Should sleep-deprived surgeons be prohibited from operating without patientsí consent?
Czeisler-CA; Pellegrini-CA; Sade-RM
Ann Thorac Surg 2013 Feb; 95(2):757-766
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 bear the burden of deciding whether an operation should go forward. A critical issue in this debate is the real-world question of whether and to what degree attending surgeons' lack of sleep affects the outcomes of their surgical procedures. Czeisler cites a single study of practicing surgeons-his group's recent paper found that complications after procedures were higher when surgeons were on call the night before than when they were not. Their study had several serious flaws; most important was absence of any data on the surgeons' actual time of sleep when on or off call-being on call does not necessarily mean lack of sleep, nor does off call necessarily mean a full night's rest. In response, Pellegrini cites several other studies that have shown no difference in surgical outcomes performed by sleep-deprived versus well-rested surgeons. None of the available studies has been well controlled. Such studies are needed, but it seems unlikely that we will ever have a randomized controlled trial evaluating the effects on surgical outcomes of various degrees of practicing surgeons' sleep deprivation. In the absence of reliable data, what should be done in the interest of patient safety? That question lies at the heart of this debate. In the face of uncertainty about the presence or degree of elevated risk to patients, we might wonder whether it is premature to mandate a consent process that is likely to confuse and frighten patients immediately before an operation, a time when they are not well situated to receive new information and make a thoughtful, deliberate decision. Perhaps the weight of making decisions about surgical procedures in the face of the surgeon's suboptimal sleep would best be borne by the institution and the surgical team, as well as by the surgeon. Mandated disclosure and written consent of the patient seem too blunt an instrument to advance the goal of patient safety. The mitigation strategies outlined by Pellegrini might better serve the interests of patients without violating their autonomy and informational needs. What will policy makers do with the facts, assertions, and beliefs presented in this debate, in this era of increasing regulation of the health care system? The policy of mandated work hours for physicians-in-training has been solidly entrenched for several years-such regulation may lie on the road ahead for practicing surgeons as well.
Sleep-deprivation; Neurophysiological-effects; Neurological-reactions; Neurological-system; Behavior; Surgeons; Medical-personnel; Health-care-personnel; Surgery; Risk-factors; Humans; Men; Women
Dr Sade, Medical University of South Carolina, 25 Courtenay Dr, Ste 7028, MSC 295, Charleston, SC 29425-2270
The Annals of Thoracic Surgery
Brigham and Women's Hospital