many applications of bone engineering.