The Evolution of the Ethical Guidelines of the American Society of Anesthesiologists.

In 1992, the American Society of Anesthesiologists Committee on Ethics was formed primarily to address the rights of patients with existing Do-Not-Resuscitate orders presenting for anesthesia. Guidelines written for the ethical management of these patients stated that such orders should be reconsidered-not rescinded-thus respecting patient self-determination. The Committee also rewrote the reigning Guidelines for the Ethical Practice of Anesthesiology by expanding its ethical foundations to reflect the evolving climate of ethical opinions. These Guidelines described ethically appropriate conduct and behavior, including anesthesiologists' ethical responsibilities to patients, themselves, colleagues, health-care institutions, and community and society.

Managing the Labyrinth of Complex Ethical Issues in Anesthesia Practice: The Anesthesiologist's Ariadne's Thread.

Facing ethical dilemmas is challenging and sometimes becomes a real burden for anesthesiologists, particularly because they rarely have previous or long-standing patient relationships that help inform clinical decision-making. Although there is no ideal algorithm that can fit all clinical situations, some basic moral and ethical principles, which should be part of every clinician's armamentarium, can guide the decision-making process. Dealing with conflicting views among providers and/or patients can be distressing but can lead to meaningful professional and personal growth for each clinician.

Ethics Consultation in Anesthesia Practice.

Because modern surgical and medical care have advanced, patients increasingly present for procedural and surgical intervention with life-limiting diagnoses and/or advanced care goals such as "do not resuscitate." Anesthesiologists now care for these patients across the complete perioperative setting and frequently find themselves at the crossroads of these mounting pressures. As the boundaries and capabilities of anesthetic care and critical care anesthesiology expand so too do the specialty's needs for support in ethical decision-making. Herein, we review the role of the ethics consultation in anesthesia practice and special ethic issues encountered by the anesthesiologist.

Disclosure of Adverse Events and Medical Errors: A Framework for Anesthesiologists.

Ethical disclosure of adverse events (AE) presents opportunities and challenges for physicians and has unique ramifications for anesthesiologists. AE disclosure is supported by patients, regulatory organizations, and physicians. Disclosure is part of a physician's ethical duty toward patients, supports fully informed patient decision making, and is a critical component of root cause analysis. Barriers to AE disclosure include disruption of the doctor-patient relationship, fear of litigation, and inadequate training. Apology laws intended to support disclosure and mitigate concern for adverse legal consequences have not fulfilled that initial promise. Training and institutional communication programs support physicians in providing competent, ethical AE disclosure.

Public Good versus Private "Goods": Ethical Implications of Drug Shortages on Anesthesiology Practice.

Drug shortages remain a serious and widespread problem affecting all health systems and patients. Anesthesiology practice is strongly impacted by shortages of sterile injectable drugs, resulting in a negative impact on the quality of care. Understanding the root causes of drug shortages guides the anesthesiologist toward an ethical response. While rationing is a common consideration in secular ethics, and indeed rationing strategies are utilized, the use of rationing alone risks normalizing and perpetuating the drug shortage problem. Drug shortages are the direct result of a market failure brought on by lack of oversight of drug production standards in some cases as well as by the impact of intermediary purchasing groups on costs and availability of drugs. Legislation needs to reestablish a responsible, competitive, and robust manufacturing drug market.

The way towards ethical anesthesia care: no aim - no game - no fame or blame?

PURPOSE OF REVIEW: This review explores the intricacies of ethical anesthesia, exploring the necessity for precision anesthesia and its impact on patient-reported outcomes. The primary objective is to advocate for a defined aim, promoting the implementation of rules and feedback systems. The ultimate goal is to enhance precision anesthesia care, ensuring patient safety through the implementation of a teamwork and the integration of feedback mechanisms. RECENT FINDINGS: Recent strategies in the field of anesthesia have evolved from intraoperative monitorization to a wider perioperative patient-centered precision care. Nonetheless, implementing this approach encounters significant obstacles. The article explores the evidence supporting the need for a defined aim and applicable rules for precision anesthesia's effectiveness. The implementation of the safety culture is underlined. The review delves into the teamwork description with structured feedback systems. SUMMARY: Anesthesia is a multifaceted discipline that involves various stakeholders. The primary focus is delivering personalized precision care. This review underscores the importance of establishing clear aims, defined rules, and fostering effective and well tolerated teamwork with accurate feedback for improving patient-reported outcomes. The Safe Brain Initiative approach, emphasizing algorithmic monitoring and systematic follow-up, is crucial in implementing a fundamental and standardized reporting approach within patient-centered anesthesia care practice.

