Ethics in IR

By Saumya Gurbani, G1, MD/PhD Program, Emory University

A 69-year-old male, with a history of recent atrial fibrillation and heart failure treated with an implanted defibrillator, presents to the hospital complaining of abdominal pain, nausea, and vomiting for the past four days. Based on his history and physical exam, his physician diagnoses him with apparent cholecystitis and requests a consult from the surgery and gastroenterology teams for treatment recommendations. The surgery team evaluates him and concludes that because of the patient’s multiple comorbidities (including COPD requiring oxygen) he would not be a good candidate for a gallbladder resection. The GI team also feels that his medical history contraindicated any procedure which would require anesthesia. They note that an MR cholangiopancreatography (MRCP) cannot be performed because of the patient’s implanted defibrillator. Both consulting teams recommend the primary team to request an interventional radiology consul to decide the next steps of treatment. A CT body fellow and IR attending are consulted by the primary medicine team and asked to perform a cholecystostomy.

At first glance, this may seem like a home-run case for the IR team. Here we have a patient where the traditional diagnostic and therapeutic procedures are contraindicated, and there is an acute need for a minimally-invasive intervention. Based upon the recommendations of the surgery and GI teams, the primary medical team assumes that IR will happily perform the procedure. Within the clinical environment at this hospital, the IR team is seen as a critically important members of the multidisciplinary team and has been given the opportunity to show the possible effectiveness of a novel treatment. But per IR guidelines, this patient is not a good candidate for a cholecystostomy. He has too many co-morbidities and based upon the multiple ultrasounds of his gallbladder, the radiologists are unsure that the intervention will work. As a result, the IR team is placed in a difficult situation as the last resort consult. In addition to determining if an IR procedure is medically appropriate for this patient, the team must also decide whether the procedure is indicated for this patient. The other specialties have declined intervention, and yet the patient and primary medical team both expect an intervention from IR. The IR fellow and attending are left with the responsibility of either finding an alternative course of action to alleviate the patient’s symptoms, or being morally (if not legally) responsible for ruling that the patient’s pathology is untreatable. This is a decision that would have to be made no matter which specialty became the consult of last resort – but should this burden be placed on any one team?

This article is not intended to highlight flaws in this particular case but to emphasize the need for early and open communication between all members of a multi-disciplinary treatment team. In particularly difficult cases, all relevant specialties must communicate with each other early and often. This is particularly true with regards to making decisions about the final care of a patient, as communication helps to avoid  unintentionally placing the burden on a single service.

A similarly challenging scenario was published as a Letter to the Editor in a 1997 issue of the Canadian Association of Radiologists Journal. In that case, a patient was suspected to have a hepatoma but had comorbidities that served as a contraindication for the standard-of-care chemotherapy. A radiologist was consulted on day eight of the patient’s hospital stay for performing a liver biopsy, but ruled that it was unsafe. Because this radiologist made the final call not to intervene, he was ultimately burdened with with the legal liability for the patient’s clinical fate if there was no intervention (i.e., if he did not perform the biopsy). He was named the responsible party for an entire cascade of decisions regarding whether or not to intervene.  Is it fair for to leave interventional radiologists with the final decision to intervene or not? Is there a risk that interventional radiologists will feel pressured to bend their appropriateness criteria to favor intervention for complicated patients that all other services have signed-off on because of the future risk of litigation from non-intervention? These questions raise professional ethical concerns with additional legal ramifications. These complicated  patients were being treated by several different medical specialties, but ultimately the burden of responsibility fell to the radiologist and not to the whole medical team. How can these multi-disciplinary teams better support each other and avoid making IR the unintentional final arbiter for intervention?

Interdisciplinary and multidisciplinary collaborations have been shown to be remarkably successful at improving patient care by encouraging better communication, coordination, and more effective care by putting the patient at the center of the clinical workflow. However, it is important to recognize that despite these efforts, it is possible in certain cases for a single party to be unintentionally burdened with the responsibility of the patient’s care. When cases are particularly complicated, all of the possible treatment teams should be consulted as early as possible so that they can avoid pressuring one team to intervene outside of their recommended standards. It’s not about assigning blame, but rather about sharing the ethical responsibility.  

In our initial patient’s case, IR declined intervention. The patient was treated conservatively with fluids and antibiotics, and was monitored as an inpatient. After six days, the patient showed significant improvement, and was discharged home with close primary care follow-up.

Acknowledgements: I would like to thank Ms. Sarah Dupont, a medical student at Emory University, who observed this case and provided, with permission, the relevant clinical details. This case does not represent the opinions (clinical or otherwise) of Emory University, its physicians, staff, or students.

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