MandM conferences provide forum for discussion of ethical issues

Morbidity and mortality (M&M) conferences provide a forum for surgeons to discuss adverse events, learn from mistakes, and improve systems-based practices. They are a central component of surgical resident education and address the Accreditation Council for Graduate Medical Education’s (ACGME) core requirements for resident education: patient care, medical knowledge, systems-based practice, practice-based learning and improvement, professionalism, and interpersonal communication skills.^1-3 Even though case presentations generally focus on technical errors and adverse outcomes, they often address broader issues in patient care. Presenters frequently highlight complexities in the health care system, safety concerns, communication breakdowns, and ethical issues related to the care provided.⁴ M&M conferences have become a cornerstone of patient safety and quality improvement initiatives.¹

One aspect of M&M conferences that has received little attention is the frequency and types of ethical issues that are raised in these meetings. The University of Toronto, ON, has created M&M conferences that make ethical issues the central focus of discussion; however, examination of ethical issues in general M&M conferences is rare.⁵ To determine the frequency and types of ethical issues that arise in M&M conferences, the authors conducted an observational study of the ethical issues raised at surgical M&M conferences at Vanderbilt University, Nashville, TN.

The goal of this study was to identify and categorize ethical issues raised in the department’s weekly surgical M&M conferences. The primary objective was to determine the frequency and variety of ethical issues raised at M&M conferences so as to make recommendations regarding focused surgical ethics education, determine areas for further research, and provide insight into the value of a clinical ethicist’s participation in these conferences.

Materials and methods

The authors conducted an institutional review board-approved observational study of surgical M&M conferences at our institution between July 15, 2014, and January 15, 2015. Two observers independently recorded each ethical issue raised in M&M conferences and categorized them according to the Armstrong Clinical Ethics Coding System (ACECS).⁶ ACECS is a comprehensive coding system for clinical ethical issues developed to enable ethics consultation services to track the types and complexity of issues they address. It includes nine categories: treatment decision making, substitute decision making, end-of-life, professionalism, reproduction, death and postmortem, resource allocation, research, and organizational ethics. Each category has several subcategories, for a total of 129 distinct codes for a range of clinical ethical issues.

We gathered all data in real time during M&M conferences; no audio or video recordings were made. Differences between the observers’ coding assignments were reviewed with the team’s clinical ethicist to achieve consensus on the final code assigned. Ten services presented cases during this period: vascular surgery, hepatobiliary and liver transplant surgery, trauma, emergency general surgery, surgical intensive care, oncology and endocrine surgery, burn, minimally invasive surgery, colorectal surgery, and renal transplant. All presenters were residents and fellows. Faculty in the audience asked questions and provided comments. The presentations were informally structured, so the presenter and attending mentor determined the content. The demographic data collected for each case included patient age and gender. Cases that did not raise ethical issues were documented as having no ACECS code. The main outcome measures were the frequency and types of ethical issues raised at M&M conferences.

Results

We observed 123 case presentations. The average patient age was 55.1 years; 47 patients were female (38.2 percent), 75 were male (61.9 percent), and one was unreported (0.8 percent). Morbidity was the focus of 81 (65.9 percent) of the cases, and mortality was at the center of 42 (34.1 percent) of the cases discussed. A total of 157 distinct ethical issues were identified. At least one ethical issue that corresponded to an ACECS code was raised in 79 (64.2 percent) cases; no ethical issued classified under ACECS in 44 cases (35.8 percent). One ethical issue emerged in 36 cases (29.3 percent), two ethical issues arose in 19 (15.4 percent) cases, three in 14 (11.4 percent) cases, four in five (4.1 percent) cases, five in four (3.3 percent), and six in one (0.8 percent). In only one of these 123 cases did the presenter mention calling upon the institution’s ethics consultation service.

Ethical issues from seven of the nine major ACECS categories were raised during M&M conferences (see Figure 1). The most common categories were treatment decision making, end of life, and professionalism.

Figure 1. Distribution of ethical issues by ACECS category

The ethical issues relating to treatment decision making fell into seven subcategories (see Figure 2), the most common being clinical candidacy or risk/benefit analysis. This issue arose, for example, in the discussion of a patient in her late 80s with declining health, prolonged hospitalization, and nonhealing lower extremity ulcers. The presenter reported that the patient care team decided to do a lower extremity bypass. M&M conference attendees questioned whether an amputation should have been performed rather than a bypass, given the low likelihood that the patient would ever walk again. The attending responded by indicating that in this situation the team was trying to offer hope to the patient and her family because they were having trouble accepting amputation as the operative option. The subsequent discussion focused on the risks and benefits of the possible procedures versus nonsurgical care.

