Ethics in cardiothoracic surgeryShould Sleep-Deprived Surgeons Be Prohibited From Operating Without Patients' Consent?
Introduction
The effects of sleep deprivation on performance of physicians has been widely studied ever since the death of Libby Zion in 1984, the subsequent campaign by her parents and others to regulate physician work hours, and the passage of the so-called Libby Zion Law by New York State in 1989 [1]. Impetus was added to investigations of the effects of sleep deprivation when the Accreditation Council for Graduate Medical Education (ACGME) adopted similar standards for accreditation of residency programs in the United States in 2003 [2]. While sleep deprivation clearly affects mental and physical functioning, results of investigations of clinical outcomes have been mixed—some finding adverse effects on patient care, others finding no such effects [3, 4, 5, 6].
The arguments for regulating work hours of residents have been extended to apply in a more limited way to attending surgeons. In a recent issue of the New England Journal of Medicine [7], two medical ethicists and a sleep specialist published a paper that opened with this scenario: “A surgeon on overnight call responds to an 11 pm call from the hospital, where a patient has presented with an acute abdomen. After working up the patient for several hours, the surgeon decides to … perform a bowel resection. By the time the procedure is completed … it is time for morning rounds. The surgeon has not slept all night and is scheduled to perform an elective colostomy at 9 am.”
The sleep specialists followed the vignette with a series of questions [7]: Does the surgeon have an obligation to disclose to the patient the lack of sleep during the past 24 hours and obtain new informed consent? Should the surgeon give the patient the option of postponing the operation or requesting a different surgeon? Should the hospital have allowed the surgeon to schedule an elective procedure following a night he was scheduled to be on call? Should it allow a surgeon to perform elective surgery after having been awake for more than 24 hours?
After discussion of the effects of sleep deprivation (fewer than 2 hours of sleep in the previous 24 hours), the researchers answered these questions in the affirmative, with these statements [7]: “Patients awaiting a scheduled elective surgery should be explicitly informed about possible impairments induced by sleep deprivation and the increased risk of complications.” “They should then be given the choice of proceeding with the surgery, rescheduling it, or proceeding with a different physician.” “If patients decide to proceed, they should explicitly consent to do so—in writing, on the day of the procedure, in front of a witness, and ideally on a standardized form designed for this purpose.”
In the same issue of the New England Journal of Medicine, three leaders of the American College of Surgeons responded to that paper in a letter to the Editor [8], agreeing that sleep deprivation could be a problem for surgeons, but disputing the necessity or wisdom of mandating a signed informed consent document. They argued that, instead, surgeons should be better educated about the effects of sleep deprivation as well as other factors that may affect performance, enabling them to weigh all issues to provide the best patient care. “A call for mandatory disclosure,” they stated, “essentially eliminates the necessary judgmental latitude surgeons should possess to determine their fitness for providing optimal patient care” [8].
In the essays that follow, two authors of those publications, Dr Charles Czeisler and Dr Carlos Pellegrini, present arguments on either side of the question of whether sleep-deprived surgeons should be required to obtain informed consent from patients before elective surgery.
Section snippets
Charles A. Czeisler, PhD, MD
More than 40 years ago, Drs Richard Friedman, Thomas Bigger, and Donald Kornfield from Columbia University College of Physicians and Surgeons in New York published a landmark paper as a Special Article in the New England Journal of Medicine [9]. In it, Friedman and colleagues reported that sleep deprivation—which was first reported to adversely affect human performance in a classic 1896 study of Patrick and Gilbert from the University of Iowa [10] and had already been documented to impair
Carlos A. Pellegrini, MD
Should a surgeon who has been awake for 22 of the previous 24 hours not be allowed to operate without the patient's written informed consent? My position is that informed consent is not the right solution.