Ethical and practical considerations of pediatric refusal in clinical anesthesia: An educational review.

Children commonly refuse induction of anesthesia. Anesthesia providers must then decide whether to honor the child's dissent or to proceed over objection. In some circumstances, a forced induction involves restraining the child, incurring both practical and ethical harms to the patient-provider encounter. This educational review explores the practical dilemma encountered when a child dissents to induction of anesthesia. In the course of exploring this dilemma, dissent and associated terms are defined and compared, and the prominent ethical underpinnings regarding pediatric decision-making are described to clarify dissent as an ethical and practical concept. Important legal and professional standards are summarized, and practice trends are discussed to depict the current state of practice, including novel approaches to honoring pediatric dissent for elective surgeries. This information is then used to invite providers to consider where they ethically situate themselves within a legally and professionally defined space of acceptable practice. Finally, these considerations are synthesized to discuss important nuances regarding pediatric refusal, and some key questions are presented for clinicians to ponder as they consider their practice of choosing whether to honor pediatric dissent at induction.

The debate rages on: physician-assisted suicide in an ethical light.

The British Medical Association and some Royal Colleges have recently changed their stance on physician-assisted suicide from 'opposed' to forms of 'neutral'. The Royal College of Anaesthetists will poll members soon on whether to follow suit. Elsewhere neutrality amongst professional bodies has preceded legalisation of physician-assisted suicide. We examine the arguments relevant to the anaesthesia community and its potential impact in the UK.

Informed consent in anesthesiology: An exploratory study / El consentimiento informado en anestesiología: un estudio exploratorio / Consentimento informado em anestesiologia: um estudo exploratório

Abstract: In the literature Informed consent (IC) assumptions is well established. However, the different stages and the conditions under which the IC for anesthetic practices is obtained, is scarce. The aim of the present study is to explore the phases and conditions of IC in anesthesiology. Anonymized clinical records of 325 patients submitted to anesthetic procedures at the Institute of Oncology of Porto were analyzed. A total agreement between the anesthetic techniques established in the IC and those performed, was reach with 270 patients. The importance of IC in clinical practice is discussed and an ideal process for IC is argued.

Resumen: El consentimiento informado (CI) está bien establecido en la literatura. Sin embargo, la información sobre las diferentes fases y condiciones en las que se obtiene el CI para las prácticas anestésicas es escasa. El objetivo del presente estudio es explorar las fases y condiciones de obtención de la CI en anestesiología. Se analizaron las historias clínicas anónimas de 325 pacientes sometidos a procedimientos anestésicos en el Instituto de Oncología de Oporto. Se alcanzó una concordancia total entre las técnicas de anestesia establecidas en el CI y las realizadas con 270 pacientes. Se defiende la importancia del CI en la práctica clínica y se discute un proceso ideal para obtenerlo.

Resumo: Na literatura o Consentimento Informado (CI) é bem estabelecido. Contudo, a informação sobre as diferentes fases e as condições em que o CI para práticas anestésicas é obtido, é escassa. O objetivo do presente estudo é explorar as fases e condições da obtenção do CI em anestesiologia. Foram analisados os registos clínicos anónimos de 325 pacientes submetidos a procedimentos anestésicos no Instituto de Oncologia do Porto. Foi alcançado um acordo total entre as técnicas anestésicas estabelecidas no CI e as realizadas, com 270 pacientes. A importância do CI na prática clínica é defendida e discute-se um processo ideal para a obtenção do CI.

The Missing Chapter: The Education of Surgery and Anesthesiology Trainees as Civic Advocates.

The SARS-CoV-2 pandemic has highlighted existing systemic inequities that adversely affect a variety of communities in the United States. These inequities have a direct and adverse impact on the healthcare of our patient population. While civic engagement has not been cultivated in surgical and anesthesia training, we maintain that it is inherent to the core role of the role of a physician. This is supported by moral imperative, professional responsibility, and a legal obligation. We propose that such civic engagement and social justice activism is a neglected, but necessary aspect of physician training. We propose the implementation of a civic advocacy education agenda across department, community and national platforms. Surgical and anesthesiology residency training needs to evolve to the meet these increasing demands.