Figure 2. Subcategories of ethical issues within treatment decision making

The subcategorization of ethical issues raised under end of life is shown in Figure 3. The most common subcategories were resuscitation for full arrest, withhold or withdraw life-sustaining treatment, and palliative care/symptom management. Whenever a case discussion noted the initiation of cardiopulmonary resuscitation (CPR), this treatment was categorized as resuscitation for full arrest. Of the 21 cases in which CPR for full arrest was mentioned, 18 ended in mortality, either from unsuccessful resuscitation or a subsequent decision to withdraw life-sustaining interventions. Of the 21 cases in which palliative care was mentioned, 18 resulted in mortality, and only one overlapped with the mention of CPR for full arrest. These results suggest that the patients who underwent CPR rarely had a palliative care consultation.

Figure 3. Subcategories of ethical issues raised within end of life

The three subcategories of professionalism in which ethical issues were raised pertained to care coordination, information disclosure, and medical error or adverse event (see Figure 4). Most of these cases were classified under medical error or adverse event. This distribution could be anticipated as M&M conferences focus on error and adverse events. Some of the errors described were technical, such as a cautery injury to the small bowel or improper technique in placing a peritoneal dialysis catheter. However, others were more focused on errors that occurred outside of the operating room, such as inappropriate orders placed by consulting services, improper preoperative cardiac workup, or inadequate supervision of residents during bedside procedures.

Figure 4. Subcategories of ethical issues raised within professionalism

Findings

This study demonstrates that presentations in surgical M&M conferences raise a variety of ethical issues, which reflect some, if not most, of the practical issues that surgeons face in clinical practice. The frequently raised ethical issues provide a road map for focusing surgical ethics education on these common scenarios. For example, surgical ethics education should include learning how to disclose and address adverse events, determining when surgeons should operate rather than when they can operate, negotiating resuscitation plans, understanding when to involve the ethics consultation service or the palliative care team, and deciding when to transition to comfort care.

Moreover, this study shows that M&M conferences frequently raise ethical issues. Training programs could take more determined steps to include discussions of ethical issues in M&M conferences, either through dedicated conferences focused on ethics or by including clinical ethics faculty in regular M&M conferences.

Dedicated ethics M&M conferences have been piloted at the University of Toronto with excellent results in changing participants’ perceptions of ethical issues and confidence in managing them.⁵ Having a clinical ethicist available gives presenters the opportunity to clarify ethical issues to learn about the underlying ethical standards and precedents that guide their analysis and resolution. As with other clinical points discussed in M&M conferences, the goal of such ethical instruction is to ensure that surgeons are better prepared to address similar issues in the future.

Furthermore, the results of this study offer an opportunity for continuous quality improvement through the identification of common ethical issues that could be avoided or minimized with changes in practice. For example, in this study, there was little overlap between patients who underwent CPR and those who had palliative care consults. Early involvement of palliative care teams for patients needing high-risk operations could help with making end-of-life decisions, developing rational plans for resuscitation, and deciding when to transition to comfort care.

Limitations

This study has several limitations. First, M&M conferences focus on adverse outcomes; therefore, the types and frequency of ethical issues discussed in these conferences are an incomplete reflection of the ethical issues that surgeons encounter daily. Nonetheless, whereas ethical issues often arise in cases that result in complications—the cases presented in M&M conferences—the data gathered likely represent many of the ethical issues that surgeons face in clinical practice.

Second, the codes recorded by the two observers were compared and combined after each conference to capture all of the issues raised, rather than with a focus on the inter-rater reliability of the ACECS coding system. The authors determined that this process was the most effective way to capture the relevant data given the real-time nature of the observational study and the complexity of the ACECS coding system. In the future, we hope to develop a more focused coding system for surgical ethics that will be simpler for use in real time. The American College of Surgeons recognizes the importance of ethics education for all surgeons, as evidenced by its 2017 publication Ethical Issues in Surgical Care,⁷ and such a coding system could help programs identify target areas for practice-based ethics instruction.

Third, this study did not distinguish between the mere mention of a topic versus in-depth discussion. To achieve this level of analytic detail, it would be best to make audio recordings of these conferences for a grounded theory analysis. Nonetheless, the study’s findings indicate that ethical issues frequently arise in M&M conferences and point to an opportunity to further ethics education in these conferences.

References

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