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You have been on the surgical oncology service for the past 2 weeks. During that time, you have been involved in the care of a 45-year-old gentleman who has had a pancreaticoduodenectomy performed for pancreatic carcinoma. The patient has had a number of complications associated with leaks from his operation and has required percutaneous drainage. His pathology report has come back that shows positive nodes as well as a positive margin. Based on this information, you know that his overall prognosis is poor. The patient has confided in you his desire not to have his life artificially prolonged unnecessarily. Nevertheless, as he has deteriorated and required intubation and pressors for his sepsis, his family has proceeded with a very aggressive course of treatment in accordance with the recommendations of the surgical attending. You believe that perhaps the patient’s wishes have been discounted by the family and the attending surgeon.

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1. How should you approach this issue?

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2. Who would be the appropriate person with whom to raise your concerns?

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Morality in the Surgical Intern

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Answers
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  1. As a junior member of the surgical team caring for the patient, it can be easy to lose track of the fact that the resident actually has a relationship with the patient and, as a result, responsibilities to the patient. The complicating factor, however, is that your relationship with your patient is not in isolation, but rather is present because of the relationship that the patient has with the attending surgeon. In an elective situation such as this, the patient has made the choice to have the attending surgeon operate on him. The relationship between the attending surgeon and the patient certainly arose prior to the relationship between the resident and the patient. As a result, the issues that are concerning you may have already been addressed preoperatively with the patient or postoperatively with the patient’s family.

  2. For the reasons noted above relating to the relationship between the attending surgeon and the patient, as a resident, you should communicate your concerns to the attending surgeon. This is best done as a private discussion between you and the attending surgeon and not in the presence of the other members of the team or in front of the family. Although frank discussions and a vigorous debate of alternative approaches to a complex patient’s care should occur in any teaching environment, ethical issues may be particularly emotionally charged for all involved and are best done privately. In such a context, the resident’s concerns can clearly be expressed as being focused on the patient’s interests and not misinterpreted as being a challenge to the attending surgeon’s ethics or judgment.

  3. For the reasons noted in question #1, the relationship between the resident and patient must always be seen in the broader context of the relationship between the attending surgeon and the ...

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