The rationale for obtaining informed consent from this patient under the circumstances described above is as follows: The operation performed by a surgeon who has not slept for 22 hours imposes a higher risk. The patient has a right to know that there is an increased risk of complications
Robert M. Sade, MD
Czeisler presents strong and persuasive scientific evidence for detrimental effects of sleep deprivation. He and Pellegrini agree on several points: lack of sleep compromises neurobehavioral performance, and the ethical and legal standards for informed consent require that surgeons disclose to patients all material issues that can affect the outcome of a planned operation. Their main disagreements focus on the nature of the material risks posed by a surgeon's sleep deprivation and who should
References (71)
- et al.
Resident fatigue in 2010: where is the beef?
Am J Surg
(2011) - et al.
Acute sleep deprivation in the thoracic surgical resident does not affect operative outcomes
Ann Thorac Surg
(2005) - et al.
Effects of proprioceptive vibratory stimulation on body movement at 24 and 36 hours of sleep deprivation
Clin Neuro
(2008) - et al.
A syndrome of hypersomnia with automatic behavior
Electroencephalogr Clin Neurophysiol
(1975) - et al.
Altered states of consciousness in disorders of daytime sleepiness
J Neuro Sci
(1975) - et al.
Sleep deprivation increases cognitive workload during simulated surgical tasks
Am J Surg
(2012) Section 405.4-Medical staff. NY Comp Codes R & Reg. Title 10 § 405 (1989)
Accreditation Council for Graduate Medical Education
Medical and genetic differences in the adverse impact of sleep loss on performance: ethical considerations for the medical profession
Trans Am Clin Climatol Assoc
(2009)- et al.
The critical care safety study: the incidence and nature of adverse effects and serious medical errors in intensive care
Crit Care Med
(2005)
Sleep deprivation, elective surgical procedures, and informed consent
N Engl J Med
Sleep deprivation and elective surgery
N Engl J Med
The intern and sleep loss
N Engl J Med
Studies from the Psychological Laboratory of the University of Iowa
Psychol Rev
A further study of the effects of loss of sleep
J Exp Psychol
Blocking in mental and motor tasks during a 65-hour vigil
J Exp Psychol
Effects of the loss of 100 hours of sleep
Am J Psychol
Alpha depression and lowered pulse rate during delayed actions in a serial reaction test: a study in sleep deprivation
Acta Physiol Scand
Studies on the physiology of sleep: I. The effects of prolonged sleeplessness on man
Am J Physiol
Effects of lack of sleep
The effects of sleep loss on performance
Impaired performance with acute sleep loss
Psychol Monogr
The effect of sleep loss on component movements of human motion
J Appl Psychol
The effect of lack of sleep on visual watch-keeping
Q J Exp Psychol
Sleep and wakefulness
Psychophysiology of sleep and dreams
Extended work shifts and the risk of motor vehicle crashes among interns
N Engl J Med
The Gordon Wilson Lecture: Work hours, sleep and patient safety in residency training
Trans Am Clin Climatol Assoc
The human circadian timing system and sleep-wake regulation
Objective assessment of sleep and alertness in medical house-staff and the impact of protected time for sleep
Sleep
Sleep deprivation and vigilant attention
Ann NY Acad Sci
The cumulative cost of additional wakefulness: dose-response effects on neurobehavioral functions and sleep physiology from chronic sleep restriction and total sleep deprivation
Sleep
Sleep deficitThe performance killer
Harvard Bus Rev
Effect of reducing interns' weekly work hours on sleep and attentional failures
N Engl J Med
Sleep and circadian rhythms in humans
Cold Spring Harb Symp Quant Biol
Cited by (7)
The impact of shift work on pain recognition, a robust ability among intensive care nurses
2023, European Journal of Pain (United Kingdom)A Dedicated Orthopaedic Trauma Room Improves Efficiency while Remaining Financially Net Positive
2023, Journal of Orthopaedic TraumaNight-time surgery and the patient's best interest
2020, European Journal of Cardio-thoracic SurgeryThe Dedicated Orthopaedic Trauma Room Model: Adopting a New Standard of Care
2019, Journal of Bone and Joint Surgery - American VolumeFatigue Management in Safety-Critical Operations: History, Terminology, Management System Frameworks, and Industry Challenges
2015, Reviews of Human Factors and Ergonomics