Ethical Tenets of Perioperative Care: “Finding My Surgical Way Home”

Abstract

In the course of their daily practice, anesthesiologists are confronted with a number of conventional ethical issues connected to situations ranging from informed consent to endof-life decision making [1]. The specialty of anesthesiology has recently evolved to include not only critical care and pain medicine but also perioperative medicine. The full spectrum of perioperative expertise is manifest in the perioperative surgical home (PSH), a new and innovative care model initially developed and now being widely advocated by the American Society of Anesthesiologists (ASA) in close collaboration with vital surgical, nursing, health care administrative, and payer stakeholders [2]. The PSH is a patient-centered, institutionled, interdisciplinary, team-based, coordinated, and-where possible-standardized care model that guides the patient from presurgical decision making to postdischarge care [3,4]. The PSH seeks to improve the surgery experience and outcomes and to add measurable value to the highest-cost segment of health care.The PSH holds significant potential to make health care more patient-centered [3]. Within its broad scope of responsibility, this innovative care model, if given the resources, can effectively address ethical issues in surgical patient care. In this paper, after describing the fundamentals of the PSH, we discuss two controversial and highly charged issues with significant ethical ramifications for anesthesiologists: patient-centered decision making and futility of care.An Overview of the Perioperative Surgical Home Multiple variants of the PSH will be implemented based upon institutional infrastructure, resources, and other factors [3][4][5]. Our prototypic PSH model at the University of Alabama at Birmingham (UAB) integrates the heretofore frequently fragmented preoperative, intraoperative, postoperative, and postdischarge phases of patient care [3]. It is based on the anesthesiologist's serving as the surgical patient's perioperativist-the primary physician who coordinates care with other team members to provide seamless continuity from preoperative evaluation to postoperative care. In the UAB PSH model, an anesthesiologist works in tandem with a nurse practitioner and a registered nurse (or social worker) case coordinator to provide, coordinate, and integrate pre-, intra-, and postoperative care. This team is readily available to address the patient's questions or concerns about his or her care and oversees the patient's transitional and rehabilitation plans on hospital discharge [3].The UAB PSH model also involves a multimodal approach, often referred to as "fast-track surgery," in which not only surgeons, anesthesiologists, and nurses but also pharmacists, physical/occupational therapists, nutritionists, and social workers are equal participants of