The Ethics of Trauma Care: What Interventional Radiologists Should Know

The last issue of Seminars in Interventional Radiology highlighted multiple ways interventional radiologists (IRs) can play a vital role in trauma care. However, this care can also raise multiple ethical challenges that differ from other areas of practice. One main difference is the urgency at which decision-making occurs, prohibiting extensive deliberation and discussion. In this article, we use a case to discuss three salient ethical issues that may arise when answering an IR trauma consult: allocation of limited resources, emergent consent, and requests for potentially inappropriate interventions. We conclude with a stepwise framework for navigating an ethically challenging trauma case.

Case

You are covering a small suburban community hospital. There is a mass shooting at a nearby concert. Multiple victims have arrived and been assessed by the trauma team with more en route. You are consulted for emergent interventions for three patients who are unstable with active extravasation. You are told one is a young mother with a grade 4 renal laceration, one is an elderly man with dementia and bleeding external iliac pseudoaneurysm, and one is the shooter who was shot by police with a large retroperitoneal bleed from multiple lumbar arteries. You only have staffing to run one fluoroscopy suite. Who do you treat first?

Distributive Justice

One set of ethical dilemmas that can arise in the setting of a mass trauma is the need to triage and allocate limited resources. ^{1 2} This tends to be less common in resource-rich settings with much of current thinking arising out of acute care in resource-poor and combat settings. ¹ Distributive justice is the general term for the socially just allocation of resources, which often involves a balance between a commitment to prioritize less advantaged, sicker patients (the principle of difference) and a commitment to achieve the greatest good with the available resources (the principle of utility). ³ For example, the three patients described earlier should be prioritized over a fourth patient who may benefit from embolization but is stable. One may also prioritize these three patients over a fifth patient with multiple gunshot wounds including through the skull who is actively being coded and unlikely to survive the trip to the fluoroscopy suite.

Situations become more challenging in settings like the case above where multiple patients are of similar acuity and potential benefit from treatment. This is where consideration of comorbidities and alternative treatment options become particularly relevant. ^{1 2} Often there are less optimal alternatives that can be used to treat patients who are not prioritized. For example, the mother with a grade 4 renal laceration could undergo emergent nephrectomy in lieu of emergent embolization. This is not ideal, but she may have a substantially higher chance of surviving surgery than the elderly man with dementia who likely has other comorbidities. Similar decision-making also occurs outside the trauma setting in IR. For example, overnight lysis for large burden venous thrombosis may be considered ideal, but mechanical thrombectomy is performed to conserve limited intensive care unit beds during a pandemic. ⁴ Although this runs counter to a commitment to always do “the best thing” for each patient, it is generally accepted that clinicians also have an obligation to the larger community that may outweigh marginal benefits between treatment options in certain settings. ⁵

Perhaps the most important point here is what criteria are not acceptable means of resource allocation. The Geneva Convention and other similar standards forbid use of race, gender, ethnicity, nationality, or social status in making these determinations. ^{1 5} In the case example, it is reasonable to feel greater sympathy for the mother and elderly man than the shooter. However, it is not appropriate to choose to save the mother and elderly man merely because they are not the shooter. Additional more debated criteria are age and chronic impairments. Some argue that these factors are equivalent to race or gender, while others view them differently. For instance, age, unlike race and gender, is something everyone experiences and is currently used in organ allocation. Thus, some argue that a 20-year-old should take priority over an 80-year-old person, all else being equal, because the 80-year-old has had 60 more years of opportunities that would be deprived from the 20-year-old. ⁵ Chronic impairment is challenging because it is not something we all experience and may limit someone's chance of benefit. It would not be appropriate to deprioritize someone because they cannot see or hear but a neuromuscular disorder could become relevant if it limits someone's ability to survive an intervention.

Often institutions have triage policies in place. Given IR's role in trauma care, it would be beneficial to be familiar with the policies at one's institution to know, for example, who are the decision-makers and what additional support is available in the setting of mass trauma.

Case Continued

A shared decision is made with the trauma team to treat the elderly man first while the mother is taken for nephrectomy, and attempts are made to stabilize the shooter in the trauma bay while awaiting embolization. The elderly man is conscious, and the IR team attempts to obtain consent while en route to the fluoroscopy suite. He know his name, the date, and where he is but seems confused about what has happened. Just prior to losing consciousness, he states that he knows has been shot and that he has lived a good life and others should be saved instead of him. The emergency medical team reported he had a spouse with him at the scene, but they were separated and have been unable to locate her.

Capacity, Consent, and Surrogate Decision-Making

Informed consent and shared decision-making are critical for fostering trust, which is at the core of the patient–clinician relationship. ⁶ Clinicians are both legally and ethically obligated to empower patients, or their surrogate decision-maker, with an understanding of the risks, benefits, and alternatives of a potential treatment so that they can make an informed decision. ^{7 8} However, this is not always feasible in emergencies such as trauma where death or harm is imminent without emergent intervention. This is one of the few clinical situations where it is permissible to proceed with an intervention based on presumed consent and the best interest principle. ^{7 9} In other words, if there is insufficient time to obtain informed consent, it is acceptable to proceed with the intervention if one can reasonably assume the patient would provide consent if they could (presumed consent) and the intervention is in the patient's best interests.