The anesthesiologist and global climate change: an ethical obligation to act.

PURPOSE OF REVIEW: Pollution and global warming/climate change contribute to one-quarter of all deaths worldwide. Global healthcare as a whole is the world's fifth largest emitter of greenhouse gases, and anesthetic gases, intravenous agents and supplies contribute significantly to the overall problem. It is the ethical obligation of all anesthesiologists to minimize the harmful impact of anesthesia practice on environmental sustainability. RECENT FINDINGS: Focused programs encouraging judicious selection of the use of anesthetic gas agents has been shown to reduce CO2 equivalent emissions by 64%, with significant cost savings. Good gas flow management reduces nonscavenged anesthetic gas significantly, and has been shown to decrease the consumption of volatile anesthetic agent by about one-fifth. New devices may allow for recapture, reclamation and recycling of waste anesthetic gases. For propofol, a nonbiodegradable, environmentally toxic agent, simply changing the size of vials on formulary has been shown to reduce wasted agent by 90%. SUMMARY: The 5 R's of waste minimization in the operating room (OR) (Reduce, Reuse, Recycle, Rethink and Research) have proven benefit in reducing the environmental impact of the practice of anesthesiology, as well as in reducing costs.

Why Would the Pope Have A Private Audience with Anesthesiologists? The Origin of the "Doctrine of Double Effect" and Its Application to Pain Control.

Sunday February 24, 1957 was a pivotal day in the history of anesthesiology and pain medicine. The leader of the Roman Catholic Church, Pope Pius XII met with anesthesiologists attending an international symposium sponsored by the Italian Society of Anesthesiologists entitled, "Anesthesia and the Human Personality". The purpose of this audience was to seek clarification about the use of opioids at the end of life to reduce suffering. Three questions had been formulated from the previous year's Italian Congress of Anesthesiologists and sent to the Holy See on this specific issue. The Pope responded during this audience remarking that there was no moral obligation to withhold pain medication that could elevate suffering. He further remarked that the suppression of consciousness that can occur with opioids was consistent with the spirit of the Christian gospels. Finally, he also stated that it was not morally objectionable to administer opioids even if it might shorten life. The moral philosophy behind these answers is the doctrine of double effect. In essence, administering medications to relieve pain, the primary effect, may also hasten death, the unintended secondary effect. In seeking answers to these questions, the Italian anesthesiologists were at the forefront of a larger and ongoing debate. As new therapies are developed that may have unintended consequences, when it is morally permissible to use them?

No Proof Found of Anesthesia Involvement in Medical Misconduct During the Nazi Period. Investigation of the Alleged Purchase of 150 Inmates From Auschwitz Concentration Camp by Bayer to Test a New Narcotic.

A comprehensive investigation was undertaken to find evidence of the frequently reported, but never authenticated, "purchase of 150 inmates" from Auschwitz concentration camp by Bayer to test a new narcotic, resulting in the death of all investigated inmates. The archives of Auschwitz camp, Bayer, and the so-called former Soviet Union, where evidence of this alleged misconduct could have been saved, were investigated, but no evidence was found. Many records concerning concentration camp experiments on humans had been destroyed, but given the Nazis' meticulous record-keeping, the death of 150 inmates should have been recorded somewhere. Unethical medical research was indeed undertaken by physicians in concentration camps in many medical specialties, but no records regarding anesthesia-related medical misconduct during the Nazi period were found despite the allegations to the contrary that have been investigated here.

Patient safety and the role of the Helsinki Declaration on Patient Safety in Anaesthesiology: A European survey.