The aforementioned case is slightly more complex in that there is some time to obtain at least verbal consent prior to the procedure, and in such a situation, we owe it to patients to attempt to have a consent conversation even if it may be abbreviated. ⁹ To provide consent, one must have competency, capacity, and be of certain age or meet other criteria that vary by state and country. ¹⁰ Competency is global legal determination. If someone has been deemed legally incompetent, they by definition do not have capacity. ⁸ Capacity is specific to the decision and point in time and can be determined by any trained medical professional. To have capacity for a particular decision, one must be able to convey an understanding of the situation, appreciate for the risks and benefits of different options, and express coherent reasoning for a particular choice. ^{7 11} If someone does not have capacity, a surrogate can make the decision on his or her behalf. ⁹ Important pitfalls include assuming that someone lacks capacity merely because he or she has a condition like dementia or lacked capacity previously. Similarly, preappointed surrogate decision-makers, such as a durable power of attorney, get to make decisions only when the patients themselves cannot. If the patient lacks capacity and no surrogate can be found, it is appropriate to rely on the best interest principle described previously. ^{7 12} Social workers can be invaluable for identifying advance directives and family members, but acute trauma care often limits the time available for extensive searches.

The elderly man in the case has dementia and is mildly confused about the situation, but is otherwise alert and oriented, understands he has been shot, and realizes that he will likely die without treatment. It is not uncommon for trauma patients with penetrating injuries to be in shock, both physiologically and psychologically, so it is reasonable to question decisions such as the elderly man's request to die. ¹² This is particularly true when the planned intervention has a high likelihood of success. It is not necessary that the request is unreasonable. Consider if his partner was present and confirmed that the patient had declared himself been DNR/DNI (do not resuscitate/do not intubate) with a POLST (physician order for life-sustaining treatment) and would not want the procedure. However, without additional time to discuss the decision with the patient or additional evidence to support his reasoning, it is justifiable to proceed with the intervention.

Requests for Potentially Inappropriate Procedures

Another salient set of ethical challenges involve requests for potentially inappropriate procedures, those that are unlikely to achieve a meaningful outcome. ¹³ These requests are not uncommon in IR, ¹⁴ particularly in the setting of a chronic critical illness such as requests for multiple biliary drains in the setting of malignant obstructive jaundice or gastrostomy tube in the setting of severe dementia. It the setting of acute trauma, IRs may be more willing to attempt a heroic intervention even with marginal chance of benefit if it is the patient's only option. ¹⁴ However, this must be weighed against the just use of available resources and an ethical obligation to avoid futile care—interventions that are clearly unable to achieve the intended outcome. For example, the trauma patient with multiple gunshot wounds, including through the skull, who is actively being coded in the trauma bay is unlikely to survive the trip to the fluoroscopy suite let alone the requested embolization.

This topic is important because a disproportionate amount of spending occurs near the end of life, ¹⁵ this care may not align with patients' goals, ^{16 17} and providing care that one views as futile is independently associated with burnout among clinicians. ¹⁸ Often these cases are not clearly futile and are challenging because it is difficult to predict the exact likelihood of procedural success. Furthermore, the perceptions of a meaningful outcome or what makes something “worth it” can vary dramatically between patients. ^{16 17} This is why current critical care and ethics guidelines advocate for the term “potentially inappropriate procedures” to convey the tentative and value-laden nature of these assessments. ¹³ This is also why attempts to establish definitive, objective criteria for futility have been futile themselves. ¹⁷ In light of these challenges, a consistent approach that regularly makes use of goals of care discussions and other advance care planning is likely more helpful than a rigid definition. This involves semistructured conversations to clarify expectations, values, and preferences prior to an intervention and that have consistently been shown to improve satisfaction and reduce anxiety and costs near the end of life. ^{19 20}

Much like consent, robust goals of care discussions are not always feasible in the setting of acute trauma. However, the authors believe an abbreviated assessment of a patient's perceptions and values surrounding an intervention can be blended into the consent conversation by paying close attention to how patients describe their understanding, risks, benefits, and reasoning. For example, if the elderly man had not lost consciousness, asking him why others should be saved instead of him or whether he would feel the same way if he was the only one hurt would have likely been revealing. These conversations are perhaps even more relevant after acute stabilization of a major trauma. Consider if the patient with the gunshot wound to the head survived but is in a persistent vegetative state. A request for a gastrostomy tube in this patient or biopsy of an incidentally found thyroid nodule should prompt the goals of care discussion.

Conclusion

Allocation of limited resources, emergent consent, and requests for potentially inappropriate procedures are all important ethical issues that can arise when caring for trauma patients in IR. It is also worth considering what we owe our patients and communities in terms of preventing trauma and follow-up care. Is it IR's “lane” to advocate for gun safety and equitable access to trauma care across in underserved communities? ²¹ These are challenging questions but important because facing these ethical questions without support can lead to moral distress and burnout. ^{2 18} Thus, at a specialty level, it may be beneficial to develop resources and fora to support IRs who regularly face these questions. Individually, IRs may familiarize themselves with their local policies related to trauma and surrogate decision-making. The authors also suggest a stepwise framework in Table 1 for reference. This is our lane.

Table 1. Framework for approaching an ethically challenging IR trauma consult.

1. Are resources limited to the point that you will have to treat some patients differently than you would otherwise?

Yes—Check institutional triage policies. Avoid use of race, gender, ethnicity, nationality, and social status in triaging care

No—Proceed to no. 2

2. Does the patient have capacity?

Yes—Obtain consent and assess preferences/goals of care. Proceed to no. 3

No—Is there time to find a surrogate?

Yes—Choose appropriate surrogate (country/state specific). 10 Obtain consent and assess goals of care. Proceed to no. 3

No—Proceed with procedure if the patient would likely agree to it and it is in their best interests

3. Is the requested procedure unlikely to achieve the goals of care?

Yes—Discuss with referring team. Follow critical care guidelines if disagreement 13

No—Proceed with the procedure

Funding Statement

Funding None.