BACKGROUND: The Helsinki Declaration on Patient Safety was launched in 2010 by the European Society of Anaesthesiology and the European Board of Anaesthesiology. It is not clear how widely its vision and standards have been adopted. OBJECTIVE: To explore the role of the Helsinki Declaration in promoting and maintaining patient safety in European anaesthesiology. DESIGN: Online survey. SETTING: A total of 38 countries within Europe. PARTICIPANTS: Members of the European Society of Anaesthesiology who responded to an invitation to take part by electronic mail. MAIN OUTCOME MEASURES: Responses from a 16-item online survey to explore each member anaesthesiologist's understanding of the Declaration and compliance with its standards. RESULTS: We received 1589 responses (33.4% response rate), with members from all countries responding. The median [IQR] response rate of members was 20.5% [11.7 to 37.0] per country. There were many commonalities across Europe. There were very high levels of use of monitoring (pulse oximetry: 99.6%, blood pressure: 99.4%; ECG: 98.1% and capnography: 96.0%). Protocols and guidelines were also widely used, with those for pre-operative assessment, and difficult and failed intubation being particularly popular (mentioned by 93.4% and 88.9% of respondents, respectively). There was evidence of widespread use of the WHO Safe Surgery checklist, with only 93 respondents (6.0%) suggesting that they never used it. Annual reports of measures taken to improve patient safety, and of morbidity and mortality, were produced in the hospitals of 588 (37.3%) and 876 (55.7%) respondents, respectively. Around three-quarters of respondents, 1216, (78.7%) stated that their hospital used a critical incident reporting system. Respondents suggested that measures to promote implementation of the Declaration, such as a formal set of checklist items for day-to-day practice, publicity, translation and simulation training, would currently be more important than possible changes to its content. CONCLUSION: Many patient safety practices encouraged by the Declaration are well embedded in many European countries. The data have highlighted areas where there is still room for improvement.

Reporting of conflicts of interest and of sponsorship of guidelines in anaesthesiology. A cross-sectional study.

Guideline recommendations may be biased due to conflicts of interest (COI) of panel members and sponsorship of the guideline. Potential impact of COI, and their management, should be transparently reported. We analysed 110 guidelines published in ten anaesthesia journals from 2007 to June 2018. We report on the number (%) that 1) published COI disclosures; 2) in a distinct paragraph; 3) described and explained the COI of panel members, and 4) of the Chairperson; 5) reported and described the presence or absence and potential impact of a sponsor of the guideline on the recommendations; and 6) reported how COI were managed. COI were published in 70/110 (64%) guidelines; in a distinct paragraph in 25/70 (36%). Panel members reported having no COI in 27/70 (39%) guidelines, disclosed COI without describing their potential impact in 41/70 (59%), and described their potential impact in 2/70 (3%). Chairpersons were identified in 50 guidelines, 32 of which published COI disclosures; 16/32 (50%) reported having no COI, 14/32 (44%) disclosed COI without describing their potential impact, 1/32 (3%) described their impact and 1/32 (3%) made no statement regarding COI. Presence or absence of a sponsor of the guideline was reported in 40 guidelines; 12/40 (30%) declared none, 24/40 (60%) reported sponsoring without explanation of the potential impact, and 4/40 (10%) described the potential influence of the sponsor on the guideline recommendations. Seventy-five guidelines reported COI of panel members and/or sponsorship of the guideline but only seven described how the COI had been managed. Disclosures of COI of panel members and of sponsors of guidelines have increased over the 12 year period, but remain insufficiently described and their potential influence on the guidelines' recommendations is poorly documented.

Predatory Open-Access Publishing in Anesthesiology.

Predatory publishing is an exploitative fraudulent open-access publishing model that applies charges under the pretense of legitimate publishing operations without actually providing the editorial services associated with legitimate journals. The aim of this study was to analyze this phenomenon in the field of anesthesiology and related specialties (intensive care, critical and respiratory medicine, pain medicine, and emergency care). Two authors independently surveyed a freely accessible, constantly updated version of the original Beall lists of potential, possible, or probable predatory publishers and standalone journals. We identified 212 journals from 83 publishers, and the total number of published articles was 12,871. The reported location of most publishers was in the United States. In 43% of cases (37/84), the reported location was judged as "unreliable" after being checked using the 3-dimensional view in Google Maps. Six journals were indexed in PubMed. Although 6 journals were declared to be indexed in the Directory of Open Access Journals, none were actually registered. The median article processing charge was 634.5 US dollars (interquartile range, 275-1005 US dollars). Several journals reported false indexing/registration in the Committee on Publication Ethics and International Committee of Medical Journal Editors registries and Google Scholar. Only 32% (67/212) reported the name of the editor-in-chief. Rules for ethics/scientific misconduct were reported in only 24% of cases (50/212). In conclusion, potential or probable predatory open-access publishers and journals are widely present in the broad field of anesthesiology and related specialties. Researchers should carefully check journals' reported information, including location, editorial board, indexing, and rules for ethics when submitting their manuscripts to open-access journals.